Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview
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Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on neurological examination Identify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing loss Determine location of neurological lesion Differentiate amongst the various movement disorders Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate between spasticity, rigidity, and flaccidity, and identify common causes of each. Differentiate upper motor neuron lesions from lower motor neuron lesions. Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causes. Compare and contrast the five clinical levels of consciousness. Given a case study perform the appropriate focused history and physical examination and formulate a differential diagnosis Determine if there is a neurological deficit Determine if there is a neurological deficit Sensory Motor Behavioral Coordinative Localize the site of the problem Determine the etiology of the problem Paresis – slight or incomplete paralysis Paresis – slight or incomplete paralysis Paralysis (plegia) – loss or impairment of motor function Hemiparesis Hemiplegia Paraplegia Quadriplegia Atrophy – a decrease in size Atrophy – a decrease in size Hypertrophy enlargement of an organ or part due to an increase in size of its constituent cells Pseudohypertrophy increase in size without true hypertrophy Spasticity – hypertonicity with increased DTRs Rigidity – stiffness or inflexibility Flaccidity – loss of tone with diminished DTRs Mental status Mental status Cranial nerves Motor function Reflexes Sensory status Coordination and balance Chief complaint Chief complaint PQRST Headache? Vertigo? Visual disturbance? Tremors or dyskinesias? Weakness? Dysesthesias/Paresthesias? Loss of consciousness? Alertness Alertness Attention Orientation Person, Place, Time, & Situation Cognitive function Perception Illusions = misinterpretations of real external stimuli Hallucinations = subjective sensory perceptions in the absence of stimuli Judgment Memory Speech Rate & rhythm Spontaneity Fluency Simple vs. complex Alert and Oriented Alert and Oriented Disoriented Obtunded Drowsy/somnolent Clouded consciousness Slow thought, movement, and speech Stuporous Marked reduction in mental and physical activity Vigorous stimuli needed to provoke a response Comatose Completely unconscious Cannot be aroused by painful stimuli Absence of voluntary movement +/- reflexes Hand drop Hand drop Blindness Unilateral diplopia Ammonia reaction (CN V vs. CN I) Absence of pain or weakness in different positions Observation is key! Observation is key! Use ingenuity! Be patient! Agitated May be threatening or violent Unresponsive Unreliable Inattentive, preoccupied, inconsistent information Hysterical Information & vocabulary Information & vocabulary Calculating Simple math Word problems Abstract thinking Proverbs Similarities/differences Construction Copy figures of increasing difficulty (i.e. circle, clock) Although confusion and/or disorientation are signs of both Delirium and Dementia, they are different Although confusion and/or disorientation are signs of both Delirium and Dementia, they are different Delirium is an acute It is potentially reversible Delirium usually occurs over a period of days to months Dementia is slow and insidious It progresses slowly over months to years Dementia is not reversible Onset? Onset? Progression? TIA = brief, intermittent visual loss Migraine = “wavy” Retinal detachment = “drawn curtain” Acute glaucoma = “rainbows” or “halos” Digitalis toxicity = yellow hue A sense of spinning A sense of spinning Suggests dysfunction of Vestibular apparatus Vestibular nerve Differentiate from “lightheadedness” and “faintness” Results from impairment of brain oxygenation CNS vs. PNS CNS vs. PNS Brain/Brain stem Spinal cord Peripheral nerves Difficult when evaluating: Radicular pain Dysesthesia/paresthesia Tremors Incoordination Cerebrum Cerebrum Impaired intellect, memory, higher brain function Brain stem LMN paralysis with loss of DTRs muscle atrophy with fasciculation LMN + anesthesia peripheral nerve or spinal root UMN involves whole muscle groups increased or spastic muscle tone +/- paralysis with DTR accentuation Positive Babinski Asymmetric pupillary light reflex Asymmetric pupillary light reflex Abnormal fundus Ocular divergence Nystagmus Muscular atrophy Fasciculations Multiple complex signs/symptoms explained by a single lesion 5th most common reason for OP visit 5th most common reason for OP visit Symptom! (not a disease) Most important diagnostic clue May awaken patient Worse with VALSALVA Tension Tension Sinus Migraine Classic Common Complicated Cluster Post-traumatic Post-LP Temporal Arteritis Temporal Arteritis ICP Subarachnoid hemorrhage Infection Ocular Trigeminal neuralgia (Tic doloureaux) TMJ syndrome Toxic Location Location Unilateral ~ migraine Periorbital ~ glaucoma/uveitis Parietal/Occipital ~ tension Neck ~ meningitis or Subarachnoid hemorrhage Quality “Throbbing” ~ vascular “Intermittent jabbing” ~ Trigeminal neuralgia “Pressure” ~ sinus Radiation? Severity Timing Constant vs. intermittent Worse in a.m. or p.m. Worst headache ever????? Associated Sx’s Associated Sx’s Visual disturbance Vertigo N/V Dysesthesias Aura Past medical history Family history Current medication/drug use Suspect an extracranial etiology if pain is the only symptom Appearance Appearance Behavior/Mannerisms Gait and Posture Motor behavior Facial expressions Mood vs. Affect MMSE Test Cranial Nerves II through XII Fundoscopic examination Test motor nerve function Test motor nerve function Grip/SAR (Grade 0-5) Station and gait – ambulate, turn, toes, heels, heel-to-toe, knee bend Romberg Test sensory nerve function Pain +/- Light touch Two point discrimination (normally <5mm) Proprioception/Stereognosis/Vibration Test deep tendon reflexes (0-4+) Test for meningeal irritation - Kernig’s & Brudzinski’s signs Straight leg raise Used to identify potential discogenic injury and nerve root injury Test Coordination Finger-to-nose Rapid alternating movements of hands & feet Corneal Corneal Pharyngeal Biceps Triceps Brachioradialis Abdominal Patellar (knee jerk) Achilles (ankle jerk) Babinski I - Olfactory I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VIII - Vestibulocochlear (Acoustic) IX - Glossopharyngeal X - Vagus XI - Accessory XII - Hypoglossal Responsible for sense of smell Responsible for sense of smell Receptors located in the upper 1/3 of the nasal septum. Test each nostril separately. Identify familiar odors. Avoid noxious substances Unilateral lesion = ipsilateral anosmia Responsible for vision Responsible for vision Test visual acuity!!!! Pupillary size Visual fields Peripheral vision Test by confrontation Fundoscopic examination CN III involved in: CN III involved in: Pupillary reflex Opening of the eyelids Most extraocular movements CN IV provides downward/inward eye movement CN VI provides lateral eye movement Check pupillary reaction/reflex Check pupillary reaction/reflex Check eye movement through all six Cardinal fields Unilateral complete paralysis is usually caused by increased ICP or an aneurysm Neither eye can move to the contralateral side Eyes “look toward the lesion” Injury may occur secondary to: Infection Orbital fracture Internal carotid aneurysm Mastoiditis Increased ICP Look for nystagmus* Adie’s (Tonic) pupil Argyll Robertson pupil irregular/unequal pupils weak/absent reaction to light exaggerated contraction to accommodation Marcus-Gunn pupil results from reduced afferent input in the affected eye** pupil fails to constrict fully rapidly stimulate each eye in succession and observe the direct and consensual light response in each stimulation of the normal eye produces full constriction in both pupils. immediate subsequent stimulus of the affected eye produces an apparent dilation in both pupils since the stimulus carried through that optic nerve is weaker Asymmetry of pupil size of >1mm suggests CN III compression Asymmetry of pupil size of >1mm suggests CN III compression Bilateral dilation suggests anoxia or drug affect Unilateral constriction is seen with sympathetic dysfunction (Horner syndrome) or carotid artery dissection Bilateral constriction is seen with: Pontine hemorrhage Drugs (opiates, Clonidine) Toxins (organophosphates) Sensory Sensory Ophthalmic branch (sensory) Cornea, conjunctiva, ciliary body , nasal cavity, sinuses, skin of eyebrows/forehead/nose Maxillary branch (sensory) Side of nose, lower eyelid, upper lip Mandibular branch (mixed) Sensory – skin of temporal region, auricles, lower lip/face, anterior 2/3 of tongue, mandibular gums/teeth Motor - innervates the muscles of mastication Cerebral lesion causes contralateral paresthesia Most lesions affect all 3 branches Inspect for tremor of the lips, involuntary chewing movements, and trismus Inspect for tremor of the lips, involuntary chewing movements, and trismus Compare muscle tension bilaterally with teeth clenched Test tactile perception Test sharp-dull discrimination Test temperature perception Test corneal reflex Tests V & VII directly and VII consensually Motor Motor Muscles of the face, scalp, and ears Autonomic Vasodilation Secretion of submaxillary/sublingual glands Sensory Taste in anterior 2/3 of tongue Ear canal/postauricular Palsies can occur secondary to: Polio, ALS, MS, tumors, syphilis, Lyme disease, Guillain-Barré Syndrome Inspect for flaccid paralysis Inspect for flaccid paralysis Differentiate UMN vs. LMN Elevate eyebrows Close eyes Show teeth Whistle Smile **Central lesions causes contralateral paralysis to lower half of face (below the eyes) Responsible for sense of hearing and balance Responsible for sense of hearing and balance Composed of the cochlear and vestibular nerves Sensory Test hearing Look for spontaneous nystagmus Look for spontaneous nystagmus Romberg test/sign Functional test of position sense Stand with feet together Close eyes and maintain for 20-30 seconds Usually combined with a check for pronator drift As above Extend arms forward in supinated position Briskly move arms downward (separately) Arms should return smoothly to original position Lesion causes Unilateral deafness Imbalance Motor Motor Autonomic Sensory Taste in posterior 1/3 of tongue Pharynx, tonsils, fauces, TM, posterior ear canal Test for Elevation of the uvula Gag reflex Mucosal anesthesia Motor, autonomic, and sensory functions Motor, autonomic, and sensory functions Palate, pharynx, larynx, neck, thorax, and abdomen Branches to: Pharynx Larynx Esophagus Heart Bronchioles Stomach Liver Celiac Perform indirect examination of the vocal cords Lesion cause: Hoarseness/aphonia Dyspnea/stridor Provides motor to Provides motor to Testing: Have patient shrug against resistance Head rotation and movement against resistance Motor to tongue Motor to tongue Testing: Tongue movement Midline Tremors Involuntary Atrophy Lingual speech Paralysis causes deviation to the weak side UMNs UMNs Transmit impulses from cortical nerve bodies to: motor nuclei in brainstem (CNs) Anterior horn cells of spinal cord LMNs Transmit impulses from anterior horn cells through anterior root into peripheral nerves Terminate at the neuromuscular junction Inspection Inspection Symmetry Muscle bulk; size and contours; flat or concave; unilateral or bilateral; proximal or distal Atrophy Palpation Percussion Check motor strength Body position (during movement and at rest) Involuntary movements Location, quality, rate, rhythm, amplitude and relation to posture, activity, fatigue, or emotions If an abnormality exists: Identify muscle(s) involved Central vs. peripheral? Learn muscle innervations Muscle tone Muscle tone Slight residual tension in normal relaxed muscle Feel muscle’s resistance to passive stretch Muscle strength Wide variance - stronger dominant side Test by asking patient to actively resist movement If muscles too weak - test against gravity only or eliminate gravity If patient fails to move, watch or feel for weak contraction Suspect decreased resistance? Hold forearm and shake hand loosely Resistance increased? Varies or persists throughout movement Always compare symmetry Always compare symmetry Note any atrophy Check muscle tone against resistance Cogwheel rigidity = jerky, released in degrees UMN paralysis = spasticity (increased tone) LMN paralysis = hypotonia Test muscle strength Fatigues quickly Fatigues quickly Efficiency Special attention to areas of: Symptomology Motor or reflex abnormalities Trophic changes Confirm with repeat testing!! Patterns of testing: Symmetrical Distal vs. proximal: scattered stimuli Vary pace Look for abnormality Look for abnormality map out boundaries in detail Source of lesion Distribution of sensory abnormalities and kinds of sensations affected +/- motor/reflex abnormality Demonstrate to patient before testing Pain and temperature Pain and temperature Crude touch (light touch without localization)Fibers cross & pass upward into thalamus Sharp safety pin or other tool Sharp safety pin or other tool Demonstrate sharp & dull Test by: Alternating sharp & dull w/ pt’s eyes closed Ask patient: Sharp or dull? Does this feel same as this? Lightest pressure needed - do not draw blood Often omitted if pain sensation normal Often omitted if pain sensation normal Two test tubes filled with hot & cold water or tuning fork heated or cooled by water Wisp of cotton Wisp of cotton Touch lightly - avoid pressure Ask patient: To respond when touch is felt Compare one area with another Position and vibration Position and vibration Fine touch Synapse in medulla, cross & continue on to thalamus 128 or 256 Hz Tuning fork If impaired, proceed proximally Grasp toe by sides - pull away from other toes Demonstrate “up” & “down” Have pt close eyes Have pt close eyes Touch pt on R cheek & L arm Ask patient where touch was felt Stereognosis, graphesthesia, two-point discrimination Stereognosis, graphesthesia, two-point discrimination Test ability of sensory cortex to correlate, analyze, & interpret sensations Dependent on touch & position sense Screen first with stereognosis - proceed to other methods if indicated Ability to identify an object by feeling it Ability to identify an object by feeling it Place familiar object in patient’s hand & ask patient to identify it Normally patient manipulates it skillfully & identifies it correctly Perform if inability to manipulate object Perform if inability to manipulate object Ability to identify numbers written in hand Use patient’s orientation Touch two places simultaneously Touch two places simultaneously Alternate stimuli Avoid pain Determine distance Segmental levels of DTRs: Segmental levels of DTRs: Supinator reflex C5, 6 Biceps reflex C5, 6 Triceps reflex C6, 7 Abdominal reflexes - upper T8, 9, 10 - lower T 10, 11, 12 Knee (Patellar) L2, 3, 4 Plantar responses L5, S1 Achilles reflex S1 primarily Grade DTR Response Grade DTR Response 4+ Very brisk, hyperactive, with clonus 3+ Brisker than average, slightly hyperreflexic 2+ Average, expected response; normal 1+ Somewhat diminished, low normal 0 No response, absent Reinforcement technique Reinforcement technique Upper extremities clench teeth squeeze thigh Lower extremities lock fingers and pull one against the other C6, C7, C8 Elbow Extension C5, C6 C5, C6 Forearm semiflexion/semipronation (NO wrist/hand flexion) L2, L3, L4 Knee Extension S1, S2 S1, S2 Ankle Plantar Flexion T8, T9, T10: T8, T9, T10: ABOVE umbilicusT10, T11, T12: BELOW umbilicusSuperficial reflex Superficial reflex Loss of anal reflex suggests lesion of S2,3,4 reflex arc Possible lesion of cauda equina Requires integration of: Requires integration of: Motor system Cerebellar system Vestibular system Sensory system Finger-to-nose with moving target Finger-to-nose with moving target Stationary finger-to-nose with eyes closed First with hands First with hands Repeat with feet Diadochokinesia = ability to perform RAM Dysdiadochokinesis = slow, irregular, clumsy movements Station & Stance Station & Stance Pt stand with feet together First, eyes open Romberg Test Then, close eyes If okay with eyes open, but sways w/ eyes closed = + Romberg Mainly tests position sense Vision can compensate for loss of position sense Often performed in conjunction with Romberg test Pronator drift Muscular strength Coordination Position sense Walk across room, turn and walk back Walk across room, turn and walk back Tandem walking Heel & toe walking Hop in place Shallow knee bend Rising from sitting position or stepping up on stool Occur with meningitis & subarachnoid hemorrhage Occur with meningitis & subarachnoid hemorrhage Brudzinski’s Sign Flex the head Marked pain in the neck Patient flexes hip and BLE Kernig’s Sign Pain when raising a straightened LE CBC, CMP, U/A CBC, CMP, U/A Specific drug levels Plain films of the spine CT of the brain & head MRI of the brain & spine Greater resolution then CT for soft tissue/plaques Angiography CSF exam EEG EMG & NCT PET/SPECT Obtained through lumbar puncture Obtained through lumbar puncture Indications: Suspected CNS infection (i.e. syphilis) Suspected subarachnoid hemorrhage Contraindicated if cerebral mass/lesion is suspected Measure opening pressure Obtain samples for cell counts, glucose, protein level , and cultures Gives adequate information about brain anatomy Gives adequate information about brain anatomy Used primarily to detect hemorrhage & tumors Can be performed with/without contrast Indications: Focal neurologic deficits Altered mental status Head trauma New-onset seizure Increased ICP Suspected mass lesion Suspected subarachnoid hemorrhage (with contrast) Abscess, intracranial tumor (with contrast) Chronic subdural hematoma, infarct, vascular malformation Six categories : Six categories : Mental status & speech Cranial nerves Motor function Sensory function Reflexes Cerebellar function Carefully evaluate the hx of the CC CN assessment is essential! Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on neurological examination Identify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing loss Differentiate amongst the various movement disorders Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate between spasticity, rigidity, and flaccidity, and identify common causes of each. Determine location of neurological lesion Differentiate upper motor neuron lesions from lower motor neuron lesions Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causes. Compare and contrast the five clinical levels of consciousness. Dostları ilə paylaş:
