Neurological 1

Chapter 23

Neurologic System

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System



Structure and Function



Subjective Data—Health History Questions



Objective Data—The Physical Exam



Abnormal Findings

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-1

Chapter 23 Neurologic System

Structure and Function Central Nervous System (CNS)  Cerebral

– – – – –

cortex

Frontal lobe Parietal lobe Occipital lobe Wernicke’s area Broca’s area

 Basal

ganglia

 Thalamus

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

 Hypothalamus  Cerebellum  Brainstem

– Midbrain – Pons – Medulla  Spinal

cord

Slide 23-2

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System

Structure and Function, cont. Pathways of the CNS 

Crossed representation



Sensory pathways – Spinothalamic tract – Posterior (dorsal) column



Motor pathways – Corticospinal or pyramidal tract – Extrapyramidal tracts – Cerebellar system



Upper motor neurons



Lower motor neurons

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-3

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System

Structure and Function, cont. Peripheral Nervous System 

Cranial nerves



Spinal nerves



Autonomic nervous system



Reflex arc

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-4

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System

Subjective Data— Health History Questions 

Headache



Incoordination



Head injury



Numbness or tingling



Dizziness/vertigo



Difficulty swallowing



Seizures



Difficulty speaking



Tremors



Significant past history



Weakness



Environmental/ occupational hazards

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-5

Chapter 23 Neurologic System

Objective Data— The Physical Exam 

Preparation – Screening neurologic examination – Complete neurologic examination – Neurologic recheck



Equipment needed – – – – – – –

Penlight Tongue blade Cotton swab Cotton ball Tuning fork (128 Hz or 256 Hz) Percussion hammer Occasionally need: familiar aromatic substance

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-6

Chapter 23 Neurologic System

Objective Data— The Physical Exam, cont. Test Cranial Nerves 

VII—Facial



I—Olfactory



II—Optic



III—Oculomotor, IV—Trochlear, VI—Abducens



VIII—Acoustic (vestibulocochlear)

V—Trigeminal



IX—Glossopharyngeal, X—Vagus



– Motor function – Sensory function

– Motor function

– Motor function

– Sensory function – Corneal reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

– Sensory function 

XI—Spinal accessory



XII—Hypoglossal Slide 23-7

Chapter 23 Neurologic System

Objective Data— The Physical Exam, cont. Motor System—Inspect and Palpate 

Muscles – – – –

Size Strength Tone Involuntary movements



Cerebellar function – Balance tests • • • •

Gait Tandem walking Romberg test Shallow knee bend

– Coordination and skilled movements • • • • Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Rapid alternating movements (RAM) Finger-to-finger test Finger-to-nose test Heel-to-shin test Slide 23-8

Chapter 23 Neurologic System

Objective Data— The Physical Exam, cont. Sensory System 





Person is alert, cooperative, and comfortable Guidelines for sensory testing Spinothalamic tract – Pain – Temperature – Light touch

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.



Posterior column tract – Vibration – Position (kinesthesia) – Tactile discrimination (fine touch) • • • • •

Stereognosis Graphesthesia Two-point discrimination Extinction Point location

Slide 23-9

•Stereognosis

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Graphesthesia

Chapter 23 Neurologic System

Objective Data— The Physical Exam, cont. 

Test the stretch or deep tendon reflexes (DTRs) – – – – – – – –

Technique Grading Reinforcement Biceps reflex Triceps reflex Brachioradialis reflex Quadriceps reflex Achilles reflex (“ankle jerk”)



Test the superficial reflexes – Abdominal reflex – Cremasteric reflex – Plantar reflex

• Clonus

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-10

–Biceps reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Triceps reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Brachioradialis reflex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Let the Lower Legs Dangle Freely to Flex the Knee and Stretch the Tendons. Strike the Tendon Directly Just Below the Patella. Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Achilles reflex (“ankle jerk”)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Test the reflexes 

Copare right and left



The response should be equal



4+ Very brisk, hyperactive with clonus (short jerking contraction of the same muscle), indicative of disease



3+ Brisker than average, may indicate disease



2+ average, normal



1+ diminished, low normal



0 no response

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System

Objective Data— The Physical Exam, cont. 

Neurologic recheck



Level of consciousness – Person – Place – Time



Motor function



Pupillary response



Vital signs

Glasgow coma scale (GCS) Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-11

Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704) Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Decorticate Rigidity (abnormal flexion)

Decerebrate Rigidity (abnormal rigidity)

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Abnormal Findings Abnormalities in Muscle Movement Paralysis • Loss or impairment of the ability to move a body part, usually as a result of damage to its nerve supply. • Loss of sensation over a region of the body. Hemiplegia • paralysis of one side of the body Paraplegia • paralysis of both lower limbs due to spinal disease or injury Quadriplegia • paralysis of all four limbs or of the entire body below the neck Paresis Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. • Elsevier partial motor paralysis Copyright © 2003, Science (USA). All rights reserved.

Fasciculations Rapid, continuous twitching of resting muscle

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Tic Repetitive twiching of a muscle group

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Myoclonus Rapid, sudden jerk at a fairly regular intervals

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Tremor Involuntary contraction of opposing muscle groups •Rest tremor •Intention tremor

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chorea

Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Athetosis

Slow, twisting, writhing, contiuous movement, resembling a snake or worm

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Chapter 23 Neurologic System

Abnormal Findings Abnormal Gaits



Spastic hemiparesis



Cerebellar ataxia



Parkinsonian (festinating)



Scissors



Steppage or footdrop



Waddling



Short leg

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-13

Chapter 23 Neurologic System

Abnormal Findings Common Patterns of Sensory Loss



Peripheral neuropathy



Individual nerves or roots



Spinal cord hemisection (Brown-Séquard syndrome)



Complete transection of spinal cord



Thalamus



Cortex

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-14

Chapter 23 Neurologic System

Abnormal Findings Abnormal Postures 

Decorticate rigidity



Decerebrate rigidity



Flaccid quadriplegia



Opisthotonos

Carolyn Jarvis Physical Examination and Health Assessment Fourth Edition. Copyright © 2003, Elsevier Science (USA). All rights reserved.

Slide 23-15