-
Regulates internal environment
Autonomic ns (symp/parasymp)
-
Motor/sensory nerves, ganglia outside CNS
Peripheral ns
-
Components of neuro exam
- Mental Status;
- CNs;
- Sensory Fn;
- Cerebellar Fn;
- Motor fn;
- DTRs
-
Mental Status exam is performed during what part of exam?
Throughout the entire patient interaction
-
Mediates higher mental functions, perception, & behavior
Cerebral cortex
-
Assoc w/speech, emotions, memory
Frontal
-
Processes sensory data
Parietal
-
Hearing, speech, long term memory, language, behavior, emotion & personality
Temporal
-
Mediates survival behavior, affect
Limbic
-
Appearance & Behavior: components
- Grooming,
- Emotional status,
- Body language
-
Body language:
- Posture,
- eye contact,
- nervousness,
- psychomotor agitation,
- immobility
-
Lev els of consciousness
- Alert;
- Lethargy;
- Obtunded;
- Stupor;
- Coma
-
Awake, responds fully and appropriately
Alert
-
Drowsy, respond to questions
Lethargy
-
Slow response and somewhat confused
Obtunded
-
Slow responses, arousable for short periods with painful stimuli
Stupor
-
-
Pt should be oriented to:
Person, place, time, & situation
-
Time disorientation
Anxiety, depression, dementia
-
Place disorientation
Psychiatric disorders, delirium
-
Person disorientation
Cerebral trauma, seizures
-
Registration
Repeat a sentence or three unrelated items
-
Recall
Show the patient 3 items, have him recall them later
-
Short-term Memory
Ask about events within the past few hours or days (weather that morning, etc.)
-
Long-term Memory
Ask mother’s maiden name, high school attended, significant historical events
-
Impaired memory
Delirium, dementia, anxiety, depression
-
Loss of immediate and recent memory with retention of remote =
Dementia
-
Ability to focus or concentrate over time:
Attention span
-
Ask pt to repeat series of numbers, serial 7s, spell WORLD backwards: tests =
Attention span
-
Ask pt to follow series of short commands or repeat short story: tests =
Attention span
-
Decreased attention span may be related to:
Fatigue, anxiety, dementia
-
“What would you do if you found a stamped envelope?” – tests:
Judgment/insight
-
Mood =
Sustained internal emotion
-
Affect =
Observable feeling/tone, more episodic*
-
Mood & Affect: Ask pt =
How they feel right now (depressed? Signs of mania?)
-
Thought process/content: Ask pt =
How and what they are thinking
-
Perceptions: assessment includes =
Hallucinations, illusions
-
-
Dysphonia:
Impairment in volume, quality, pitch of voice
-
CN II: tests
Acuity, fields, funduscopic
-
CN III tests
pupillary response (direct and consensual); Inspect eyelids for drooping; EOMs
-
CN IV (Trochlear) test
EOM: Inferio-medial
-
CN VI (Abducens) test
EOM: Lateral deviation
-
Tests for Primary Sensory Functions
Light touch; superficial pain; temp
-
Sensory fn test of shoulders = tests:
C5
-
Sensory fn test of thumb = tests:
C6
-
Sensory fn test of middle finger = tests:
C7
-
Sensory fn test of pinky = tests:
C8
-
Sensory fn test of inner forearms = tests:
T1
-
Sensory fn test of lateral thigh = tests:
L3
-
Sensory fn test of medial ankle = tests:
L4
-
Sensory fn test of 1st inter-digital space = tests:
L5
-
Sensory fn test of Little toe/Lateral ankle = tests:
S1
-
Where test vibration sense
Toe, ankle, knee, Finger, wrist, elbow, shoulder
-
Stereognosis
Ability to identify common object; Tactile agnosia suggests parietal lobe lesion
-
Graphesthesia
Identify drawn figure
-
Two-point discrimination
Use one or two points (2-8 mm is normal in fingertips)
-
Decorticate rigidity
Rigid flexion; Corticospinal tract above brainstem
-
Decerebrate rigidity
Rigid extension; Brainstem
-
Aphasia
Disorder in producing or understanding language
-
-
-
Anesthesia
Total or partial loss of sensation
-
Hyperesthesia
Increase in sensitivity to sensory stimuli
-
Nystagmus:
- Rhythmic oscillation of eyes;
- Cerebellar disease,
- drug toxicity
-
Resting tremor
Pronounced at rest; Parkinsonism
-
Intention tremor
Appears with activity; Multiple Sclerosis
-
Postural tremor
Appears when maintaining a posture; hyperthyroid, fatigue, benign essential
-
Bell’s Palsy
- Peripheral paralysis of facial nerve;
- Central lesion will only affect lower face
-
5.07 Monofilament tests for:
Test for protective sensation
-
The motor cortex is located in:
The precentral gyrus of the frontal lobe
-
Corticospinal tracts AKA:
Pyramidal tracts
-
Corticospinal tracts originate in the
Motor cortex
-
3 “motor pathways” :
Corticospinal tracts, basal ganglia and the cerebellum
-
Aids motor cortex in integration of voluntary movement
Cerebellum
-
Coordinates control of muscle tone, posture and equilibrium
Cerebellum
-
Cerebellar functions: at ____ level
Unconscious
-
Responsible for fine movement of the hands
Cerebellum
-
Upper motor neurons (UMN): Originate & terminate:
Within CNS
-
UMN are neurons of the:
Corticospinal tracts and the basal ganglia
-
UMN can influence or modify the:
Lower motor neurons
-
Examples of UMN disease:
CVA, multiple sclerosis & cerebral palsy
-
The “final common pathway:
LMN
-
Examples of lower motor neuron disease
Spinal cord lesions
-
“Lower” or primitive pathway =
Basal Ganglia System:
-
Basal Ganglia System AKA
Extrapyramidal system
-
Extinction phenomenon
Touch pt at 2 diff areas of body; they s/b able to exactly locate both
-
Point localization
Touch a point, ask pt to open eyes & indicate location touched
-
5.07 Monofilament: pos test may indicate:
Peripheral neuropathy, Diabetes mellitus
-
LMNs located in:
Peripheral nervous system (cranial nerves & spinal nerves)
-
Spinal nerves: how many pairs?
31
-
Sensory afferent fibers of dorsal root carry impulses:
From sensory receptors to the spinal cord
-
Sensory/motor fibers supply/receive information in:
Dermatomes
-
Motor exam:
- Mx tone/bulk;
- Mx strength;
- DTRs;
- Cerebellar fn
-
Cerebellar function:
- Gait/balance;
- Coordination;
- Romberg
-
Coordination tests:
- Rapid alternating movements;
- point-to-point testing
-
Mx inspection: hands
Thenar/hypothenar eminences
-
Mx inspection: Palpation:
Mx tone; Mx strength
-
The normal, mild resistance of a relaxed muscle to a passive stretch
Tone
-
Increased tone =
Spasticity
-
Spasticity causes:
Awkward, rigid movements;
-
Rigidity that persists throughout the range is called:
Lead-pipe rigidity
-
Decreased Mx tone =
Flaccidity
-
Mx inspection: Palpation: Muscle strength:
Compare symmetrically
-
Mx strength scale =
Graded on a 0-5 scale
-
Mx strength scale: 0 =
No voluntary contraction
-
Mx strength scale: 5 =
Full muscle strength against resistance
-
Weakness may result from:
Pain, fatigue or disuse
-
Strength testing is often combined with:
ROM
-
Mx strength scale: a grade of 3 or less =
Consistent with disability
-
Babinski response indicates:
dz of pyramidal tract in adults
-
-
-
DTRs: Brachioradialis:
C5, 6
-
-
-
Grading DTRs: 0 =
No response
-
Grading DTRs: 1+ =
Sluggish
-
Grading DTRs: 2+ =
Expected response
-
Grading DTRs: 3+ =
Brisk, slightly hyperactive
-
Grading DTRs: 4+ =
Hyperactive; clonus may be present
-
DTRs can be recorded:
In chart-style or by using a stick-man figure
-
Biceps Reflex: expected response
Visible or palpable flexion of the elbow
-
Triceps Reflex: Response:
Visible or palpable extension of the elbow
-
Brachioradial Reflex: Response:
Elbow flexion with supination of the hand.
-
DTRs include tests of:
Biceps, triceps, brachioradial, patellar, ankle
-
Patellar Reflex: Response:
Extension of the lower leg
-
Ankle Reflex: Response:
Plantar flexion of the foot
-
Plantar Reflex is a _____ reflex
Superficial
-
Plantar Reflex: Response:
Plantar flexion of the toes
-
Cerebellar Function tests:
Coordination/Fine Motor Skills
-
Rapid alternating movements (RAM):
Evaluate rhythm/flow/speed
-
Point-to-point testing:
- Finger to nose;
- Heel to shin
-
Test of balance:
- Romberg test;
- Observe normal gait;
- Tandem gait
-
Gait Patterns: Spastic hemiparesis =
Stroke
-
Gait Patterns: Spastic diplegia =
Scissoring
-
Gait Patterns: Steppage =
Foot drop
-
Gait Patterns: Waddling =
Weak hip abductors
-
Gait Patterns: Cerebellar ataxia =
Wide based gait
-
Gait Patterns: Sensory ataxia =
Loss of position sense
-
Gait Patterns: Parkinsonian =
Shuffling
-
Gait Patterns: Antalgic limp =
Painful extremity
-
Plegia:
Absence of strength (paralysis)
-
Hemiplegia:
Paralysis of one half of the body
-
Paraplegia:
Paralysis of the legs
-
Paresis:
Impaired strength (weakness)
-
Hemiparesis:
Weakness of one half of the body
-
Epicondyles:
For tenderness associated with fx
-
Patella:
For pain, fx, stability
-
Patella tendon:
Tendonitis
-
-
Joint line:
Meniscus tears, ACL tears
-
Med/Lat collaterals:
Ligament strains
-
-
Medial tibial plateau:
Pes anserine bursitis
-
Posterior joint space:
PCL, Bakers cyst
-
What are the 7 primary components of Past Medical History?
- Childhood illnesses,
- adult illnesses,
- psychiatric illnesses,
- hospitalizations,
- medications,
- allergies,
- health maintenance
-
What are the 7 primary components of the HPI?
- Location,
- quality,
- quantity (severity),
- timing,
- setting,
- alleviating/aggravating factors,
- associated symptoms
-
What are the major childhood illnesses that should be inquired of in the PMH?
- Measles,
- mumps,
- rubella,
- scarlet fever,
- rheumatic fever,
- polio
-
What are the major allergies which should be inquired about in the PMH?
- Food allergies,
- animals or insects,
- latex
-
What 3 questions should be involved in the skin review of systems?
Any rash, itching, or color changes
-
What 20 components should be evaluated in the review of systems?
- Skin,
- head,
- eyes,
- ears,
- nose,
- mouth,
- throat,
- neck,
- breast,
- respiratory,
- cardiac,
- gastrointestinal,
- urinary,
- reproductive,
- peripheral vascular,
- musculoskeletal,
- neurologic,
- hematologic,
- endocrine,
- psychiatric
-
What should be inquired about during the eye portion of the ROS?
- Double or blurry vision,
- color changes
-
What should be inquired about during the breast portion of the ROS?
- Lumps,
- pain or discomfort,
- discharge,
- regularity of self examination
-
What should be inquired about during the genital review of systems (male)?
- Discharge,
- sores,
- testicular pain or masses,
- STD's
- sexual preference
- Note: pain on urination can be asked here but is commonly asked during urinary portion of ROS
-
What should be inquired about during the genital review of systems (female)?
- Age at menarche,
- regularity/frequency/duration of periods,
- last menstrual period,
- age at menopause (if applies),
- menopausal symptoms,
- discharge,
- itching,
- sores,
- STD's
- sexual preference,
- number of pregnancies,
- deliveries,
- abortions,
- birth control.
-
What should be inquired about during the hematologic review of symptoms?
- Easy bruising or bleeding,
- past transfusions and any reactions to them
-
What should be inquired about during the endocrine ROS?
- heat or cold intolerance,
- excessive sweating,
- diabetes,
- excessive thirst or hunger
-
What should be inquired about during the psychiatric ROS?
- Nervousness,
- stress,
- depression,
- memory problems
-
What questions should be asked in succession to detect a drinking problem?
- Start with, "How much alcohol do you drink?",
- follow with "Have you ever had a drinking problem?" and "When was your last drink?";
- if affirmative to first and within 24 hrs to second follow with CAGE
- Cut Down, Annoyed by criticism, Guilt, Eye-opener
-
What should be inquired about during the neurologic ROS?
- Weakness,
- paralysis,
- numbness or loss of sensation,
- tingling,
- tremors or other involuntary movements
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