Neurological Sheet

History

I- Personal history 1-

Name:

2-

Age: - 1st 3y → Duchen type of myopathy. limb pelvis girdle myopathy. nd rd - 2 – 3 decade Fascio scapulohumoral - 2 – 15y → Fredreich’s ataxia Syringomyelia. - 15 – 30y D.S. - 4 – 5 decade th

3- Sex: Sex ♀

th

S.C.D.

Motor neurone disease Myasthenia gravis. Chorea. Meningioma (80% in ♀).

4- Marital state: esp. repeated abortions or still birth ($). 5- Occupation: → Lead and → Peripheral neuritis (P.N ) Arsenic. Mn parkinsonism. Driver disc prolapse 6- Residence: → Migrain is common in urban area, which nutritional disorders are common. 7- Special habits: - Alcohol → P.N. 8- Lt. Handed or Rt. Handed: → Why? (Broca’s area ) • Speach center is located in dominant hemisphere. • The dominant one so: in Rt. handed people it is located in lt hemisphere and vice - versa.

II- C/O: in the patient own words If there is more than one complaint list them according to their importance. Cardiac Chest Onset C/O abdominal Course Duration (only in neurological sheet)

II- C/O: in the patient own words Epilepsy. 1- Similar attacks D.S. Vascular lesions.

2- Fevers: • T. myelitis. • Poliomyelitis. • Encephalitis. • D. encephalomyelitis. • Meningitis and its sequalae. • Brain abscess. • Pontine hage. • Infective polyneuropathy. 3- Trauma and op.: in case of paraplegia& cauda equinui lesion. 4- T.B. , B , → 1ry (chancre)

sore in gentalia. = Painless and disappear without treatment. 2ry fever, headache, irridocyclitis, generalized LNs., Skin rash not itchy. vascular

not

6- Drugs as:  Steroids  Sedatives → ataxia  Analgesics. + contraceptives  Vaccination.  Primperan (metaclopramide) →  Extra  in children 7- Ear diseases and eye diseases: 8- Convulsions & loss of consciousness. 9- Cardiac disease & Rhe. Fever → Ms + AF → embolic hemiplegia. 10- Syphilis

valve lesions e.g

Acute meningitis. S in CNS.

Meningeal

Chronic meningitis. Vascular (E.A.O) → (end arteritis obliterans) Tabes. GPT.

Trumma of brain. III- Family history: 1. of similar condition. 2. history of consanguinity. 3. of any nervous disease. 4. of cong. Abnormalities. - Nervous diseases with +ve F.H (Heredofamilial disease)

V- Present history: 1. Onset, course and duration 2. Patient tells his story with analysis of each. 3. Ask leading questions 4. Write +ve data chronologically then –ve data. 5. Symptoms of other system Embolism Hge Acute → Dramatic (within seconds) Trauma Sudden (within hours) → thrombosis,DS & DEM

Onset

Rapid (within days) → Inflammations as meningitis encephalitis Gradual (within weeks, months and years) Systemic degenerative diseases:myopathy, H. Cereb. Ataxia . MND. Space occupying lesion brain tumour (unilat. Or bilat)

N.B: Demyelinating disease usually of acute onset but may be gradual

Course: Regressive

inflammatory. Vascular lesion except hage. As

Thrombosis Embolism Space occupying lesion Progressive Systemic degenerative disease Motor neurone disease hage Epilepsy Intermittent (episodic) Migraine - Remittent (Remission and exacerbation) not reach base line Demyelinating disease as D.S Rec. embolism Vascular causes as Hypertensive encephalopathy Angiomatous malformation

Stationary: = fate of any disease Duration: long duration exclude malignancy Leading questions 1- Symptoms of ↑ I.C.T: Headache: characterized by

Occipital → neck Early hours of morning Bursting Awaken pt. from sleep Poor response to analgesics And good response to dehydrating drugs (diuritics) at its peak → vomiting

Blurring of vision Not necessary projectile Vomiting:

May be proceeded by nausia or not Usually at peak of headache Related to meal or not.

Convulsions Endocrinal dist.: Sleep disturbance

♀: menstruation disturbance ♂: Impotence

2- History of fits and loss of consciousness: With fits or not. •

Aura ( visual, auditory, olfactory )

•

Special march (start in thumb, big toe & angle of the mouth)

•

Generalized or localized → tonic & clonic.

•

With loss of conciousness or not + injuries + biting tongue + Micturation.

Ictal

•

Duraltion.

Postictal

•

Post effect. (few hours or days)→ sleep, fatigue & Automatism.

Preictal

3- Speech disorders:

Dysarthria Aphasia

Receptive.

Expressive A) Aphasia = disturbance in higher neurological and psychological functions of speech. Receptive (Sensory):

Auditory (Word deafness). Visual (Word blindness).

Expressive (Motor):

For spoken speech (Broca’s area 44) For written speech(agraphia , extensor area 45)

B) Dysarthria: = Defective articulation or disturbance in peripheral motor function of Speech 7 → ms of face 9,10 → Voice 12 → tongue - Types: (6) ∆ → Slurred

- Cerebellar → stacatto

extra ∆ → Slow montonous - ∆ & Cerebellar → scanning - 9 & 10 ∆ → Nasal tone - 10 th → Hoarsness of Voice - (1),(2),(3) = cerebral symptoms.

4- Cranial nerves: nerves (a) Olfactory:

Anosmia Hyosmia.

Hallucinations of smell Parosmia and cacosmia = bad odours hallucination seen in uncinate fits. NB: - Unilateral anosmia is more significant than bilateral → tumours. - Most common cause is local cause (influenza) (b) Optical nerve: 1- Visual acuity.

2- Visual field.

3- Visual hallucination. 4- ± color of vision (c) III, IV, VI (oculamotor, trochlear and abducent): 1-Diplopia. 3- Squint. 5- ± Exophthalmos

2- Ptosis. 4- Dazling.

(d) V (Trigeminal): Trigeminal Pain, tingling, numbness.

Sensory

Temperature , Disturbance.

Touch. Motor : Difficulty in mastication (e) VII (Facial n.): 1- Inability to close eye. Motor

2- Accumulation of food on one side. 3- Drippling of saliva from one side. 4- Deviation of mouth to same side of paralysis.

Sonsory → 5-Taste of food (ant. 2/3).

(f)VIII ( Vestibulo-choclear n) •

Deafness.

•

Tinnitus.

•

Hallucination.

•

Vertigo

Cochlear

Vestibular

(g) IX, X (glossopharyngeal and vagus) 1. Nasal tone of voice. 2. Regurge of food from nose. 3. Dysphagia. 4. Hoarseness of voice. = aphonia or dysphonia.

Palate Pharynx Larynx

(h) Accessory (XI): •

Can not rotate his face to other side.

•

Can not raise his shoulder properly on the diseased side. → Sign > symptom

(i) Hypoglossal (XII): 1. Difficulty of speech. 2. ↓ weakness 3- Distal or pro tongue or deviated tongue. 3.

± Difficulty of mastication.

Movement of the

5- Motor system 1- State. 2- Tone. 3- Power

1- Unilateral or bilateral. 2- Symmetrical or asymmetrical.

Weakness

3- Distal or proximal. 4- flexor or extensor. 5-Abductor or adductor. 6-Trunk muscles: abd. Ms. Or back ms.

4- Fasciculation. 5- Involuntary movement.

1- State 2- Tone:

Atrophy (wasting). Pseudo hypertrophy e – weakness. Flaccidity (hypotonia) = LMNL, cerebellar, chorea

Stiffness (hypertonia) =  or extra  3- Power: Weakness or paralysis 1. Unilat. Or bilat. 2. Symmet. Or asymm. 3. Distal or proximal. UL Distal

Proximal LL

Distal - Dorsiflexion

Proxima - Plantiflexion

4- Flexor or extensor: UL Floxer

Extensor LL

Floxer 5- Abductor or adductor:

Extensor UL

Abd. 6- Back ms. Trunk 7- Abd. Ms.

Add. LL

4- Fasciculations: If +ve → A.H. cell lesion. 5- Involuntary movement: • Proximal or distal. • Static or kinetic. • Rhythmic or jerky. • What ↑ (emotions). • What ↓ (sleep). • Discreption ( Pill rolling ). Sensory Effect of closure of the eyes = Sensory ataxia. • Intention tremors • Dysmetria • Dysdiadokokinesia

7- Sensory system: • Irritation

→

tingling + pain.

• Root pain: occurs at the site of certain dermatome and ↑ by Coughing and straining. • Numbness. 1- Superficial sensation: 2- Deep sensation. 3- Cortical sensation. Sign > symptom

Pain Temp. Touch

8- Sphencteric disturbances: 1- Bladder: (common) : bilat . represented so not affected in hemplegia. (a) Desire. (A) (b) Control. (c) Voluntary act. (E) (d) Retention. (e) Hesitancy. 2- Rectum → as Bladder → very late affected 3- Erection and ejaculation.

Types of bladder disturbances

- Precipitency

= ∆

- Hesitancy =∆ • Not feel desire = afferent lesion = Sensory atomic Bladders as in TD • Not able to evacuate = Efferent lesion = motor atonic • Autonomic B L = No aff & eff • Automatic BL = No cortical control Hypothalamic 1. 2. 3. 4. 5.

Polyphagia or anorexia with rapid loss or gain of weight. Polyurea, polydepsia (D.I.). Sleep rhythm disturbance. Amenorrhoea. Heat regulation disturbance. Loss of libido Hypogonadal function Atrophy of gentalia. Loss of hair.

10- Gait: disturbance or not.

Symptoms of other systems.

Summary 1. Age of onset of the disease. 2. Family history. 3. Past history.

Onset.

4. Present history

Course.

Motor.

+ve data of

Sensory. Speech

1- Pyramidal lesion: 1. No atrophy. 2. Hypertonia. 3. Weakness or paralysis of

D>P distribution

Abd > Add

4. Superf. Reflexes: lost + extensor planter.

Ex > F in UL

5. Deep reflexes: hyper-reflexia.

Fl > Ex in LL

6. +ve path . reflexes 7. Presence of clonus 2- LMNL: 1. 2. 3. 4. 5.

Weak or paralysis. Atrophy. Hypotonia. Superf. Reflexes: Deep reflexes: Lost

Lost at level. Lost planter.

3- Cerebellar : • Nystagmus • Ataxia. • Kinetic tremors. • Speech disturbance. • Gait disturbance 4- Extra - ∆: involuntary movement at rest.

A- General exam: As usual by stress on: • Pellagric rash. • Skin manifestation of leprosy. • Bed sore. • Cong. Anomalies as

o Pes cavus o High arched palate.

• Heart in hemiplegia.

(B) Neurological examination : • Mental state. • Speech.

Sitting

• Cranial nerves. • Motor system. • Reflexes. • Coordination.

Supine

• Involuntary movement. • Sensory system. • Gait rombergism. • Rombergism.

Standing

1- Mental or intellectual function:  Percussion in paraplegia  Heart exam  Exam of :  Skull  Spine  Skel . deformities

 Trophic changes

Patient is: Fully conscious  Well oriented to place, time and person.  With average intelligence.  Intact memory (recent & remote )  Proper mood (no euophoria or depression).  Normal behaviour.  No hallucination = perception without stimulus.  No illusion = mis-interpretation of real stimulus

Visual Auditory

 No delusion = false fixed believes not subjected to logic.

Slurred = lesion. Stactto = cerebellar lesion.

2- Speech (A) Dysarthria

Scanning =  & cerebellar lesion. Slow monotonus = extra  (parkinsonism) Nasal tone = 9 & 10 paralysis. Hoarseness of voice = 10 perralysis.

(B) Aphasia Motor = lesion in Broca’s area. • Inability to express himself in sopken words. • Inability to formulate written words.

Sensory Visual aphasia = • Word blindness • Inability to understand written words. • Lesion in the supramarginal gyrus

Auditory aphasia = • Word dealness. • Inability to understand spoken words. • Lesion in the upper post. part of temporal lobe.

(C) Aphonia and dysphonia: → in 9th and 10th n.

paralysis → Palatal.

Paralysis → nasal tone. Bilateral vocal cord paralysis.

3- Cranial nerves: I- Olfactory: 1. Each nostril separate. 2. Familiar sub & Not irritant substances.

II- Optic:

3. Closure of eyes.

1. Visual acuity by counting fingers at one meter hand movement & perception of light. 2. Field of vision by confrontation method. 3. Colour of vision. 4. Fundus exam.

(III- Oculomotor, IV- Trochlear, V- Abducent). Ptosis. Inspect: Squint. * size. * Shape. * Centrality. * Equality *Reaction to light (Direct , Consensual) *Accommodation reaction.

 Pupil  Single movement on each eye.

• Voluntary. • Reflex. Reflex

 Conjugate movement  Accommodation and convergence.

 Nystagmus: • Positional or on fixation • • • •

Horizontal or vertical or rotatory. Pendular or has slow and rapid Movement. Direction of rapid phase. Amplitude on both sides

Types of Nystagmus? Vestibular, Cerebellar, Occular, Brain stem

V- Trigeminal n: Motor

Reflexes

1-Temporalis: 1- Corneal: 5-7 afferent in 5th + motor nu. Of 7th on both sides closure of both eyes. 2- Masseter Lesion of 5th Rt.: touch the Rt. cornea → lost corneal on both sides. 3- Pterygoid Touch the Lt. cornea →nor. Reflex on both sides. Lesion of 7th Rt.: touch the Rt. lost Rt. reflex but nor. Lt. Touch the Lt. corena →Lost Rt. reflex but nor. Lt. 2- Jaw reflex: 5-5 → Normally absent. It present bilateral ∆ lesion above the level of trigeminal nu.

Sensory 1- Compare the 3 divisions on both sides 2- Compare the 3 divisions on the same side related to each other. 3- Compare the sensations of the central part of the face with the peripheral one 4- Compare C2 (angle of jaw) with other areas.

NB Causes of exaggerated Jaw R.? (3)

M.N. disease. Bil. Hemiplegia above pons. D.S.

VII- Facial nerve: Motor

= Muscles of expression. 1- Frontalis. 2- Orbicularis oculi. 3- Buccinator. 4- Zygmotic & Retractor angylii. 5- Buccalis oris.

Sensory

Scretory

Taste of the ant. Efferent secretory 2/3 of the tongue. to: (Joins the facial n. - Sublingual. in the facral canal - Submental. of the temporal - Lacrimal. lobe.

Reflexes

1. Corneal R S &S 2. Glabellar R. (7=7)

Q: DD. between UMNL. and LMNL. of facial n.?

Exam of the facial n. 1- Inspection:

Wrinkles.

(A) Asymmetry of the face: Wasted nasolabial folds. (B) Deviated angle of the mouth towards nor. side. C) Dribbling of saliva. (D) Dropping of lower eyelids with tears flowing over it. (E) Fasciculations and invol. Movement. N.B: long-standing paralysis → Contracture → Deviation of Mouth towards the paralysed side.

2- Motor: ( 5 muscles ) 3- Taste: •Protrude the tongue. •Hold Rt. with gauje. •Apply substances to the lat. Sides:

1- Sweat. 2- Soure. 3- Salt. 4- Bitter.

VIII- Vestibulo-cochlear: 1- Audiatory: → Hearing 1- Whispering test: → Normal heard at one meter. 2- Tunning fork test: to diffe. Between C.D and N.D.

Normally 1- Air condition > bone conduction. 2- Middle ear disease or blockade of ext. meatus →↓ air condition but nor. bone condition. 3- In disease of cochlea and auditory n. both air condition and bone condition are equally impaired.

(a) Rinne’s test: The tunning fork is placed

1st near a ear. Then, on the mastoid process.

• Normally: air cond. Is stronger and last longer than B.C. • Deafness due to cochlear lesion → maintained normal level. • Deafness due to middle ear disease → reversed relation.

(b) Weber’s test: → Tunning tork is placed on the pt. forehead in the mid-line and compare sounds in 2 ears. • Normally: heard equally well on both sides. • Nerve deafness or cochlear →↑ sounds on normal side. • Middle ear disease →↑ sounds on the diseased side due to ↑ bone conduction.

(2) Vestibular: not routinely tested except in vertigo. 1. Positional nystagmus. 2. Caloric test. 3. Galvanic test = electric (+) of mastoid. IX-Glossopharyngeal: •

Motor: Pharynx.

•

Sensory: post. 1/3 of tongue, tonsils and pharynx.

•

Taste: post. 1/3 of tongue. Dysphagia.

• Paralysis:

Anaesthesia of pharynx. Lost taste on post. 1/3 of tongue.

X - Vagus nerve: palate. Motor:

Larynx. Pharynx. Palatal paralysis.

Paralysis:

Laryngeal paralysis. anaesthesia of the larynx on the affected side.

Viscero-sensory:

Pharynx. Larynx. G.I.T. Heart. Lung.

Paralysis

Vagus nerve * motor

Palale.

 Palatal Paralysis

Pharynx.

 Laryngeal paralysis

Larynx.

 anaesthesia of larynx On affected side.

Pharynx

* Viscero – sensory

Larynx. + heart & lung. G.I.T.

- Efferent:

Heart. Bronchi. G.I.T.

Dysphagia. - History:

Nasal regurge. Change of voice. Insp. Stridor on exertion.

- Exam: 1- Open the mouth and say ah.

Deviation of uvula. Limitation of movement.

2- Stim-palate patatal R , bitateral. 3- Stim. Post. Pharyngeal wall pharyngeal R. 4- Taste to the post. 1/3 of tongue + laryngeoscope for vocal cords.

N.B.: Palatal reflex: touch uvval (5)

more up (10).

Pharyngeal reflex: touch post . ph . wall (q)

gagging

(10) By use of 2 tonque depressors XI- Accessory nerve: 1- Sternomastoid: ask the patient to move his head to one side against the resistance. Push the chin downwards against resistance muscles should be palpated to feel contractions 2- Trapezius: ask the pt. to raise his shoulder against resistance.

pt. can not rotate his face to one side. N B Paralysis of both Weak evaluation of shoulders on one side. Upper angle of scapula rotates upward. XII- Hypoglossal: all the interensic ms. of the tongue on one side. 1. Inspect atrophy or fasiculations. 2. Ask pt. to protrude his tongue in the mid. line. And lock for

Inability to protrude it. Any deviation. Any invol. movement.

1. Ask the pt. to press his check with his tongue. 2. Tap the tongue if you suspect myotonia - Unilateral UMNL or LMNL → deviated tongue towards the side. LMNL → atrophyparalyzed or fasciculations. - Bilateral UMNL or LMNL → can not protrude his tongue. + spastic atrophy and fasciculations

Motor system Atrophy 1- State

UMNL → Little atrophy

LMNL→ Marked atrophy Hypertrophy: → Myopathy as Duchene’s myopathy

• Inspect all the muscles of the body and see thenar and hypothenar ms. • Tibia.

Normal 2- Tone Hypoyonia:

LMNL UMNL. In shock stage Cerebellar ataxia Chorea Ms. disease

Hypertonia: UL Hand shaking test(up&down) Elbow F1&ext Shalder circumduction LL Ankle shaking test (l at) Regidity Knee : flex & ext. Hip - Circumducyion - Rollong test

- Frog`s sign

Clasping Knife spasticity. of antigravity ms. + Suddenly give way. UL During extension and LL. with flextion= ∆ lesion. all through (lead pipes) = extra ∆ . or Cog wheel = lead pipe interrupted by tremors. = ext ∆. Hysterical rigidity: resistance gradually.

3- Power: → weakness or paralysis.

Comment: •

Is there is weakness.

•

Bilat. or unilat.

•

If bilat. → Symmetrical or asymmetrical.

•

Is weak more distal or proximal in LL dorsiflex or plantiflexian.

•

Is weak more flexor or extensor.

•

Is weak more abductor or adductor.

•

Is weak has special predilcation to certain gp. Of muscles.

•

Back & abd . ms .exam.

UL (2-2-2-4) Hand

hand grip. Opponence ms.

Wrist : Flex & ext. Elbow : Flex & ext.

Shoulders LL(2-2-4) Ankle Knee Hip

.Flex .Ext .Abd Add ( dorsi & plantiflexian ). ( flex & Ext ). ( F & Ext . from heed). ( F & Ex . from thogh). ( F & Ex . Ex in prone position) ( Abd & add)

Examples Case I -Weak in UL. & LL. - Bilat. - Symm. - Distal > prox. In UL. & LL. - Ext. > flex. in UL. Flex > Ext. in LL.

Case II - Weak in UL. & LL. - Bilat. - Symm. - Distal > prox. In UL. & LL. - Ext. > flex. In both UL. & LL.

Case III - Weak of UL. & LL. - Bilat. - Symm. - Prox. > distal in UL. & LL. - Flex. = Ext. in both UL. & LL.

- No sp. Predilicatn. Weak of ∆

- No sp. Predilicatn. Weak of pheripheral neuritis

- Sp. Predilicatn. Weak of Myopathy

Case IV - Weak of LL. - Bilat. Or unilat - Asymm. - Prox. & distal, - Flex & ext. variable from pt. to pt. and from limb to limb

Cauda equina Lesion

4-Fasciculations. 5- Invol . movements.

5- Reflexes: A- Superficial: 1. Abdominal: DZ-12. (a) Normally contraction of ms. (b) lesion

absent contraction.

(c) could detect level in per preplegia. (d) Umblical level = 10th . 2. Planter reflexes (S1): 3. Cremastric R.

Causes of extensor planter: (6). •

UMNL.

•

Infants (1st. y).

•

Under anesthesia.

•

Deep sleep.

• Deep coma. (B) Deep reflexes: (1) U.L.: • Biceps: C 5-6. •

Triceps: C 6-7.

•

Bracheo-radilalis: C 5-6.

•

Einger jerk C 8 – T 1

Normally absent

If present ∆ lesion Above c8. = Jerk flexion of fingers.

2-Hoffmann’s sign: Sudden flexion of the terminal phalanx of middle finger. Normally nothing. ∆ → Flex other fingers and adduction of the thumb. It ∆ lesion above c8. 3- Warten-berg: Pt. supine his hand and slightly flex his fingers while the examiner pronate his hand and flex both fingers against each other resistance. Normally → thumb is extended. → ∆ thumb is adducted and flexed strongly.

(2) LL

• Ankle R s 1,2 • Ankle R l2,3 (l 2,3,4)

(C) Path reflexes: 1- Finger Jerk. 2- Hoffman’s R. 3- Jaw R. 4- Corasping R. 5- Suckling R.

Pin ∆

6- Coordination:

UL

1. Finger nose test UL. 2. Finger finger test UL.

Eye opened. Eye closed.

3. Finger finger test. 4. Dysdiadokokinesia. 5. Redband test. 6. Buttoning & Unbuttoning.

LL

•Standing (suraying). •Walking along astraight line. •Heel knee test. •Hyporeflexia ( pendular knee jerk).

NB : • Sensory ataxia: = post. column lesion → pt. perform. • These tests correctly under vision. • The above tests carried on opening and closed eyes. 7- Involuntary movement: • Static or kinetic. • Distal or proximal. • Rhythmic or jerky. • Effect of voluntary movement. • Effect of emotions. • Effect of sleep.

8- Sensations: (a) Superficial:

Pain → pin prick. Temp.

Touch → cotton. *From below upwards to detect a level. *Compare 2 sides to detect hemianaesthesia. *Around a circumference of a limb to detect wether: Peripheral neuritis →↓ equality. Sensory loss →↓ along the affected radicle.

(b) Deep sensation: 1. 2. 3. 4.

sense of movement. up. Sense of position: Down. Muscle sense. Maleoli Vibration sense: Tibial tuberosities. ASIS.

UL Trunk

Radial tuberosity. Olecranon. Clavicle. Sternum. Olecranon

* Test for myotonia

Reflexes

Vol.myotonia → hand fist & shake hands Mechanical Tap thenar eminence→ adduct thumb & delayed abd. Tap tongue → dimple sign * Test for fatigability to exclude myasthenia - Look up for 1 min (ptosis) - Abduct shoulder at “ go ” for one min - Blow cheeks against resistance

Test for myopathy:  Gower sign ( climbing ) test = weak glut max & spine extensor  Wadding gait = weak glut. med. & mininws  Exag. lumber lordosis = weak back extensor  Pot belly abdomen = weak Abd . ms  Winging of scapula = weak serratus ant . & trapezius  Rhombolds ms : ask pat. to catch his hands post .  Latis . dorsi hold post axil . fold & ask pat . to cough while pt . clasp his hands behind back.  Clavicular head of pect . major ( not effected in myotonia & myop.) stretch arms & clasp hands .  Beevor`s sign .pt sit * shifted umb. up weak lower abd ms. (pelvic girdle) * detect level of lesion in paraplegia.

(c) Cortical sensation: 1- Tactical localization = localize the site of pin prick. 2-Tactilc discrimination = dilt . 2 pricks. 3-Stereogenosis. 4- Graphaesthesia. Spine

Exam Skull

Deformities Tenderness

Swelling defects

Skeletal deformities Bladder : percussion. Trophic changes :

Shape

Brut

Coldness. Bed sores and ulcers. Charcot joint.

Other systems. (9) Gait and (10) Rombergism :

Types of gait :

• Circumduction gait → unilateral U.M.N.L.

uni.

• Spastic ( scissor ) gait → bilateral U.M.N.L = cerbral palsy. bil • High steppage gait : due to root drop → P.N. esp. personal ms Dystrophy. P.N • Stamping gait → sensory ataxia. • Shuffling gait → parkinsonism Short steppage (mild), prepulsion & Retrepulsion. • Wadding gait → muscle dystrophy( pseudo – hypertrophic ) myopathy). • Drunken gait : → bilateral cerrebellar ( wide base ) as deviation (unilateral corebeller). Friedreiches. • Waking along astaight line

Zigzag (Marie`s) bilat.

• Dancing gait : chorea due to hypotonia + involuntary movements. ext 

Patterns of sensory loss :

1. Mononeural (e.g. ulnar N. lesion ) 2. Stoke & glove (P.N.) 3. Patchy loss (leprosy) 4. Radicular loss ( root lesion) 5. Level (tract lesion – paraplegia ) 6. Jacket with sleeve (intramedullary lesion) 7. Hemianaesthesia (hemiplegia) 8. Crossed hemianaesthesia (PICA occlusion) 9. Brown – sequard syndrome 10. Saddle loss (cauda & conus) 11. Dissociated loss (syringomylia) 12. Deep sensory loss (SCD) 13. Thalamic los (thalamic syndrome) 14. Cortical sensory los (post central gyrus loss) 15. Face : loss of inner sensation in Tables dorsalis – loss of outer sensation in syringobulbia.

Causes of dissociated sensory loss “loss of pain & temp. with preserved touch” : 1. Syringomylia & syringobulbia. 2. Brown sequard syndrome. 3. Intramedullary tumours. 4. Cerebellar artery occlusion syndrome.

Causes of tender calf muscles : 1. Diabetic neuropathy. 2. Landry-Guillian-Barre syndrome. 3. Neutritional neuropathy. 4. Others : DVT & myositis.

Examination of sensory system Superficial sensation : - Pain using pin prick - Touch using a piece of cotton - Temp using hot & cold test tubes. a. Compare both sides of body (leg to lef, arm to arm) to detect hemihypothesia in hemiplegia. b. Descending search to detect level (in focal paraplegia) jacket sensory loss (intramedullary lesion), stock & glove hyposthesia (in P. Neuropathy). c. Compare different dermatomes (for radicular sensory loss), test sensation all around limb.

Sensory Supply of Body : C2

Angle of jaw, lateral aspect of the neck

C3,4

Shoulder, down to manubrium

C5

Lateral aspect of arm

C6

Lateral aspect of forearm, thenar eminence & thumb

C7

Middle aspect of forearm, middle of palm, middle 3 fingers

C8

Medial aspect of forearm, hypothenar & little finger

T1

Medial aspect of arm

T2-T7

Thorax (T5 : nipple)

T8-T12

Abdomen (T10:umbilicus – T12:inguinal ligament)

L1

Upper 1/3 front of the thigh

L2

Middle 1/3 front of the thigh

L3

Lower 1/3 front of the thigh

L4

Anterolateral aspect of thigh, front of knee, med.aspect of leg, foot & toe.

L5

Lat. Aspect of the thigh, lat. Aspect of leg , middle 1/3 of dorsum of the foot & middle 3 toes.

S1

Posterolateral aspect of the thigh & leg, lateral 1/3 of dorsum of the foot & little toe.

S2

Posterior aspect of thigh, leg & sole of foot.

S3,4,5

Anal, perianal,& gluteal region (saddle area) in concentric manner.

Examination of coordination Cerebellar ataxia : tests are +ve with opened eyes & ↑ with eye closure. Sensory ataxia tests are +ve only with eye closure. 1. Eye : nystagmus 2. Tongue : staccato speech 3. Neck : nodding 4. Trunk : titubation 5. Limb : intention “kinetic tremors”

In UL : • • • • • •

Finger – to nose test : tip of finger from a distance  nose Finger – to finger test : each tip of hid forefinger travel to meet each other in midline. Finger – to doctor’s finger test. Dysdiadokokinesia : inability to perform rapid alternating movement e.g. pronation & supination. Rebound phenomenon : with sudden release of flexed elbow, the forearmmay hit patient face . Buttoning and unbuttoning test : earlies sign.

In LL :

a) Standing : Swaying (trunkal ataxia). b) Walking along straight line (Gait). c) Heel-to knee test : patient raises his leg, brigs down its heel onto his other leg slides it down along shaft of tibia. d) Hypotonia & hyporeflexia : pendulous knee jerk.