socm physical exam of the neurological system pfn: sompyl0m

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Slide 1JSOMTC, SWMG(A)

SOCMPhysical Exam of the Neurological

SystemPFN: SOMPYL0M

Hours: 2.0


Terminal Learning Objective Action: Communicate knowledge of “Physical Exam of the Neurological System”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet


References

Bates’ Guide to Physical Examination And History Taking (11th edition; 2013; Lynn S. Bickley)

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Reason

As a SOCM Medic/Corpsman, your ability to conduct a good neurologic exam will affect your ability to diagnose and disposition (organize a treatment plan for) your teammates with head, dive, blast, or other high‐impact injuries.


Agenda

Identify the physical exam techniques and common findings when assessing mental status

Identify the physical exam techniques and common findings when assessing cranial nerves

Identify the physical exam techniques and common findings when assessing cerebellar and motor system functions


Agenda

Identify the physical exam techniques and common findings when assessing sensation

Identify the physical exam techniques and common findings when assessing deep tendon reflexes and the Babinski reflex

Communicate the neurologic evaluation of the stuporous or comatose patient

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Physical Exam Techniques and Common Findings when Assessing

Mental Status


Important Areas of Examination

Mental status

Cranial Nerves I through XII

Cerebellar system/Motor

Sensory system

Deep tendon, abdominal, and plantar reflexes


Nervous System

During the Exam, Solve Three Questions

Is the mental status intact?

Are the right and left finding symmetric?

If not, is the problem in the central or peripheral nervous system?

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Common or Concerning Symptoms

Headache

Dizziness or vertigo

Generalized, proximal, or distal weakness

Numbness

Loss of consciousness

Seizures

Tremors or involuntary movements


Neurologic Examination

Mental Status

Appearance and behavior

Speech and language

Mood

Thoughts and perceptions

Cognitive function


Cognitive Function

Ability to make new memories ‐ Ball, diamond, and tree

Math ‐ Serial sevens

Ask to recall the 3 objects

Language – Recognize a written word, spell it backwards without looking

Abstract thought – “people that live in glass

houses shouldn’t throw stones”

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Loss of Consciousness

Get a complete description

Warning signs?

What position was the patient in?

How long did it last?

Could voices be heard?

How rapidly did they recover?

Did anyone else observe the event?


Headache

Ask about severity, location, and duration

Ask about any associated symptoms

Visual changes

Weakness

Loss of sensation

Is headache affected by coughing, sneezing, or sudden movements?


Dizziness or Vertigo

Need to elicit what the patient is experiencing

Are there any associated symptoms

Diplopia (double vision)

Dysarthria (difficulty forming words)

Ataxia (difficulty with balance)

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Stroke and TIA

Stroke – sudden neurologic deficit

Cerebrovascularischemia ( 80‐85%)

Hemorrhagic (10‐15%)

Transient Ischemic Attack (TIA) – similar to a stroke but lasting between 1 – 24hrs with no structural defects


Stroke and TIA

Most Common Signs

Sudden numbness or weakness

Sudden confusion, trouble speaking or understanding

Sudden trouble walking, dizziness, or loss of balance

Sudden trouble seeing in one or both eyes

Sudden severe headache


Stroke and TIA

Cincinnati Stroke Scale

Facial Droop

•Normal: Both sides of face move equally

• Abnormal: One side of face does not move at all

Arm Drift

• Normal: Both arms move equally or not at all

• Abnormal: One arm drifts compared to the other

Speech

•Normal: Patient uses correct words with no slurring

• Abnormal: Slurred or inappropriate words or mute

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Stroke Risk Factors

Primary prevention targets “modifiable risk factors”

Hypertension

Smoking

Hyperlipidemia

Diabetes

Excess weight

Lack of exercise

Heavy alcohol use



Cranial Nerves



Cranial Nerve I –Olfactory – Sense of Smell

Patient should close both eyes

Occlude one nostril

Present a familiar non‐noxious odor; e.g., coffee

Ask patient to identify

Test other nostril

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Cranial Nerve II – Optic ‐ Vision

Test visual acuity (Snellen Chart)

Test visual fields

Inspect optic fundi



Cranial Nerve II and III –Optic and Oculomotor

Inspect the size and shape of the pupils

Reactions to light

Convergence

Accommodation



CN III – Oculomotor – innervates superior rectus, inferior oblique, medial rectus, and inferior rectus

CN IV – Trochlear – innervates superior oblique

CN VI – Abducens – innervates lateral rectus

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Cranial nerves III, IV, and VI – Oculomotor, Trochlear, and Abducens

Test extraocular movements – LR6, SO4, R3

Identify nystagmus (involuntary jerking movement)

Look for ptosis (drooping of the upper eyelids) CNIII lesion



Cranial Nerve V – Trigeminal

Motor ‐ Palpating the temporal and massetermuscles, note the strength of muscle contraction

Sensory – Forehead, cheeks, and chin

• Pain sensation – Sharp/dull

• Temperature sensation – Hot/cold

• Light touch – Cotton wisp

Corneal Reflex –Touch cornea with a fine wisp of cotton (Have patient remove contact lenses)



Cranial Nerve VII – Facial expression

Note any asymmetry or abnormal movements

Ask patient to

• Raise both eyebrows

• Frown

• Close both eyes tightly (test strength by trying to open them)

• Show upper and lower teeth

• Smile

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Cranial Nerve VIII – Vestibulocochlear ‐Hearing

Use whispered voice to assess hearing. If there is a deficit, determine if damage is:

• Conductive (air through ear)

• Sensorineural (damage to cochlear branch)

Weber test (lateralization)

Rhinne test (air and bone conduction)



Cranial Nerves IX and X – Glossopharyngeal and Vagus

Listen to the patient’s voice

Ask about difficulty swallowing

Have patient say “Ahhh”

•Movements of the soft palate and pharynx should be symmetrical



Cranial Nerve XI –Spinal Accessory

Look for muscular atrophy or fasciculation's

Ask patient to shrug shoulder against resistance

Turn head against resistance

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Meningeal Signs

Important if you suspect meningeal inflammation or subarachnoid hemorrhage


Neck Mobility

Make sure there is no c‐spine injury

Ask the patient to touch their chin to their chest

If they can’t, place your hands behind their head and flex their neck forward

If this causes pain, consider it a Positive Meningeal sign


Meningeal Signs

Brudzinski’s Sign

Flex the neck forward

A normal reaction is to remain relaxed

Watch for the hips and knees to flex

Kernig’s Sign

Flex the legs then straighten the knee

This should not produce pain

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Cranial Nerve XII – Hypoglossal

Listen to how well the patient speaks

Look at the patient’s tongue

• Does it lay symmetrically in lower jaw?

• Look for atrophy or fasciculations

• Stick tongue straight out and move in a circle

• Puff out cheeks



Cerebellar and Motor System Functions


Cerebellar/Coordination

Movement requires the nervous system to function in an integrated way

Motor system – muscle strength

Cerebellar system – rhythmic movements and steady posture

Vestibular system – balance and coordinating eye, head, and body movements

Sensory system – sense of position and proprioception

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To test coordination

Rapid alternating movements

Point to point movements

Gait and other body movements

Standing in specific ways

Note: Patients with obvious disability should not be asked to do standing or walking tests!



Rapid alternating movements

Arms – Observe speed, rhythm, and smoothness of the movements of bothhands

Legs – Note any slowness or awkwardness



Point to point movements

Arms – Finger to nose test, observe for accuracy and smoothness of movements

Legs – Heel to shin test, note smoothness and accuracy, repeat with patient’s eyes closed

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Gait

Walk across the room and return

Walk heel to toe

Walk on toes, then on heels

Hop in place on one foot then the other

Shallow knee bend with one leg then the other

Rise from a seated position without arm support



Stance

Romberg test

Stand feet together

Eyes closed

30 to 60 sec without support

Be ready to catch the patient



Stance

Test for Pronator drift

Have patient stand for 20‐30 sec.

Eyes closed

Arms straight out

Palms up

If the patient cannot stand allow them to sit

Tap arms down – they should return to horizontal position

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Seizures

Sudden excessive electrical discharge in the cerebral cortex

Get a complete description

Precipitating events

Warning signs (Aura)

Age of onset

Frequency

Medications

History of head injury


Motor System

Focus on

Body position

Involuntary movements

Characteristics of the muscles (bulk, tone, and strength)

Coordination


Motor System

Body Position – Look at the patient’s position during movement and at rest

Involuntary Movements

Tremors, tics, and fasciculation's

Fibrillations: Pt will sense them, but are not visible to medic

Note their location, rate, rhythm, and quality

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Motor System

Muscle Bulk

Inspect size and contour of muscles

Atrophy?

Bilateral

Unilateral

Proximal

Distal


Motor System

Muscle Tone

Tested by feeling the muscle’s natural resistance to passive movement

Note any variances in resistance or jerkiness during the range of motion


Motor System

Muscle Strength

Have patient actively move against your resistance or resist your movements

Not a competition

If unable to, test them against gravity, or with gravity eliminated

If unable to do that watch or feel for muscular contraction

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Scale for Grading Muscle Strength

Muscle strength is graded on a 0 to 5 scale:

0—No muscular contraction detected

1—A barely detectable flicker or trace of contraction

2—Active movement of the body part with gravity eliminated

3—Active movement against gravity only

4—Active movement against gravity and some resistance

5—Active movement against full resistance without evident fatigue (This is normal muscle strength)


Muscle StrengthTest flexion (C5, C6 – Biceps) Test extension (C6, C7, C8 –

triceps)


Muscle Strength

Test extension at the wrist (C6, C7, C8, radial nerve )

Test grip (C7, C8, T1)

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Muscle StrengthTest finger abduction and adduction (C8, T1, ulnar nerve)

Test opposition of the thumb (C8, T1, median nerve)


Muscle Strength

Muscle strength of the trunk

Flexion, extension, and lateral bending of the spine

Thoracic expansion and excursion during respiration


Muscle Strength

Test flexion at the hip (L2, L3, L4 – iliopsoas)

Test extension at the hips (S1‐gluteus maximus)

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Muscle Strength

Test adduction at the hips (L2, L3, L4 –adductors)

Test abduction at the hips ( L4, L5, S1 –gluteus medius and minimus)


Muscle Strength

Test extension at the knee (L2, L3, L4 – quadriceps)

Test flexion at the knee (L4, L5, S1, S2 – hamstrings)


Muscle Strength

Test dorsiflexion at the ankle (L4, L5 – tibialis anterior)

Test plantar flexion (S1 –gastrocnemius, soleus)

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Weakness

Paresis: incomplete paralysis

Generalized

Localized

Rapid or slow onset

What areas are involved?


Tremors

May occur with or without neurological manifestations

Ask about any body movements they seem unable to control

e.g., Parkinson’s disease



Sensation

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Sensory System

Types of sensations you will be testing

Pain

Temperature

Position

Vibration

Light touch

Discrimination

Note: If gross sensations are not intact, the results of other sensation tests are unreliable


Sensory System

Patterns of testing

Compare symmetric areas

Compare proximal and distal areas

Vary the pace of testing

When you detect an abnormality, map out boundaries


Pain

Use something with a sharp and dull side

Without the patient looking, demonstrate both sharp and dull

Move along the areas asking “Is this sharp or dull?”

Do not draw blood

Never reuse on another patient

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Temperature

Often omitted if pain reception is normal

Use one heated object and one cooled object

Similar to the pain sensation test; ask the patient to identify hot or cold


Light Touch

Touch the patient lightly

Avoid any pressure

Ask the patient to respond whenever a touch is felt


Vibration

Vibration

Use a low frequency tuning fork (128Hz)

Tap on the heel of your hand

Place on the patient’s fleshy areas (e.g., fingertips)

Ask the patient to tell you when the vibration stops

If vibration sense is impaired, move proximally and try again

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Proprioception

Grasp the patient’s finger or toe on the sides

Demonstrate “up” and “down”

With the patient’s eyes closed ask for a response of “up” or “down” as you move the digit


Discriminative Sensations

Discriminative Sensation –Requires the sensory cortex to correlate, analyze, and interpret sensations

Stereognosis – place a familiar object in the patient’s hand, and without looking be able to identify it



Number identification (Graphesthesia)

With the blunt end of a pen or pencil, draw a large number

Have the patient identify that number

Useful when patient has motor impairment, that prevents them from doing the stereognosis test

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Two point discrimination

Use an opened paper clip

Alternate between single and double stimulus

Do not cause pain

Find minimal distance the patient can still discriminate one from two points



Point localization – Briefly touch the patient, then ask the patient to open their eyes and point to where they where touched

Extinction – Simultaneously touch corresponding areas on both sides of the body


Dermatomes

A dermatome is a band of skin innervated by the sensory root of a single spinal nerve

Each spinal nerve (except C1) has a specific cutaneous sensory distribution; C1 is motor only

Do not memorize all the dermatomes

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Dermatomes


Numbness

Ask clarifying question

Location

Sensations

Paresthesias: Odd sensations, with or without stimuli

Dysesthesias: Distorted sensations to a stimulus

Anesthesia: Loss of sensation


Reducing the Risk of Peripheral Neuropathies

Diabetes is the most common cause

Counsel patients to keep their glucose under control

When HgA1c (avg. glucose level over 3 months) is ≤ 7.4% onset of neuropathies drop by 50‐60%

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Physical Exam Techniques and Common Findings when Assessing Deep Tendon Reflexes and the

Babinski Reflex


Deep Tendon Reflexes

Get your patient to relax

Talking to your patient distracts their mind and give you a more accurate assessment.

With your wrist relaxed, strike the tendon with a quick and direct blow


Scale for Grading Reflexes

0 ‐ No response

1+ ‐ Somewhat diminished; low normal

2+ ‐ Average; normal

3+ ‐ Brisker than average; possibly but not necessarily indicative of disease

4+ ‐ Very brisk, hyperactive, with clonus(rhythmic oscillations between flexion and extension)

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Biceps Reflex (C5, C6)

Patient’s arm should be partially flexed at the elbow, palm down

Place your thumb firmly over the biceps tendon

Strike your thumb so the force goes through your thumb into the biceps tendon



Triceps Reflex (C6, C7)

Flex the patient’s arm at the elbow, palm toward the body

Strike the triceps tendon above the elbow

Use a direct blow from directly behind it

Watch for triceps contraction and elbow extension



Supinator or brachioradialis (C5, C6)

Patient’s arm rested on abdomen or lap, forearm partially pronated

Strike the radius, 1‐2 in. above the wrist

Watch for flexion and supination of the forearm

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Knee Reflex (L2, L3, L4)

Patient sitting or lying down, with knee flexed

Strike the patellar tendon just below the patella

Watch for quadriceps contraction and knee extension



Ankle Reflex (primarily S1)

Patient sitting with foot dorsiflexed

Strike the Achilles tendon

Watch for plantar flexion

Also watch for the speed of relaxation after contraction


Clonus

When reflexes seem hyperactive

Support knee in a partly flexed position

Dorsiflex and plantarflexthe foot, reminding the patient to relax

Rapidly dorsiflex the foot

Look and feel for rhythmic oscillations

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Abdominal Reflex

Lightly and quickly stroke the patient’s abdomen on both sides, above (T8, T9, T10) and below (T10, T11, T12) the umbilicus

Note contraction of the abdominal muscles and deviation of the umbilicus toward the stimulation.


Plantar Reflex (Babinski sign)

Plantar Response (L5, S1)

Use a tongue blade, and run it along the lateral aspect of the foot from the heel and curve medially to the ball of the foot

Use the lightest stimuli that will provoke a response


Anal Reflex

Anal reflex (S2, S3, S4)

Use a dull object

Stroke the four quadrants of the anus

Watch for muscular contraction (Anal Wink)

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Straight Leg Raise

Straight Leg Raise

Tests for sciatica pain

Raise the patient’s straightened leg until some pain is illicted

Back off until the pain goes away

Then dorsiflex the foot

Pain is a positive sign for sciatica


Asterixis

Identifies possible metabolic encephalopathy in mentally impaired patients

“Stop traffic” with arms extended and fingers spread

Hold position for 1‐2 min

Watch for sudden, brief, non‐rhythmic flexion of the hands and fingers

Seen in liver disease and uremia


Winging of the Scapula

Ask the patient to extend both arms and push against a wall

Observe the scapulae

“Winging” or protrusion of the scapula, suggests weakness of the serratus anterior muscle

Seen in muscular dystrophy and long thoracic nerve damage

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The Neurologic Evaluation of the Stuporous or Comatose Patient


Evaluation of the Stuporous or Comatose Patient

Coma signals a potentially life‐threatening event

First assess for life threats

Establish the patient’s level of consciousness

Examine the patient neurologically


“Don’ts” When Assessing a Comatose Patient

Don’t dilate the pupils, this takes away the single most important clue to the cause of the coma (Structural vs. Metabolic)

Don’t flex the neck, if there is any question of head or neck trauma

Immobilize the neck

Rule out any injury with an x‐ray

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Level of Consciousness

Alert – Patient looks at you and responds appropriately

Verbal – Responds to loud voice (lethargy) or responds to a gentle shake (obtunded)

Pain – Responds to painful stimulus (stupor)

Unresponsive – no response to any stimuli (coma)


Neurologic Evaluation

Respirations ‐ Observe rate, rhythm, and pattern of respirations

Pupils – Compare size, equality, and their reaction to light

Ocular movement – Observe the position of the eyes and eyelids at rest, check for deviation of the eyes to one side



Oculocephalic Reflex

This tests for brainstem function

Hold open the patient’s upper eyelids

Turn the patient’s head rapidly

If the patient’s brainstem is intact, the eyes will move to the opposite side (opposite to the movement)

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Oculovestibular reflex

Make sure tympanic membrane is intact and ear canals are clear

Elevate the patient’s head to 30°

With a large syringe through a small catheter, inject ice water into the ear canal

Watch for deviation of the eyes toward the stimuli


Posture and Muscle Tone

If no spontaneous movement, may need to apply painful stimuli

Classify the resulting pattern

Normal – Pt. withdraws or pushes away

Stereotypic – Abnormal postural response

Flaccid – No response


Reading an Radiographic Image

Follow a systematic approach

Know your anatomy

Look for asymmetry

Go from broad observations to specific detail

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Reading an Radiographic Image


Three Phases of a Subdural Hematoma


Normal X‐ray of the C‐spine

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Burst Fracture – High energy axial loading injury; majority result in neurologic deficit


Recording Your Findings

Document your findings in each of the five components of the neuro exam

Mental Status

Cranial Nerves I‐XII

Motor System

Sensory System

Deep tendon, abdominal, and plantar reflexes


Recording Your Findings

“Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Cranial Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar—Rapid alternating movements (RAMs), finger‐to‐nose (F→N), heel‐to‐shin (H→S) intact. Gait with normal base. Romberg—maintains balance with eyes closed. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2+ and symmetric with normal plantar reflexes.”

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Questions?


Terminal Learning Objective

Action: Communicate knowledge of “Physical Exam of the Neurological System”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Bates’ Guide to Physical Examination and History Taking, 10th ed., Lynn S. Bickley2009

Learning Radiology: Recognizing the Basics, 2nd ed., William Herring, 2012

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Agenda

Identify the physical exam techniques and common findings when assessing mental status

Identify the physical exam techniques and common findings when assessing cranial nerves

Identify the physical exam techniques and common findings when assessing cerebellar and motor system functions


Agenda

Identify the physical exam techniques and common findings when assessing sensation

Identify the physical exam techniques and common findings when assessing deep tendon reflexes and the Babinski reflex

Communicate the neurologic evaluation of the stuporous or comatose patient


Reason

As a SOCM Medic/Corpsman, your ability to conduct a good neurologic exam will affect your ability to diagnose and disposition (organize a treatment plan for) your teammates with head, dive, blast, or other high‐impact injuries.

38


Break

socm physical exam of the neurological system pfn: sompyl0m

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