neurological 1

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

Neurologic System

Chapter 23

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

Structure and Function

Subjective Data—Health History Questions

Objective Data—The Physical Exam

Abnormal Findings

Chapter 23

Neurologic System

Slide 23-1

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

Structure and Function

Central Nervous System (CNS)

Cerebral cortex– Frontal lobe– Parietal lobe– Occipital lobe– Wernicke’s area– Broca’s area

Basal ganglia

Thalamus

Hypothalamus

Cerebellum

Brainstem– Midbrain– Pons– Medulla

Spinal cord

Chapter 23

Neurologic System

Slide 23-2

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.

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

Chapter 23

Neurologic System

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.

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

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.

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

Subjective Data—Health History Questions

Headache

Head injury

Dizziness/vertigo

Seizures

Tremors

Weakness

Incoordination

Numbness or tingling

Difficulty swallowing

Difficulty speaking

Significant past history

Environmental/occupational hazards

Chapter 23

Neurologic System

Slide 23-5

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

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

Slide 23-6

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

Objective Data—The Physical Exam, cont.

Test Cranial Nerves I—Olfactory

II—Optic

III—Oculomotor, IV—Trochlear, VI—Abducens

V—Trigeminal

– Motor function

– Sensory function

– Corneal reflex

VII—Facial

– Motor function

– Sensory function

VIII—Acoustic (vestibulocochlear)

IX—Glossopharyngeal, X—Vagus

– Motor function

– Sensory function

XI—Spinal accessory

XII—HypoglossalSlide 23-7

Chapter 23

Neurologic System

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

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

Chapter 23

Neurologic System

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

Objective Data—The Physical Exam, cont.

Sensory System

Person is alert, cooperative, and comfortable

Guidelines for sensory testing

Spinothalamic tract– Pain

– Temperature

– Light touch

Posterior column tract– Vibration

– Position (kinesthesia)

– Tactile discrimination (fine touch)

• Stereognosis• Graphesthesia• Two-point discrimination• Extinction• Point location

Slide 23-9

Chapter 23

Neurologic System

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

•StereognosisGraphesthesia

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

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”)

• Clonus

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

Slide 23-10

Chapter 23

Neurologic System

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

–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)

Slide 23-11

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

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.

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 bodyParaplegia• 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• partial motor paralysis

Abnormal FindingsAbnormalities in Muscle Movement

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

FasciculationsRapid, continuous twitching of resting muscle

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

TicRepetitive twiching of a muscle group

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

MyoclonusRapid, sudden jerk at a fairly regular intervals

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

TremorInvoluntary 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.

ChoreaSudden, 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 FindingsAbnormal Gaits

Spastic hemiparesis

Cerebellar ataxia

Parkinsonian (festinating)

Scissors

Steppage or footdrop

Waddling

Short leg

Slide 23-13

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

Chapter 23

Neurologic System

Abnormal FindingsCommon Patternsof Sensory Loss

Peripheral neuropathy

Individual nerves or roots

Spinal cord hemisection (Brown-Séquard syndrome)

Complete transection of spinal cord

Thalamus

Cortex

Slide 23-14

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

Chapter 23

Neurologic System

Abnormal FindingsAbnormal Postures

Decorticate rigidity

Decerebrate rigidity

Flaccid quadriplegia

Opisthotonos

Slide 23-15