Neurological Assessment · Neurological S. Examination IMPORTANT AREAS OF EXAMINATION Mental status—Behavior and Mental Status.(level of consciousness & orientation). Cranial nerves

Neurological AssessmentINSHIRAH QADRI

Components of the Central

Nervous System

© Pat Thomas, 2006.

❑ Cerebral Cortex – “gray matter” center for

highest functions

❑ Cerebrum has two Hemispheres

❑ Four Lobes in each hemisphere: frontal, parietal,

temporal, & occipital

❑ Left Hemisphere – dominant in 95%

Central Nervous System (CNS)

Central Nervous System© Pat Thomas, 2006.

Central Nervous System (CNS)

Frontal Lobe

• Personality

• Behavior

• Emotions

• Intellectual Function

• Precentral gyrus of frontal lobe:

initiates Voluntary movement

(Controls skeletal muscle)

• Broca’s Area: Motor Speech /

Expressive

Parietal Lobe

❑primary center for sensation.

❑Postcentral Gyrus – Primary

Center for Sensation

Temporal Lobe

Primary Auditory Center

Taste and Smell

➢ Wernicke’s Area:

➢ Language Comprehension / if damage→Receptive aphasia

➢ No meaning of language, like hearing foreign language

Occipital Lobe

Primary Visual Receptor

Center

Cerebellum

• Under the occipital lobe

• Motor coordination, equilibrium,

muscle tone

• Unconscious level that adjusts

voluntary movements

Brain Stem

Mid brain → Motor neurons &

tracts

Pons → ascending & descending

fibers tracts

Medulla → ascending &

descending fibers tracts connecting

the brain & spinal cord.

Medulla has vital autonomic

nervous system

Autonomic Nervous System

• works without

conscious thought

(glands, cardiac

muscle, smooth

muscles: digestive

system, respiratory

system & the skin)

Basal Ganglia

Grey matter deep in the

hemispheres coordinating

motor movements and posture.

E.g.:, the arm swing

Alternating with the legs

during walking

Forebrain

Cerebrum:

Thalamus: Synapses contact sensory pathways between the spinal cord and the brain stem

Hypothalamus: control center for temperature, heart rate, BP, sleep, ant. & pos. pituitary gland, autonomic nervous system activity & emotional status

Spinal Cord

carries sensory & motor info.

The main highway that connects the brain to the spinal nerves

Upper and lower motor neurons

Peripheral Nervous System

• Reflex Arc, Cranial

nerves, Spinal

nerves.

Cranial Nerves – 12 pairs31 pairs

The Nerve

Sensory stimulus, posterior

root, spinal cord, synapse

with a motor neuron in the

anterior horn, anterior root,

muscle.

Reflex arc:

Types of Reflexes

Deep Tendon – knee jerk,

(patellar)

Superficial – corneal reflex, abd.

Reflex

Visceral – organic, pupil response

to light & accommodation

Pathologic – abnormal / Babinski.

Cranial Nerves

• enter and exit the brain

• The 12 pairs of CN supply the

head and neck except the vagus

nerve which travels to the heart

,resp. muscle ,stomach and

gallbladder.

Subjective Data

• Headache

• Incoordination

• numbness or tingling

• Difficulty swallowing

• Difficulty speaking

• past history

• Head injury

• Dizziness

• Seizures

• Tremors

• weakness

Neurological S. Examination

IMPORTANT AREAS OF EXAMINATION

Mental status— Behavior and Mental Status. (level of consciousness & orientation).

Cranial nerves — I through XII

Motor system — coordination, gait, & stance

Sensory system — pain and temperature, position & vibration, light touch, discrimination.

Deep tendon — abdominal, and plantar reflexes

Test Cranial Nerves

I: Olfactory :S / test sense of smell

II: Optic: S / Visual acuity & fields and

ophthalmoscope

III, IV,VI: oculomotor, trochlear,

abdocent):S /M Pupils size, reflex,

accommodation & asses extra ocular

movement.

V: trigeminal

M /clench teeth (muscles of

mastication)

S / cotton wisp to face; light

touch& corneal reflex

(blink).

VII: facial: M / facial

expression during movements;

smile, close eyes then open,

frown, lift eyebrows, show

teeth. puff cheeks

S / taste (sugar, salt, lemon).

VIII: Acoustic: S / hearing

acuity; whisper, Weber, Rinne

and Romberg’s tests

IX & X: glossopharyngeal & vagus

M / uvula & soft palate rise, positive

gag reflex,

Assess quality of nasal voice. Is it

hoarse? .vocal cord paralysis.

Palate paralysis nasal voice

Assess swallowing

S /IX CN taste on post 1/3 tongue

(biter)

XI (spinal accessory N) :M /

shoulder shrug, neck muscle strength

ROM .

XII (hypoglossal N) – M / tongue

midline w/ forward thrust, say “light,

tight, dynamite”

Inspect & Palpate the motor

system

• Muscle size• Appropriate to age, symmetric or < 1cm

difference

• Strength • Equal bilaterally.

Tone = normal degree of tension in relaxed muscles

• Mild resistance to passive stretch

• Involuntary movement

• Absent

Cerebellar Function

Balance Test:

Gait: observe a person walk 10-20 ft. & return to

starting point smooth, rhythmic ,effortless, well

coordinated with hand, step length 15 inch from

heel & smooth turns.

Walk straight & stay balanced ,while walking

straight line in a heel to toe (Tandem walking).

Cerebellar

Function

• Romberg test; ask the person to stand up with feet togother and arms at sides, close eyes.

Noramal➔ maintain posture & balance with slight swaying.

• shallow knee bend or to hop in place;

• Balanced

• Rising up (if the client old age or weak )

• Unable to perform shallow knee bend or hop

Coordination

Rapid alternating movement (RAM);

• quick rhythmic pace & smoothnes .

Thumb index test

• quick rhythmic pace & smoothnes .

Counting the fingers; quick & accurately.

Finger to finger; smooth & accurate movement.

• Finger to nose ; smooth &

accurate movement

• Heel to shin: moves heel in a

straight line down the shin.

Sensory System Assessment

• Ensure the client is alert, cooperative, comfortable & has an adequate attention span.

• Compare sensations on symmetrical body parts.(bilaterally)

• Proceed from the point of decreased sensation toward the sensitive area

• Draw results on a diagram

• If discover abnormity perform all sensation tests

Sensory System Assessment

➢Ask the person to close eyes

➢Routine screen includes light touch, superficial pain, vibration & stereognosistest.

➢Avoid leading questions- use unbiased directions

➢May need to repeat the sensory tests or break it into parts when the client tired.

Sensory System Assessment

Spinothalamic Tract:

Pain – perceive a pinprick

with at least 2 sec. elapse

between each stimulus

Dscriminate sharp & dull

points; bilaterally, feel

symmetric .

Sensory System Assessment

Spinothalamic Tract:

Temperature –able to

discriminate heat & cold stimuli

bilaterally.

Light Touch – apply a wisp of

cotton to skin, brush over the skin

in random order and irregular

intervals

• able to feel, symmetric.

Posterior column tract

Vibration – tuning fork

( 128Hz) over bony

prominences

• able to feel vibration

Posterior column tract

• Proprioception (Position )

;Kinesthesia: ability to perceive

passive movement of extremities.

Move a finger or toe up & down

Normal: detect movement

Posterior column tract

Stereognosis – recognition

of familiar objects by feeling

size & weight With closed

eyes.

Graphesthesia – read a

number by traced on skin

Posterior column tract

Two points discrimination;

able to distinguish the separate

of two pin points on the skin.

Normal: varied with the tested

region

The most sensitive is the finger

pads: (normally < 5 mm on the

fingerpads).

The least sensitive – the upper

arms, thighs, and back

Posterior column tract

Extinction; able to feel

stimulus at both sides of

the body.

Point location; able to

localize the sensation

touch.

Reflexes (response graded 0 – 4+)

Deep tendon reflexes

Reinforcement.

❑Test reflexes using a percussion hammer,

comparing one side of the body with the other to

evaluate the symmetry of response.

❑The client should be clench teeth, make fist or

squeeze one thigh with the opposite hand for

arms

❑The client should be interlock fingers and pull

one hand against the other for legs.

Reflexes

• Biceps Reflex – (C5 to C6) striking on

bicep → Forearm flexion

• Triceps Reflex–( C7-C8) extension of

forearm+striking on the triceps tendon

• Brachioradialis Reflex C5-C6 – flexion

& supination of forearm while striking

2 inch above the wrist.

Reflexes

Quadriceps Reflex (knee Jerk )

L2-L4 → leg extension

Achilles Reflex (ankle Jerk)

L5-S2 striking on the Achilles

→ plantar flexes against your

hand

Superficial reflexes

Abdominal reflexes (upper T8-

T10,lower T10 -L2) → Ipsilateral contraction of the abdominal muscle with deviation the umbilicus toward the stroking,

Cremasteric reflex (L1-L2); strok the

inner aspect of the thigh → elevation of the ipsilateral testicle

Planter reflex (L4-S2);

→ plantar flexion of the, inversion & flexion of the forefoot