ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF NEUROLOGICAL EXAMINATION

SCREENING TEST: Visual Acuity , Test Eye Fields , Fundoscopy, Pupils, Eye

movements,Facial Sensation ,Facial movements, Mouth: Open your mouth & Tongue ,

Arms and Legs: Motor, Arms and Legs: Reflexes, Coordination (Cerebellar), Arms and

Legs : Sensory , GAIT

MENTAL STATUS EXAMINATION: orientation,personal information,fund of knowledge,general data,calculation,problem solving,name of objects shown,response to request

EXAMPLES:digit span,reading,writing,drawing,gnostic functions (recognition of objects),practice functions,insight and judgment,proverbs,rote – repetetion forward and backward

CRANIAL NERVE EXAMINATION:

TESTING FOR OLFACTORY NERVE:

Each nostril tested separately Can the patient smell coffee or soap with each nostril Do not use noxious odors, since they may stimulate pain fibers from cn v(ammonia) Normal, anosmia,dysnomia

VISUAL ACUITY: Test one eye at a time ,record smallest size read Acuity testing by:snellen’s chart,near vision chart, bedside material if unable to read largest letters - count fingers,see hand movements,percieve light Corrected by pinhole : Error of Refraction NOT correctable: ophthalmologic problems: cataract, corneal lesion,retinal hemorrhage/

infarct , macular degeneration Optic neuropathy: inflammatory, ischemic, compressive Bilateral occipital lesions: cortical blindness

GROSS SCREENING FOR MAJOR FIELD DEFECT:

Ask patient to look with both eyes at your eyes Index finger : ask which index finger you move: ( right, left or both ) Test for visual inattention

TESTING FOR VISUAL FIELDS:

Monocular field defects - Anterior to optic chiasm Bitemporal field defects - Optic Chiasm Homonomous field defects - Behind Optic Chiasm Congruous homonomous - Behind Lateral Geniculate Bodies

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF

field defects EVALUATION OF PUPIL:

Check for direct light reflex,Check for consensual light reflex Equal, large, small (size in mm) pupils +/ - Reaction to light +/- Accomodation

TEST FOR EYE MOVEMENTS (CN 3,4,6):

Look at position of head

Look at eyes (ptosis, position of primary gaze)

Test eye movements in pursuit

Test saccadic movements

Ptosis + eom abnormalities + unequal pupil - CRANIAL NERVE III Paralysis

DOUBLE VISION RULES:

Double vision is maximal in the direction of gaze of the affected muscle False image is the outer image False image arises in the affected eye Eye muscle paresis but no diplopia : supranuclear or internuclear lesion

SUGGESTS BRAINSTEM LESION: diplopia,dysarthria,dysphagia,deafness, dizziness.decrease facial sensation,decease facial movement, Hemiparesis,Hyperactive reflexes, Spasticity,Babinski

CRANIAL NERVES V AND VII: THE FACE:

EVALUATION OF TRIGEMINAL NERVE: SENSORY:

Test corneal reflex Test light touch and pinprick in each division on both sides Compare one side to the other; if abnormal, test

temperature If sensory deficit is found, determine its edges Ophthalmic / maxillary / mandibular

MOTOR: Test for muscles of mastication Look at side of the face is there sign of the temporalis

muscle atrophy ? ask the patient to clench his teeth feel the masseter & temporalis muscles

Ask the patient to push his mouth open against your hand Resist his jaw opening with your hand under his chin note

if the jaw deviates to one side EVALUATION OF FACIAL NERVE: Look at symmetry of the face

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF

Ask the patient to: Show you his teeth /gums Smile Close your eyes tightly as if you had soap in them Look up the at the ceiling

VIIITH CN: AUDITORY NERVE:

Screen hearing:

Face the patient and hold your arms with your fingers near each ear

Rub your fingers together on one side while moving the finger noiselessly on the other

Increase intensity as needed and note any assymetry If abnormal, proceed with the weber and rinne’s tests.

CRANIAL NERVES IX-X-XII CN: THE MOUTH:

Listen to the patient’s voice: is it hoarse or nasal? Look at tongue; put out tongue ask patient to swallow watch for smooth co-ordination of

action Ask patient to say “ aaah” look at uvula / watch the movements of soft palate and the

phyarynx Test gag reflex stimulate back of the throat on each side

MOTOR EXAM :

MOTOR SYSTEM TESTING:

Look at the position of patient overall Look for wasting Look for fasciculation Test for tone Test muscle groups in a systematic way for power Test reflexes

GRADING OF MOTOR PARALYSIS:

0/5 : Does not move at all 1/5 : Moves a little (flickers) 2/5 : Moves when gravity is eliminated 3/5 : Moves against gravity 4/5 : Moves against resistance but weak 5/5 : Normal

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSFSCREENING FOR MOTOR SYSTEM

Pronator test : Ask patient to hold his arms out in front palms facing upwardw and to close eyes

One arm pronates and drifts downwards: weakness Both arms drift downwards: bilateral weakness Arm rises: suggest cerebellar disease Fingers continuously move up and down:deficit of point position sense

CHARACTERISTICS OF MUSCLE DISEASES:

Proximal weakness >> distal weakness,usually symmetrical Intact cns No sensory deficit Reflexes usually normal, occ. depressed No babinski Absent fasciculation

CHARACTERISTICS OF NEUROPATHY:

Distal weakness >> proximal weakness Hypo to areflexia Atrophy Fasciculation +/- Sensory abnormality No babinski

REFLEXES:

TENDON REFLEX GRADING SYSTEM:  masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e. Babinski sign). Globally, brisk reflexes suggest an abnormality of theUMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate. A reflex hammer is used for this testing

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF

SENSORY EXAM: Light touch,Pain.Temperature.Vibration.Position sense.Graphesthesia.Stereognosis, and.Two-point discrimination (for discriminative sense).Extinction.Romberg test - 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. epicritic sensation

Explain each test before you do it Patient’s eyes should be closed Pompare symmetrical areas Compare distal and proximal When you detect an area of sensory loss,map out its boundaries

CEREBELLAR EXAMINATION:

TESTING FOR CO-ORDINATION:

Arms: Finger to nose test alternate pronation- supination test

Legs : Heel to shin test Trunk : Ask pt. to sit up from lying

w/o using hands

Arms oscillates before coming to rest Pt develop tremors as finger approaches target Disorganization of movement of hands and heels Truncal ataxia

GRADE REFLEX

ZERO ABSENT

1 HYPOACTIVE

2 “ NORMAL”

3 HYPERACTIVE W/O CLONUS

4 UNSUSTAINED CLONUS

5 SUSTAINED CLONUS

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSFUNILATERAL INCO-ORDINATION: Ipsilateral cerebellar syndrome,vascular disease, demyelination, mass lesions

BILATERAL INCO-ORDINATION: Bilateral cerebellar syndrome,drugs, alcohol, demyelination, vascular disease,rare: hereditary degeneration, paraneoplastic

TRUNCAL AND GAIT ATAXIA, W/O LIMB INCO-ORDINATION: Midline cerebellar syndrome,lesion of cerebellar vermis

EVALUATION OF GAIT:

ASK PATIENT TO WALK : IS GAIT SYMMETRICAL?

IF GAIT SYMMETRICAL:Look at size of paces, look at posture and arm swing

IF NORMAL PACES:

Look at lateral distance between feet Look at knees Look at pelvis and shoulders

O Look at whole movement

IF GAIT ASSYMETRICAL:

Is the patient in pain? Look for a bony deformity Look at knee heights

FURTHER TESTS:

Ask patient to walk as if on a tight rope Ask the patient to walk on his heels Ask the patient to walk on his toes

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF

ALAMURI KHADHAR BASHA ASSIGNMENTSURGERY DEPT - DMSF