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Examination of Nervous Examination of Nervous SystemSystem
VentricleVentricleThalamusThalamusHypothalamusHypothalamusMetathalamusMetathalamus Third ventricle Third ventricle EpithalamusEpithalamusSubthalamusSubthalamus
AREAAREA FUNCTIONFUNCTION EFFECT OF EFFECT OF LESIONLESION
11 VISUO-VISUO-SENSORY SENSORY AREA 17AREA 17
Perception of Perception of visual visual impression of impression of color size color size motionmotion
Homonymous Homonymous hemianopiahemianopia
22 VISUO-VISUO-PSYCHIC PSYCHIC 18,1918,19
Correlation of Correlation of visual visual impulses with impulses with past memory past memory & recognition & recognition of object seenof object seen
TEMPORAL LOBETEMPORAL LOBES/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OF EFFECT OF
LESIONLESION11 AUDITO-AUDITO-
SENSORY SENSORY AREA 41 AREA 41 4242
Perception of Perception of auditory auditory impression of impression of loudness, loudness, quality & pitchquality & pitch
Impaired Impaired hearinghearing
22 AUDITO-AUDITO-PSYCHIC PSYCHIC AREA 22AREA 22
Correlation of Correlation of auditory auditory impression impression with past with past memory and memory and identification identification of sound heardof sound heard
THALAMUSTHALAMUS FUNCTIONSFUNCTIONSIt is a major station where all specific sensory impulses It is a major station where all specific sensory impulses
(excepting smell) relay before finally terminating in (excepting smell) relay before finally terminating in the cerebral cortex like hippocampal, visceral, the cerebral cortex like hippocampal, visceral, straital, cerebellar, extroception & taste impulsestraital, cerebellar, extroception & taste impulse
LESIONLESION Lesion of thalamus cause impairement of all type of Lesion of thalamus cause impairement of all type of
sensibillities sensibillities joint sense being the most affected.joint sense being the most affected.
THALAMIC SYNDROMETHALAMIC SYNDROMEIt is characterized by disturbance of sensation, It is characterized by disturbance of sensation,
hemiplegia emotional disturbance ,weakness and hemiplegia emotional disturbance ,weakness and tremor. tremor.
4.TEMPERATURE REGULATION-It maintains a balance 4.TEMPERATURE REGULATION-It maintains a balance between heat production & heat loss between heat production & heat loss
5.REGULATION OF FOOD & WATER INTAKE5.REGULATION OF FOOD & WATER INTAKE
6.SEXUAL BEHAVIOUR & REPRODUCTION-Through 6.SEXUAL BEHAVIOUR & REPRODUCTION-Through control of ant pituitary it controls gametogenesis, control of ant pituitary it controls gametogenesis, uterine, ovarian cycle, maturation & maintenance of uterine, ovarian cycle, maturation & maintenance of secondary sexual characterstics.secondary sexual characterstics.
7.BIOLOGICAL CLOCKS- Wakefulness & sleep is 7.BIOLOGICAL CLOCKS- Wakefulness & sleep is maintained by it.maintained by it.
8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE & 8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE & REWARD all these controlled by hypothalamusREWARD all these controlled by hypothalamus
• ObesityObesity• Hyperglycaemia & glycosureaHyperglycaemia & glycosurea• Autonomic epilepsy which is characterized Autonomic epilepsy which is characterized
by flushing, sweating, salivation, by flushing, sweating, salivation, lachrimation, tachycardia, retardation of lachrimation, tachycardia, retardation of respiratory rate, unconsciousness.respiratory rate, unconsciousness.
• Sexual disturbance- precocity or impotenceSexual disturbance- precocity or impotence• Disturbance of sleep-somnolence(persistent Disturbance of sleep-somnolence(persistent
sleep) or narcolepsy (paroxysmal sleep)sleep) or narcolepsy (paroxysmal sleep)• Acute ulceration in the upper part of Acute ulceration in the upper part of
BASAL GANGLIABASAL GANGLIA FUNCTIONFUNCTION It regulates muscle tone, posture & helps It regulates muscle tone, posture & helps
in smoothering voluntary movements.in smoothering voluntary movements. It controls automatic associated It controls automatic associated
movements, like the swinging of arms movements, like the swinging of arms during walking. It coordinated during walking. It coordinated movements of different parts of the bodymovements of different parts of the body
It is required to initiate voluntary It is required to initiate voluntary movements.movements.
Presence of healthy basal ganglia Presence of healthy basal ganglia inhibits the appearance of tremorinhibits the appearance of tremor
• Damage of basal ganglia is cause Damage of basal ganglia is cause PARKINSONISMPARKINSONISM
• +VE SIGN-+VE SIGN-
• Rigidity- hypertonia of flexors & extensors of Rigidity- hypertonia of flexors & extensors of limb. It is a lead pipe rigidity.limb. It is a lead pipe rigidity.
• Tremor- Involuntary rhythmic alternating Tremor- Involuntary rhythmic alternating contraction of agonist & antagonist muscles of contraction of agonist & antagonist muscles of joints.Drum beating tremor.joints.Drum beating tremor.
Static tremor-tremor at rest but disappear while Static tremor-tremor at rest but disappear while attempts to do something -VE SIGN attempts to do something -VE SIGN
Patient is not inclined to initiate voluntary Patient is not inclined to initiate voluntary movements.movements.
Associated movements are reduced like-facial Associated movements are reduced like-facial expressions with changing emotions(masked expressions with changing emotions(masked facies) ,movements hand while walkingfacies) ,movements hand while walking
Posture – universally flexed attitude while Posture – universally flexed attitude while standingstanding
Gait – festinating gait-great tendency to falling Gait – festinating gait-great tendency to falling forward “as if catch his elusive centre of forward “as if catch his elusive centre of gravity” gravity” 05/02/23
• Cerebellar damage causes cerebellar syndrome. It Cerebellar damage causes cerebellar syndrome. It may be due to thrombosis ,injury, tumor. Sign & may be due to thrombosis ,injury, tumor. Sign & symptoms divided into 2 groupssymptoms divided into 2 groups
• A. Voluntary motor activity signsA. Voluntary motor activity signs
DYSMETRIA-Patient fails to gauge exact degree of DYSMETRIA-Patient fails to gauge exact degree of contraction of the muscles needed.contraction of the muscles needed.
INTENTION TREMOR- no tremor at rest but on INTENTION TREMOR- no tremor at rest but on attempting to do something tremor appearsattempting to do something tremor appears
DYSARTHRIA-Defects in articulation while patient is DYSARTHRIA-Defects in articulation while patient is talking.talking.
NYSTAGMUS-Hz rhythmic oscillation of eyes.NYSTAGMUS-Hz rhythmic oscillation of eyes. DYSDIADOCHOKINESIA-Patient fail to perform rapid DYSDIADOCHOKINESIA-Patient fail to perform rapid
alternative movements like pronation & supination of alternative movements like pronation & supination of forearm.forearm.
B.TONE POSTURE EQUILIBRIUM SIGNB.TONE POSTURE EQUILIBRIUM SIGN HYPOTONIAHYPOTONIA Ability to balance is severely weakened. Ability to balance is severely weakened. Tilting the head towards the side of lesion. Tilting the head towards the side of lesion.
ORIENTATION OF ORIENTATION OF TIME,PLACE,PERSONTIME,PLACE,PERSON
• Ask about the day,date,month, Ask about the day,date,month, year, time,time of day like year, time,time of day like morning,evening etcmorning,evening etc
• Ask about where he is-name the Ask about where he is-name the place, city where he livesplace, city where he lives
• Ask about himself or other person Ask about himself or other person in room, about relativesin room, about relatives
• Hallucination is perception of sensation in Hallucination is perception of sensation in the absence of any sensory stimulus. It may the absence of any sensory stimulus. It may be auditory, visual, olfactory, taste, tactile.be auditory, visual, olfactory, taste, tactile.
• Delusion is false beliefs which cannot be Delusion is false beliefs which cannot be corrected in spite of evidence.It may be corrected in spite of evidence.It may be
of grandeur,of grandeur, of poverty, of poverty, of nihilistic,of nihilistic, of love,of love, of infedility,of infedility, of influenceof influence
• DYSPHAGIA-Difficulty in DYSPHAGIA-Difficulty in language function.It is due to language function.It is due to lesion in Broca’s area , lesion in Broca’s area , Wernicke’s area.Wernicke’s area.
• DYSARTHRIA-Indistinct speech DYSARTHRIA-Indistinct speech due to weakness of orolingual due to weakness of orolingual muscle concern with production muscle concern with production of consonant.of consonant.
• Sense of smell from Sense of smell from nasal mucosa to brainnasal mucosa to brain
• Tested by asking the Tested by asking the patient to sniff various patient to sniff various non irritating substance non irritating substance each nostril seperatelyeach nostril seperately
• Lesion of nerve may Lesion of nerve may cause cause
3.OCULOMOTOR3.OCULOMOTOR• Somatic –external muscles of eyeSomatic –external muscles of eye• P S- smooth muscles of pupil ,ciliary P S- smooth muscles of pupil ,ciliary
body of eyebody of eyeComplete paralysis of 3Complete paralysis of 3rdrd nerve nerve Ptosis,Ptosis, Diplopia,Diplopia, Lateral squint,Lateral squint, Downward deviation,Downward deviation, Dilatation of pupil,Dilatation of pupil, Slight proptosis,Slight proptosis, Loss of accomodation Loss of accomodation 05/02/23
• Supplies superior oblique. It cause Supplies superior oblique. It cause downward movement,lateral downward movement,lateral movement, & intorsion.movement, & intorsion.
Complete paralysis of 4Complete paralysis of 4thth nerve nerve causescauses
Medial squint,Medial squint,Upward deviation of eyeball,Upward deviation of eyeball,Diplopia-only below hz planeDiplopia-only below hz plane
7.FACIAL7.FACIAL• Motor-Muscle of facial expressionMotor-Muscle of facial expression• Sensory-Taste sensation of ant 2/3 of Sensory-Taste sensation of ant 2/3 of
tonguetongue• P S-Submandible,Sublingual,Lachrimation P S-Submandible,Sublingual,Lachrimation
glands glands• TestTest Motor function can be tested by Motor function can be tested by
inspection of facial expression & facial inspection of facial expression & facial mobilitymobility
Sensory function can be tested by asking Sensory function can be tested by asking the different taste of ant 2/3 of the tongue. the different taste of ant 2/3 of the tongue.
FACIAL PALSY(BELL’S PALSY)FACIAL PALSY(BELL’S PALSY)• Infranuclear lesion of facial nerve known Infranuclear lesion of facial nerve known
as Bell’s Palsy,the whole of the face of the as Bell’s Palsy,the whole of the face of the same side gets paralysed.same side gets paralysed.
Assymetry of face,Assymetry of face, Affected side is motionless,Affected side is motionless, Wrinkles is lost,Wrinkles is lost, Flattening of nasolabial fold,Flattening of nasolabial fold, Any attempt to smile draws the mouth to Any attempt to smile draws the mouth to
the normal side,the normal side, During mastication food accumulates During mastication food accumulates
between the teeth & cheek,between the teeth & cheek, Dribbling of saliva through angle of mouthDribbling of saliva through angle of mouth05/02/23
8.VESTIBULOCOCHLEAR8.VESTIBULOCOCHLEAR1.Cochlear-Hearing1.Cochlear-Hearing2.Vestibular-Equilibrium2.Vestibular-EquilibriumTest for Cochlear functionTest for Cochlear functionBy TICK-TICK of watch at each ear.If By TICK-TICK of watch at each ear.If
impairment of hearing than following impairment of hearing than following test r done to determine whether the test r done to determine whether the disease is of vestibulocochlear system or disease is of vestibulocochlear system or from middle ear disease.from middle ear disease.
WEBER’S TESTWEBER’S TEST• Vibrating tuning fork is placed on Vibrating tuning fork is placed on
forehead.forehead.• Normally vibration r equally both side.Normally vibration r equally both side.• Conductive Deafness-better diseased Conductive Deafness-better diseased
side because external sound side because external sound interfering with the vibration is less interfering with the vibration is less on affected side.on affected side.
• Sensorineural deafness-better on Sensorineural deafness-better on healthy side. healthy side.
9 GLOSSOPHARYNGEAL9 GLOSSOPHARYNGEAL• MIXED NERVE+ PS FIBERSMIXED NERVE+ PS FIBERS• SENSORY-Taste over the posterior one third SENSORY-Taste over the posterior one third
of the tongue.of the tongue.• MOTOR-Middle constrictor of pharynx andMOTOR-Middle constrictor of pharynx and stylopharyngeus muscle-responsible for gag stylopharyngeus muscle-responsible for gag
responseresponse• Test-GAG REFLEX Test-GAG REFLEX stimulation of posterior pharyngeal wall by stimulation of posterior pharyngeal wall by
cotton applicator results in elevation and cotton applicator results in elevation and constriction of pharyngeal musculature and constriction of pharyngeal musculature and retraction of tongue.retraction of tongue.
12 HYPOGLOSSAL 12 HYPOGLOSSAL • MOTOR-Muscle of tongueMOTOR-Muscle of tongue• Test Test Tongue should be observe at rest & Tongue should be observe at rest &
on protrusion, various movement r on protrusion, various movement r notednoted
If paralysis tongue is deviated to If paralysis tongue is deviated to affected sideaffected side
If bilateral than dysphagia, dyspnea & If bilateral than dysphagia, dyspnea & dysarthriadysarthria
C. MOTOR SYSTEMC. MOTOR SYSTEM• BULK OF MUSCLESBULK OF MUSCLES• STRENGTH OF MUSCLESSTRENGTH OF MUSCLES• TONE OF MUSCLESTONE OF MUSCLES• GAITGAIT• INVOLUNTARY MOVEMENTSINVOLUNTARY MOVEMENTS
1. BULK OF MUSCLES1. BULK OF MUSCLES• HYPERTROPHY-Muscles r enlarge from HYPERTROPHY-Muscles r enlarge from
their normal sizetheir normal size In muscular dystrophy-large muscles In muscular dystrophy-large muscles
may develop esp calves, buttocksmay develop esp calves, buttocks HYPOTROPHY-Wasting of musclesHYPOTROPHY-Wasting of muscles Wasted muscles r small, soft, flabbyWasted muscles r small, soft, flabby If wasting is associated with fibrosis If wasting is associated with fibrosis
fingers fingers Flexors of fingersFlexors of fingers Flexors of wrist Flexors of wrist Extensors of wristExtensors of wrist BrachioradialisBrachioradialis
Dorsiflexion & planter flexion of feet & Dorsiflexion & planter flexion of feet & toes toes
Flexors of kneeFlexors of kneeExtensors of knee Extensors of knee Flexors of hipFlexors of hipExtensors of hipExtensors of hipAbductors of thighAbductors of thighAdductors of thighAdductors of thighRotators of thighRotators of thigh
Medical Research Council Medical Research Council Scale for grading muscle Scale for grading muscle
functionfunction• GRADEGRADE• 0 - Complete paralysis0 - Complete paralysis• 1 - A flicker of contraction only1 - A flicker of contraction only• 2 - Power detectable only when gravity is 2 - Power detectable only when gravity is
excluded excluded by appropriate postural adjustment by appropriate postural adjustment• 3 - The limb can be held against the force of 3 - The limb can be held against the force of
gravity, gravity, but not against the examiner’s but not against the examiner’s resistanceresistance
• 4 - There is some degree of weakness, usually 4 - There is some degree of weakness, usually described as poor, fair, or moderate described as poor, fair, or moderate strengthstrength
• 5 - Normal power is present5 - Normal power is present05/02/23
3. TONE OF MUSCLES3. TONE OF MUSCLES•TONE is the resistance TONE is the resistance
offered by normal muscles offered by normal muscles to passive movements. It to passive movements. It is greatest in muscles is greatest in muscles which maintain posture ie which maintain posture ie antigravity muscles-flexors antigravity muscles-flexors in upper limb & extensors in upper limb & extensors of lower limbof lower limb
• HYPOTONIA-HYPOTONIA-• It is characterized by flabby muscles It is characterized by flabby muscles
which offer less resistance to passive which offer less resistance to passive movements, leading to an increased movements, leading to an increased range of passive movements & limb range of passive movements & limb is unable to maintain posture is unable to maintain posture
CAUSESCAUSES 1 . Lower motor neuron disease-1 . Lower motor neuron disease-
• 1. ROMBERG’S TEST1. ROMBERG’S TEST• 2. TANDEM WALKING2. TANDEM WALKING• 3. FINGER NOSE TEST3. FINGER NOSE TEST• 4. FINGER TO FINGER TEST4. FINGER TO FINGER TEST• 5. FOR DYSDIADOCHOKINESIA5. FOR DYSDIADOCHOKINESIA• 6. POSTURAL HOLDING IN 6. POSTURAL HOLDING IN
• A.TREMOR-A.TREMOR- StaticStatic-tremor at rest & not at voluntary -tremor at rest & not at voluntary
movement eg. Parkinsonism movement eg. Parkinsonism PosturalPostural-when limb is actively maintained in a -when limb is actively maintained in a
certain position eg. certain position eg. HyperthyroidismHyperthyroidism
IntentionIntention-It is on willed movement esp -It is on willed movement esp desired desired object is approached object is approached eg Cerebellar eg Cerebellar syndrome syndrome
HystericalHysterical-tremor in any limb and examiner -tremor in any limb and examiner restrained on that limb it may restrained on that limb it may move to move to another part of body another part of body
VISCERAL REFLEXVISCERAL REFLEX• Pupillary relexPupillary relex Shining light on eye Shining light on eye Constriction of the pupilConstriction of the pupilAbsence may indicate Absence may indicate -edema of the brain-edema of the brain-head injury-head injury-advance brain tumor-advance brain tumor-loss of optic nerve -loss of optic nerve
5.SENSORY SYSTEM5.SENSORY SYSTEM• Following sensation should be testedFollowing sensation should be tested TouchTouch PainPain TemperatureTemperature Position Position VibrationVibration Cortical sense-tactile localization,Cortical sense-tactile localization, tactile discriminationtactile discrimination tactile extinctiontactile extinction stereognosisstereognosis05/02/23
Kernig’s sign-severe stiffness of hamstrings Kernig’s sign-severe stiffness of hamstrings causes an inability to straighten the leg causes an inability to straighten the leg
when the hip is flexed to 90 degreewhen the hip is flexed to 90 degree
Brudzinski’s neck sign-severe Brudzinski’s neck sign-severe neck stiffness causes patient’s hip neck stiffness causes patient’s hip & knee to flex when neck is flexed& knee to flex when neck is flexed
EEGEEG• It is used in investigation of It is used in investigation of
epilepsy, diagnosis of encephalitis, epilepsy, diagnosis of encephalitis, dementia.dementia.
• Electrodes applied to the patient’s Electrodes applied to the patient’s scalp pick up small changes of scalp pick up small changes of electrical potential, which after electrical potential, which after amplification are recorded on paper amplification are recorded on paper or displayed on a video monitor or displayed on a video monitor and recorded electronically.and recorded electronically.
EMGEMG• Electrical activity occurring in Electrical activity occurring in
muscle during voluntary muscle during voluntary contraction, denervated at rest can contraction, denervated at rest can be recorded with needle electrodes be recorded with needle electrodes inserted percutaneously into the inserted percutaneously into the belly of the muscle.belly of the muscle.
• It is useful in desease of muscle – It is useful in desease of muscle – myopathies and dystrophies, LMN myopathies and dystrophies, LMN lesion lesion