examination final

8/18/2019 Examination Final

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Dr.SHAWQI AHMAD MUHAISEN


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MOTOR SYSTEM:

GENERAL

There are five pattern of muscular

weaness

1. Upper motor neurone (UMN) !

increase" tone# increase" refle$es#

p%rami"al pattern of weaness &wea

e$tensors in the arm# wea fle$ors in

the le'.2. Lower motor neuronr (LMN) (

wastin' fasciculation# "ecrease" tone

an" a)sent refle$es.

3. Musce !"se#se ( wastin'# "ecrease"

tone# impaire" or a)sent refle$es.

$. Neurmuscu#r %unct"on ( fati'ua)le

weaness# normal or "ecrease" tone#

normal refle$es.

&. 'unct"on# we#ness ( normal tone#

normal refle$es without wastin' with

erratic power.


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*AT TO +O

Loo #t t,e pos"t"on o- t,e p#t"ent oer#

*oo especiall% for a hemiple'ic positionin'# fle$ion of el)ow an"

wrist with e$tension of nee an" anle.

Loo -or w#st"n/

Loo -or -#sc"cu#t"on

Test -or tone

Test musce /roups "n # s0stem#t"c w#0 -or power

Test re-ees


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TONE

*AT TO +O

Ensure the patient is rela$e"# or at least "istracte" )% conversation.

+epeat each movement at "ifferent spee"s.

Arms

Tae the han" as if to shae it an" hol" the forearm. ,irst pronate an"supinate the forearm. Then roll the han" roun" at the wrist.

Hol" the forearm an" the el)ow an" move the arm throu'h the full

ran'e of fle$ion an" e$tension at the el)ow.

Le/s

Tone at the knee

-ut %our han" )ehin" the nee an" lift it rapi"l%. Watch the heel. Hol"the nee an" anle. ,le$ an" e$ten" the nee.

Tone at the ankle

Hol" the anle an" fle$ an" "orsifle$ the foot.


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*AT YOU 'N+ Normal / Sli'ht resistance throu'h whole ran'e of movements. Heel will lift minimall% off

the )e". Decreased tone/ *oss of resistance throu'h movement. Heel "oes not lift off )e"

when nee is lifte" 0uicl%.

Mare" loss of tone 1 flaccid.

Increased tone:! +esistance increases su""enl% &2the catch23 heel easil% leaves )e" when nee is lifte"

0uicl% ( spasticity.

! Increase" throu'h whole ran'e# as if )en"in' a lea" pipe ( lead pipe rigidity. +e'ular

intermittent )rea in tone throu'h whole ran'e ( cogwheel rigidity.

! -atient apparentl% opposes %our attempts to move his lim) ( 4egenhalten or paratonia.

Ro t,e wr"stRo t,e nee


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Spec"# s"tu#t"ons M0oton"# ( slow rela$ation followin' action. +0ston"# ( patient maintains posture at e$treme or movement with contraction of a'onist

an" anta'onist. recuss"on m0oton"# ma% )e "emonstrate" when a muscle "imples followin' percussion

with a patella hammer. Most commonl% sou'ht in a)"uctor pollicis )revis an" the ton'ue.

*AT T MEANS '#cc"!"t0 or re"uce" tone ( common causes/ lower motor nurone or cere)ellar lesion5

rare causes/ m%opathies# 2spinal shoc2 &e.'. earl% after a stroe3# chorea.

Sp#st"c"t0/ upper motor lesion.

R"/"!"t0 #n! co/w,ee r"/"!"t0/ e$trap%rami"al s%n"romes ( common causes/-arinson2s "isease# phenothia6ines.

M0oton"# &rare3 ( cause/ m%otonic "%stroph% &associate" with frontal )al"in'# ptosis#

cataracts an" car"iac con"uction "efects3 an" m%otonica con'enita. -ercussion m%otonia

ma% )e foun" in )oth con"itions.


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MOTOR SYSTEM:

ARMS

Test"n/ s,ou!er #4!uct"on Test"n/ e4ow -e"on


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Test"n/ e4ow etens"on Test"n/ -"n/er etens"on

Test"n/ -"n/er -e"onTest"n/ -"n/er #4!uct"on


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Test"n/ -"n/er #4!uct"on Test"n/ t,um4 #4!uct"on


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Test"n/ stren/t, o- supr#sp"n#tusTest"n/ stren/t, o- 4r#c,"or#!"#"s


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MOTOR SYSTEM:

LEGS

Test"n/ ,"p -e"on

Test"n/ ,"4 etens"on


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Test"n/ nee etens"on Test"n/ nee -e"on

Test"n/ !ors"-e"on o- t,e -oot Test"n/ p#nt#r-e"on o- t,e -oot


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Test"n/ "ners"on o- t,e -oot Test"n/ eers"on o- t,e -oot


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MOTOR SYSTEM:

RE'LE5S+efle$es can )e 'ra"e"/

7 1 a)sent

8 1 present onl% wit reinforcement

98 1 present )ut "epresse"

:8 1 normal

;8 1 increase"


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Test"n/ t,e tr"ceps re-eTest"n/ t,e nee re-e


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T,e #ne re-e 6 t,ree w#0s to

/et "t

Reinforcement

If an% refle$ is uno)taina)le "irectl% as the patient to

perform a reinforcement manoeuvre. In the arms asthe patient to clench his teeth as %ou swin' the

hammer. In the le's as the patient either to mae a

fist# or to lin han"s across his chest an" pull one

a'ainst the other# as %ou swin' the hammer.

Demonstration of clonus

At t,e #ne: Dorsifle$ the anle )risl%# maintain the footin that position# a rh%thmic contraction ma% )e foun".

More than three )eat is a)normal.

At t,e nee: With the le' strai'ht tae the patella an"

)rin' it )risl% "ownwar"s5 a rh%thmic contraction

ma% )e note". Alwa%s a)normal.

Re"n-orcement


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*AT YOU 'N+ AN+ *AT T MEANS

ncre#se! re-e or conus ( this in"icates upper motor neurone lesion a)ove the root at

that level.

A4sent re-ees/

! 'enerali6e" ( in"icates peripheral neuropath%! isolate" ( in"icates either a peripheral nerve or# more commonl%# a root lesion.

Re!uce! re-ees &more "ifficult to =u"'e3 ( occurs in a peripheral neuropath%# muscle

"isease an" cere)ellar s%n"rome.

en!u#r re-e ( this is usuall% )est seen in the nee =er where the refle$ continues to

swin' for several )eats. This is associate" with cere)ellar "isease.

Sow re#"n/ re-e ( this is especiall% seen at the anle refle$ an" ma% )e "ifficult to

note. It is associate" with h%poth%roi"ism.


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*AT T MEANS

7#4"ns"8s s"/n pos"t"e ! in"icates upper motor neurone lesion.

7#4"ns"8s s"/n ne/#t"e ( normal.

No response ( ma% occur with profoun" upper motor neurone weaness &toe una)le toe$ten"35 ma% occur if there is a sensor% a)normalit% interferin' with the afferent part of the

refle$.


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SENSATON:

GENERAL

There are five mo"alities of sensation.

Sp"n# cor! sect"on s,ow"n/

sensor0 "nput (re!) -rom #n!

motor output (4#c) to t,e r"/,t(R) s"!e

Sensor0 oss "n t,e

,#n!: #. Me!"um (re!

#n! un#r (4#c)

neres

Sensor0 oss "n t,e,#n!: 4. re!"# nere


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Sensor0 oss "n t,e #rm: 9.

A"#r0 nere

+erm#tomes "n t,e #rm

Sensor0 oss "n t,e e/: #. L#ter# cut#neous

nere o- t,e t,"/, 4. 9ommon perone#

nere 9. 'emor# nere !. Sc"#t"c nere


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otent"# s"tes -or

test"n/ "4r#t"on

sense

*AT TO +OVibration sense

Use a 9:> H6 tunin' for# those of hi'her fre0uenc%

&:?@ or ?9: H63 are not a"e0uate.

Test ( as the patient to close his e%es# place the

tunin' for on the )on% prominence# as if he can

feel the vi)ration.

9,ec ( hec the patient reports feelin' the vi)ration

an" not =ust the contact of the tunin' for. Strie

the tunin' for an" stop it vi)ratin' imme"iatel%an" repeat the test. If the patient reports that he

feels vi)ration# "emonstrate the test a'ain.

Joint position sense

With the patient2s e%es open show him what %ou are

'oin' to "o. Hol" the "istal phalan$ )etween %our

two fin'ers. Ensurin' that %our fin'ers are at B7o

to the inten"e" "irection of movement# move the

"i'it# illustratin' which is up an" which is "own.

*ow to test %o"nt

pos"t"on sense


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Pin prick

Test ( as the patient to close his e%es then appl% ran"oml% sharp an" )lunt stimuli an" note the

patient2s response.

Light touch

Use a piece of cotton wool.

Test ( as the patient to close his e%es# test the areas as for pin pric# appl% the stimulus atran"om intervals.

9,ec ( this is "one )% notin' the timin' of the response to the irre'ular stimuli. ,re0uentl% a

pause of 97!:7 secon"s ma% )e useful.

Special situation

S#cr# sens#t"on ( this is not usuall% screene". It is essential to test sacral sensation in an%patient with/ Urinar% or )owel s%mptoms Cilateral le' weaness Sensor% loss in )oth le's r where a cor" conus me"ullaris or cau"a e0uine lesion is consi"ere".

Temper#ture sens#t"on

Screening It is usuall% a"e0uate to as a patient if the tunin' for feels col" when applie" to the feet an"

han"s.

Formal testing

,ill a tu)e with warm water an" col" water.


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Ot,er mo!#"t"es

Two-point discrimination

This re0uires a two!point "iscriminator ( a "evice lie a )lunte" pair of compasses.

Test ( 'ra"uall% re"uce "istance )etween pron's# touchin' either with one or two

pron's. Note the settin' at which the patient fails to "istin'uish one pron' from twopron's.

9,ec ( ran"om se0uence of one or two pron's allows %ou to assess testin'.

! Normal/ in"e$ fin'er ?mm5 little fin'er F mm5 hallu$ 97 mm.

N.C. Garies consi"era)l% accor"in' to sin thicness.

ompare ri'ht with left.


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*AT YOU 'N+

#tterns o- sensor0 ossSensor% "eficits can )e classifie" into ei'ht levels of

the nervous s%stem/

1. S"n/e nere

2. Root or roots

3. er"p,er# nere

$. Sp"n# cor!&. 7r#"nstem

;. T,##m"c sensor0 oss

Sensor0 oss #ssoc"#te! w"t, sp"n#

cor! es"ons: #. 9ompete tr#nserse

es"on 4. *em"sect"on o- t,e cor!

Goe #n! stoc"n/

oss


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-. 7r#"nstem es"on

/. T,##m"c sensor0 oss


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9O


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*AT T MEANS Un"#ter# "nco


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Cerebellr Examination


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GAT

Alwa%s e$amine patient2s 'ait. It is a co!or"inate" action re0uirin' inte'ration of sensor% an"

motor functions. The 'ait ma% )e the onl% a)normalit% on e$amination. The mostcommonl% seen are/ hemiple'ic# parinsonian# marche a2 petits pas# ata$ic an" unstea"%

'aits.

Rom4er/8s test is convenientl% performe" after e$amination the 'ait. This is a simple test

primaril% of =oint position sense.

As t,e p#t"ent to w#

Ensure %ou are a)le to see the arms an" le's a"e'uatel%.

s t,e /#"t s0mmetr"c#>

4ait can usuall% )e "ivi"e" into s%mmetrical an" as%mmetrical even thou'h the s%mmetr% is

not perfect.

"f s#mmetrical$

Loo #t t,e s"?e o- p#ces Small or normal

"f small paces$

Loo #t t,e posture #n! #rm sw"n/ Stoope" with re"uce" armswin' ( parkinsonian &ma% )e "ifficult to start an" stop (

festinant 3.

Upri'ht with mare" armswin' ( marche a' petits pas.


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If normal paces:

Loo #t t,e #ter# !"st#nce 4etween t,e -eet normal wi"el% separate" ! broad based *e's unco!or"inate" ( cerebellar

rossin' over# toes "ra''e" ( scissoring.Loo #t t,e nees normal nees lifte" hi'h ( high-stepping.

Loo #t t,e pe"s #n! s,ou!ers normal

mare" rotation of pelvis an" shoul"er (waddling.

Loo #t t,e w,oe moement normal "is=ointe" as if for'otten how to wal# patient fre0uentl% appears roote" to pot ( apraxic. )i6arre# ela)orate an" inconsistent ( functional.

"f as#mmetrical

s t,e p#t"ent "n p#"n> %es ( painful or antal'ic 'ait.

Loo -or # 4on0 !e-orm"t0 orthopae"ic 'ait.


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+oes one e/ sw"n/ out to t,e s"!e> %es ( hemiplegic gait.

Loo #t t,e nee ,e"/,ts normal

one nee lifts hi'her ( foot drop.

As t,e p#t"ent to w# #s "- on # t"/,t 6 rope &"emonstrate3 if patient fall consistentl% ( unstea"% ma% fall pre"ominantl% to one si"e.

As t,e p#t"ent to w# on ,"s ,ees &"emonstrate3 If una)le to ( foot "rop.

As t,e p#t"ent to w# on ,"s toes &"emonstrate3 If una)le ! weaness of 'astrocnemius.

#r"nson"#n: in"icates )asal 'an'lion "%sfunction ( common causes/ -arinson2s "isease#

ma=or tran0uillisers. Sc"ssor"n/: in"icates spastic paraparesis ( common causes/ cere)ral pals%# multiple scelrosis#

cor" compression. Sensor0 #t#"#: in"icates loss of =oint position sense &+om)er'2s positive3 ( common causes/

peripheral neuropath%# posterior column loss &see )elow3. 9ere4e#r #t#"#: veers towar"s si"e of lesion ( common causes/ "ru's &e.'. phen%toin3#

alcohol# multiple sclerosis# cere)rovascular "isease.


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#!!"n/ /#"t: in"icates wea or ineffective pro$imal muscles ( common causes/ pro$imal

m%opathies# )ilateral co'enital "islocation of the hip. Apr#"c /#"t: in"icates the cortical inte'ration of the movement is a)normal# usuall% with

frontal lo)e patholo'% ( common causes/ normal pressure h%"rocephalus# cere)rovascular

"isease. *em"pe/"c: unilateral upper motor neurone lesion ( common causes/ stroe# multiple

sclerosis. 'oot !rop: common causes ( unilateral/ common peroneal pals%# p%rami"al lesion# *?

ra"iculopath%. Cilateral/ peripheral neuropath%.

Non


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SUMMARY O' S9REENNG

NEUROLOG9AL E5AMNATON

If the histor% reveals no su''estion of focal neurolo'ical "eficit# no speech "istur)ance an" no"istur)ance of hi'her function# then %ou can use a screenin' neurolo'ical e$amination.

Screen"n/ neuroo/"c# e#m"n#t"on up"s ( "irect an" consensual reactions. Test -"e!s to han" movements.

'un!oscop0. E0e moements to pursuit on up'a6e an" lateral 'a6e. '#c"# sens#t"on to li'ht touch with fin'er tip in all three "ivisions of tri'eminal. '#c"# moement ( screw up %our e%es ( show me %our teethJ. Mout, ( open %our mouthJ &loo at ton'ue3 an" sa% KahhL &o)serve palate3. -lease put out

%our ton'ueJ. Test nec -e"on.

Arms


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Le/s! *oo for wastin'

! Test tone at hip

! Test power &hip fle$ion an" e$tension# nee fle$ion an" e$tension# foot

"orsifle$ion an" plantar fle$ion3.

! +efle$es &nee# anle an" plantar response3.

Sens#t"on

! Test =oint position sense in toes an" fin'ers

! Test vi)ration sense on toes an" fin'ers

! Test li'ht touch an" pinpric "istall% in han" an" feet.

9oor!"n#t"on ( test fin'er ( nose an" heel ( shin. G#"t.


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T%&' ()*

examination final

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