neurologic exam
TRANSCRIPT
ASSESSMENT: Neurologic
ExaminationMa. Tosca Cybil A. Torres, RN, MAN
AN IMPORTANT ASPECT OF THE NEUROLOGIC
ASSESSMENT IS THE HISTORY OF
THE PRESENT ILLNESS
HEALTH HISTORY
Should include: • Onset• Character• Severity• Location • Duration • Frequency of s/sx• Associated complaints• Precipitating and
aggravating factors• Progression, remission,
and exacerbation
• Presence and absence of similar symptoms among family members
• Review of medical history
• History of falls or trauma• Use of alcohol,
medications and illicit drugs
Common Clinical Manifestations
• Pain (chronic or acute) • Seizures• Dizziness and vertigo • Visual disturbances • Weakness• Abnormal sensation
Physical Examination
• A neurological assessment is divided into five components: I. Cerebral function
II. Cranial nerves
III. Motor system
IV. Sensory system
V. Reflexes
• Follows a logical sequence and progresses from higher levels of cortical function (ex: abstract thinking) to lower levels of function (ex: determination of the integrity of the peripheral nerves)
I. Assessing cerebral function
Interpretation and documentation of neurologic abnormalities, particularly mental status abnormalities, should be
SPECIFIC and NONJUDGMENTAL.
Mental Status
• Assessment begins by observing client’s appearance and behavior• Posture• Gestures• Movements• Facial expressions• Motor activity • Manner of speech • LOC• Orientation
State of Awareness
State Description
Full consciousness Alert; oriented to time, place, person; understands verbal and written words
Disoriented Not oriented to time, place, or person
Confused Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment
Somnolent Extreme drowsiness but will respond to stimuli
Semicomatose Can be aroused by extreme or repeated stimuli
Coma Will not respond to verbal stimuli
Intellectual function
• Serial 7s• Interpretation of well-known
proverbs/idioms• Capacity to recognize similarities• Judgement
Though Content
¥ Is the patient’s thoughts: ø Spontaneous ø Naturalø Clearø Relevant ø Coherent
Check: • Illusions• Hallucinations• preoccupations
Emotional Status
• Assess:µAffectµMoodµConsistency of verbal
communication to non verbal cues
Perception
Agnosia- inability to interpret or recognize objects seen through the special senses.
♠Visual ♠Auditory ♠Tactile ♠Body parts and relationships
Motor Ability
• Ask client to perform a skilled act• Successful performance requires the
ability to understand the activity desired and normal motor strength
Language Ability
Aphasia- deficiency in language function• Broca’s Aphasia (non-fluent aphasia)- speech
output is severely reduced and is limited mainly to short utterances of less than four words.
• Wernicke’s Aphasia (fluent aphasia) -ability to grasp the meaning of spoken words is chiefly impaired, while the ease of producing connected speech is not much affected.
• Global aphasia- most severe form of aphasia, and is applied to patients who can produce few recognizable words and understand little or no spoken language. Global aphasics can neither read nor write.
Broca’s Aphasia
Wernicke’s Aphasia• Ex:
• I called my mother on the television and did not understand the door.
• It was too breakfast, but they came from far to near.
• My mother is not too old for me to be young.
II. Examining the Cranial Nerves CRANIAL NERVE CLINICAL EXAMINATION
I (OLFACTORY) With eyes closed, ask patient to identify familiar odor. Each nostril tested separately
II (OPTIC) Snellen Chart; ophthalmoscopic examination
III (OCULOMOTOR), IV (TROCHLEAR),VI (ABDUCENS)
Test for ocular rotations, nystagmus, conjugate movements Test for pupillary reflexes, ptosis
V (TRIGEMINAL) With eyes closed, touch forehead, cheeks, and jaw for sensitivity to sharp or dulls objects. If responses are incorrect, test for temperature sensationWhile looking up, lightly touch a wisp of cotton against each corneaHave client clench and move the jaw from side to side
VII (FACIAL) Observe symmetry while client performs facial movements Assess taste
CRANIAL NERVE CLINICAL EXAMINATION
VIII (ACOUSTIC) Whisper or watch-tick testTest for lateralization (Weber Test)Test for air and bone conduction (Rinne Test)
IX (GLOSSOPHARYNGEAL) Assess ability to swallow and discriminate b/w sugar and salt on posterior 3rd of tongue
X (VAGUS) Assess gag reflexNote hoarseness in voice and ability to swallow
XI (SPINAL ACCESSORY) Palpate and note strength of trapezius muscles while client shrugs shoulders against resistancePalpate and note strength of sternocleidomastoid muscle as client turns head against opposing pressure of the examiner’s hand
XII (HYPOGLOSSAL) While protruding the tongue, note any deviation or tremors. Ask client to move tongue from side to side against a tongue depressor
III. Examining the Motor System
• Assess muscle size, tone, and strength, coordination, and balance
• Note for rigidity, spasticity and flaccidity
• Muscle Strength Grading
0 – No contraction1 – Slight contraction, no movement2 – Full range of motion without gravity3 – Full range of motion with gravity4 – Full range of motion , some resistance5 – Full range of motion, full resistance
Balance and Coordination
• Rapid, alternating movements• Point-to-point testing • Ataxia- incoordination of voluntary muscle
action • Romberg test
• Stretch or Deep Tendon Reflexes A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below.
Grading DTR's
0 – Absent1 – Decreased but present2 – Normal3 – Brisk and excessive4 – With clonus
IV. Examining the Reflexes
Reflexes
• Biceps reflex• Triceps reflex• Brachioradialis reflex• Patellar reflex• Ankle reflex
• Superficial reflexes• Corneal • Abdominal reflexes• Gag• Cremasteric• Plantar• perianal
V. Sensory Examination
The sensory examination is
largely subjective and
requires the cooperation of the patient.
• Assessment of the sensory system involves: • Tactile sensation • Superficial pain • Vibration • Integration of sensation • Proprioception • Stereognosis
Diagnostic Evaluation
• CT scan
• CT scan
• MRI
Cerebral angiography
Myelography
• An x-ray of the spinal subarachnoid space after injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture
Post myelography care
• Head elevated to 30-45 degrees for 3H or as prescribed by the AP
• Encouraged to increase OFI • Assess VS and ability to void • Untoward signs------headache, fever, stiff
neck, photophobia, and seizures
Electroencephalography (EEG)
Electromyography (EMG)
Lumbar Puncture
• CSF analysis• Queckenstedt’s test
• End of discussion