General physical & Mental examination of neurologic patient

SEMINAR by : ABHILASH DASHEmail ID : physio.abhilash@gmail.com

Contents

o General physical examination

o On observation

o On examination

o Mental status examination

o Level of consciousness

o Memory test

o Mini mental status examination

o Glasgow Coma Scale

o Lobular function test

o References

General Physical Examination

Check BMI, vital sign like Pulse rate, Blood pressure, Respiratory rate and Rhythm,

Body Temperature.

On observation of the Head

Hydrocephalus - head and face resembles as inverted triangle, forehead being

large, bossed and bulging forward and downward.

Microcephally – head appears as a triangle the right way up, the forehead sloping

backward, the occiput forward and cranium coming to a rounded point.

In Acromegally- Head increased by elongation with enlargement of jaw,

forehead and nose while teeth separated, excessive folded around the eye ,hand

and feet are enlarged, digits, blunt ended and spade – like.

In Paget’s Disease – Head is enlarged and appears unnaturally rounded ,scalp

being red, warm and covered with dilated vessels.

Paget’s Disease

HydrocephalusAcromegally

Microcephally

THE FACE

Parkinson's face- Mask like face with reduced blinking frequency.

Maxedema face- Puffy lids and loss of the outer third of the eyebrows,

scanty and dry hair, dry skin, expressionless face and enlargement tongue.

Facial asymmetry, hemiatropy, pouting of lips and transverse smile occur in

Myopathies.

Plethoric, fat, hairy face in Crushing Syndrome.

Exopthalmos and lid retraction in Hyperthyrodism.

LMN facial palsy

Forward dropping of neck of muscle weakness in MG, Progressive

muscular disease.

Fixed drooping of eyelid with winkled forehead in Ocular myopathy

Parkinson's face Maxedema face

Crushing Syndrome

Hyperthyrodism

facial palsy

facial atrophy

Ocular myopathy

THE SKIN

Note for allergic lesion and Dermatographia

Scleroderma- Calcium deposit in skin

Adenoma sebaceum- It consist of pink ,globular coat on cheeks, nose,

chin, forehead and upper lip.

Herpes zoster- Redness, allegetic type itching, painful skin rash and

blister formation.

Herpes simplex- Blistering source forms in the mouth or in genital organ,

skin.

Bed sore-particularly prone to develop anaesthetic areas .

Scars, burns, destruction of terminal phalanges- occurs in Spyringomyelia,

Leprosy and Hereditary sensory neuropathy.

Adenoma sebaceum

Herpes zoster

Herpes simplex

Scleroderma

Hereditary sensory neuropathy

Spyringomyelia

Dermatographia

THE BACK

Scoliosis is common in muscular dystrophy, ataxia.

Gross kyphoscoliosis may cause cord compression and

paraplegia.

Excessive lordosis common in muscular dystrophy ,myasthenia

gravis.

Gibbus deformity of spine – Localizes angular deformity of

spine caused by spinal TB or by secondary deposits of malignancy.

Gibbus deformity

Scoliosis Gross kyphoscoliosis

THE EYE

Ptosis- -3rd nerve palsy, myasthenia gravis, Horner’s syndrome,

myatonic dystrophy.

Pupil- Unequal pupil- Unilateral 3rd nerve palsy, brain herniation

compress 3rd nerve.

Dilated pupil -3rd nerve sympathetic paralysis.

Constricted pupil- 3rd nerve parasympathetic paralysis, Horner’s

Syndrome.

On Examination

Palpation Feel the surface of skull for bony irregularity or deficiency. This may be

congenital, traumatic or post- operative.

A Rigid Spine-

• Lumbar spine remain straight when there is paravertebral

muscle spasm resulting from lumbar spine or disc disease.

• In ankylosing spondylitis the whole spine move as one and

flexion occurs at hip joint.

• Patient who have in wearing spinal supports for a long time

develop a state of rigidity of their spinal movements.

Percussion Children with hydrocephalus and separation of sutures – tapping the skull

with fingertip produces a tympanic , impure and rather high-pitched note-

called cracked-pot sound.

Sign of Meningism Neck stiffness-

Kerning's sign-

Brudzinski’s sign-

Mental status examinationLevel of Consciousness

Full consciousness- The patient is alert, attentive, follows command , respond promotely to external stimulus if asleep, and once awake remains attentive.

Lethargy- The patient is drowsy but partially awaken to stimulation . Patient will answer questions and follows command but will do slow slowly and in attentively.

Obtundation- The patient is difficult to arouse and needs constant stimulation to follow a simple command. Although they are may be verbal response with one or two words ,the patient will drift back to sleep between stimulation .

Stupor- The patient arouse to vigorous and continuous stimulation typically a painful stimulation is required. The only response may be an attempt to withdraw from remove the painful stimulation.

Coma- The patient does not respond to continuous stimulation .there no verbal sound ,no movement, except possibly by reflex.

Memory test

IMMEDIATE memory- Digit span- ask patient to repeat a sequence of 5, 6, or 7 random numbers.

RECENT memory- Ask patient to describe present illness, duration of hospital stay, or recent events in the news.

REMOTE memory- Ask about events and circumstances occurring more than 5 yrs. ago.

VERBAL memory- Ask the patient to remember a sentence or a short story and test after 15 minutes.

VISUAL memory- Ask the patient to remember objects on a tray and test after 15 minutes.

Causes of disorders of memory- Korasakoff’s psychosis, post traumatic

amnesia, temporal lobectomy, psychogenic amnesia

Glasgow Coma Scale (GCS)

Action Response Score

Eyes open Spontaneously 4

To speech 3

To pain 2

None 1

Best verbal response Oriented 5

Confused 4

Inappropriate words 3

Incomprehensive sounds 2

Best motor response Obeys commands 6

Localized pain 5

Flexion withdrawal 4

Abnormal flexion 3

Abnormal extension 2

Flaccid 1

Total 15

Maximum

Score

Patient’s

ScoreMini Mental Status Examination(MMSE)

Questions

5 “What is the year? Season? Date? Day of the week? Month?”

5 “Where are we now: State? County? Town/city? Hospital? Floor?”

3 The examiner names three unrelated objects clearly and slowly, then

asks the patient to name all three of them. The patient’s response is

used for scoring. The examiner repeats them until patient learns all of

them, if possible. Number of trials: ___________

5 “I would like you to count backward from 100 by sevens.” (93, 86, 79,72, 65,

…) Stop after five answers.

Alternative: “Spell WORLD backwards.” (D-L-R-O-W)

3 “Earlier I told you the names of three things. Can you tell me what those

were?”

2 Show the patient two simple objects, such as a wristwatch and a pencil, and

ask the patient to name them.

1 “Repeat the phrase: ‘No ifs, ands, or buts.’”

3 “Take the paper in your right hand, fold it in half, and put it on the floor.”

(The examiner gives the patient a piece of blank paper.)

1 “Please read this and do what it says.” (Written instruction is “Close

your eyes.”)

1 “Make up and write a sentence about anything.” (This sentence must

contain a noun and a verb.)

1 “Please copy this picture.” (The examiner gives the patient a blank

piece of paper and asks him/her to draw the symbol below. All 10

angles must be present and two must intersect.)

30 TOTAL

Limitation of MMSE

Score more than 24 is normal. Cognitive impairment:-20-24 Moderate cognitive impairment:-13-20 Severe cognitive impairment:-<12

LOBULAR FUNCTION TEST

Frontal lobe Ask the Patient if he/she had planned to visit to the doctor.

Ask and note whether the patient is able to give the history properly and has preserved inside about his problem.

Forward and backward digit span.

Ask the patient to produce as many words as possible.

Ask the patient to name animal, fruits or vegetables as many as he can in one minute.

Motor Luria test.

Luria graphic test.

The stroop test- RED, BLACK, WHITE, GREEN, BLUE, YELLOW

Parietal lobe

Ideational apraxia- Unable to perform works which involves a series of

motor activity

Right leg orientation- Test done in fore steps by increasing difficulty.

Finger agnosia- 3 steps increasing difficulty

Cortical sensation- look for asterognosis, graphaesthesia, barognosis, 2

point discrimination

Simple and complex calculation.

Geographical orientation-

Constructional ability test by drawing.

Clock drawing test-

Temporal lobe

Long term memory- inability to form new LTM seen in

Korsakoff’s Psychosis, Alzhemer’s Dementia,

Short term memory.

Occipital lobe

Prosopagnosia- in ability to recognize familiar objects.

Visual memory

References

1. BICKERSTAFF ’s Neurological Examination by KAMESHWAR PRASAD

2. Neurological Assessment by RUBEN D. RESTREPO

3. Neurological Examination by WILLIAM HOWLETT

4. Neurological intervention for Physical Therapy by MARTIN KESSLER

5. A Concise Guide to Neurology by REMA PAI

6. Neurology Illustrated by KENNETH W LINDSAY, IAN BONE

7. Internet

THANK YOU

Can the brain understand the brain??Can it understand the mind??Is it a giant computer, orSome other kind of giant machine,Or something more!!!!!!!!!

Can the brain understand the Brain??Can it understand the Mind??Is it a Giant Computer, orSome other kind of Giant Machine,Or something more !