clinical examination nervous system
DESCRIPTION
Part 1TRANSCRIPT
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Clinical examination of the Nervous System
DrPuneet Kaur
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Schemata
Examination OfHigher FunctionsCranial nervesMotor system(incl reflexes)Sensory systemAutonomic nervous system
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Examination of Higher Functions
Mental stateMemory Speech
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Two cerebral Hemisphere:1.Dominant or Cerebral Hemisphere-categorization and symbolization2.Representational Hemisphere-spatiotemporal relations
Hemisphere specialisation related to handedness
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Mental state
Appearance and BehaviorEmotional stateDelusions and HallucinationOrientation in Place and TimeLevel Of ConsciousnessIntelligence
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Appearance and Behaviour
DressPersonal HygieneGeneral GroomingFacial ticsVerbal or physical aggression
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Emotional state
Mood : facial expression (reflective of depression, mania, anxiety, schizophrenia)
Sleep and dreams : insomnia , sleep disturbing dreams
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Delusions and Hallucinations
Delusion : false and unshakeable beliefs which continue to be held despite evidence to contrary.Hallucination : False impressions referring to organs of special sense(hearing , smell , vision etc) for which no cause can be found.
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Orientation In Place and Time
Disorientation : Organic Brain DiseaseSchizophrenicsHysterical states
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Level of Consciousness
Stupor-Patient shows some response, example to painful stimuli
Coma-makes no psychologically meaningful response to external stimulus or to internal need
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Intelligence
Approximate from occupation and educational qualifications
Formal testing: calculating ability , serial subtraction, copying a complex figure etc
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Memory
Recent or short term memoryRemote or long term memory
Retrograde amnesia for events immediately before brain concussion
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Language or Speech
Aphasias
Dysarthria
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Aphasia
Sensory or Fluent aphasiaLesion in Wernicke area-area 22,sensory speech centre(Posterior end of the superior temporal gyrus in the dominant hemisphere)Symptoms:-speech not disturbed but the person talks excessively that makes little sense-Pure word blindness or anomic aphasia
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Motor or non fluent aphasiaLesion in the Broca’s area-area 44,motor speech centre(inferior frontal gyrus of dominant hemisphere)Symptoms:-Loss of articulate speech or inability to write or both-person is dumb and speech is slow-words are hard to come by limited to 2-3 words
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Global aphasia:result of loss of both Wernicke’s and Broca’s area
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Dysarthria
There is difficulty in spoken speech.
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Cranial Nerves
12 pairs of cranial nervesSome are afferent(sensory)Some are efferent(motor)Some are mixed nerves
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First nerve : Olfactory nerve
Origin : From the olfactory epithelium
Function: Pure sensory nerve concerned with olfaction (smell)
Paralysis:-AnosmiaTest:-Clove oil presented to each nostril separately
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Anosmia : complete absence of smell
Parosmia : is alteration in the character of smell
Hypoosmia :reduction in the sense of smell
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Second Nerve : Optic Nerve
Origin :From the Retina
Function: Pure sensory nerve-transmission of visual sensations to brain
Test-Visual acuity -Field of vision -Color vision -Examination of fundus(Opthalmoscopy)
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Visual acuity
Near vision: Jaeger’s chartDistant vision: Snellen’s chart
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Factors affecting visual acuity
Optical: state of image forming mechanism of eye
Retinal factors: acuity maximal at the fovea centralis
Stimulus factors : size of object and distance from eye,color of object
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Field of vision
Confrontation testsPerimetryRed pin test
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Color vision
Yarn (spun thread) matching test or Holmgreins skeins of colored wool test
Ishihara chartsEdridge green lantern
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Third(Oculomotor)Fourth(trochlear)Sixth(Abducent)nerves
Origin: from a series of nuclei which begins in the floor of the sylvian aqueduct extending upto the fourth ventricle
Function: Mixed nerves-innervate the eye muscles and bring sensation from proprioceptors in eye muscles
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Test1.Look for ptosis ,squint,nystagmus2.Test for ocular movement3.Examination of Pupil
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Fifth nerve: Trigeminal nerve
Origin : From the lateral surface of Pons at about its middle
Function: It is a mixed nerve with sensory, motor and secreto-motor components
3divisions-Opthalmic -Maxillary - Mandibular
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Effect of Paralysis of 5th nerve
Opthalmic division-loss of cut. sensation
-loss of corneal reflex Maxillary division-loss of palatal
reflex -loss of cut.sensation Mandibular division-loss of sensation -weakness of muscles of mastication
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Test for sensory function
Touch, pain,pressure,temperature over the face
Corneal reflex-Touch the cornea with a wisp of cotton-subject blinks
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Test for motor function : Muscles of mastication
Clench teeth-masseter and temporalis stand out with equal prominence on each side
Open mouth : jaw will deviate to paralysed side-pushed by healthy external pterygoid
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Seventh Nerve-Facial
Origin: From the Pons , lateral to that of the sixth nerve nucleus
Function:Mixed nerveMotor fibre-all the muscle of face and scalp except levator palpebrae superiorisStylohyoidBuccinatorStapedius muscle
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Sensory fibres-taste sensation from ant. 2/3 of tongueSecreto-motor fibres-supplies lacrimal gland , sublingual and submandibular salivary gland(all salivary gland except the parotid gland)
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Effect of paralysis of 7th nerve
Loss of facial expression Furrows over forehead smoothen out Hyperacusis Loss of taste-ant 2/3 of tongue Xeropthalmia,decreased salivation
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Tests for 7th nerve
Smile or show upper teeth Close his eyes against resistance Whistle Inflation of cheeks Loudness of sound Taste :ant 2/3 Schirmer’s test for lacrimation
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8th nerve: Auditory or vestibulocochlear
Origin : From the groove in between the junction of Pons and Medulla.
Function:Pure sensory nerve supplying the
Vestibular and cochlear portion of ear
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Effect of Paralysis of 8th nerve
VertigoNystagmusLossof hearing
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Tests for vestibular function
Romberg’s signStand with feet together and close his eyesBarany’s caloric testWater at 7 degree celsius above and below normal body temperature
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Cochlear function : Hearing tests
Watch test Tuning fork test : Rinne’s , Weber’s , Schwabach Audiometry
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9th nerve:Glossopharyngeal Origin:5-6 rootlets to upper part of
medulla oblongata Function : Mixed nerveMotor fibres supply stylopharyngeus msSensory fibre to posterior 1/3 portion of tongueAnd mucus membrane of pharynxSecretomotor fibres supply the parotid gland
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9th nerve paralysis
Loss of taste from post. 1/3 of tongue
Decreased salivary secretion
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Test of 9th nerve
Taste sensation in Post. 1/3 of tongue
Palatal reflex
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10th nerve: Vagus
Origin:Attached by 8-10 rootlets to the lateral aspect of medulla oblongata below the origin of 9th nerve
Function: mixed nerveMotor to involuntary ms of respiration,heart and part of GIT & voluntary ms of pharynx, larynx and soft palateSensory to GIT upto right 2/3 of colon &mucus memb. of pharynx, larynx and soft palate.
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Paralysis of 10th nerve
Regurgitation of fluids through nose
Nasal tone in voiceHoarse and deep voice
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Test for 10th nerve
Soft palate movement Laryngoscopy
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11th nerve:accessory
Origin :Cranial part and spinal part
Function: Pure motor nerveSupplies Sternocleidomastoid and Trapezius
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Test Of 11th nerve
Move the headShrug shoulder
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12th nerve: Hypoglossal
Origin: From lowermost part of medulla oblongata
Function :Pure motor nerveSupplies all Ms of tongue.
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Paralysis of 12th nerve
Defective articulation Deviation of tongue
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Test of 12th nerve
Tongue protrusion-deviation