Health Assessment Neuro

Health History

• Headache

  • OLDCART

    • associated symptoms: visual changes? Coughing? Sneezing? Suddent movement of head

      • Associated with increased pressure

• Dizziness or Vertigo

  • Has many meanings

  • need to elicit exactly what patient means

  • OLDCART

• Weakness

  • Generalized or localized

  • inability to move

  • Proximal or distal

• Loss of sensation

• Fainting or blacking out

• Seizures

• Tremors

Syncope

Presyncope

Disequilibrium

Ataxia

Vertigo

Diplopia

Dysarthria

TIA

Seizures

• Different types

• Acute symptomatic seizure

• Epilepsy, head trauma, withdrawal from alcohol/drugs, metabolic insults (glucose, calcium), stroke

• May involve loss of consciousness

• Abnormal feelings before seizure?

• How long do they last?

• How frequent? Any change in frequency?

• Any history of head injury?

• What are you doing to treat seizure?

Tremors

Involuntary movements

With or without other neurologic manifestations

Parkinson's

Restless Leg Syndrome- pregnancy, renal disease, meds

Uncontrollable body movements?

Bilateral?

CNS

• Basal Ganglia

  • Movement

• Thalamus

  • Sensory

• Hypothalamus

  • Homeostasis and hormones

• Spinal cord

  • Supplies entire body

Motor and sensory pathways

• Motor fibers

  • Voluntary movement, muscle tone

  • Walking

  • Cerebellar system

    • sensory and motor equilibrium and posture

Peripheral Nervous system PNS

Cranial Nerves

1. Olfactory

2. Optic

3. Oculomotor

4. Trochlear

5. Trigeminal

6. Abducens

7. Facial

8. Vestubocochlear

9. Glossopharyngeal

10. Vagus

11. Accessory

12. Hypoglossal nerve

Sensory Fibers

Pain, Temperature, touch

Vibration, proprioception

Spinal Reflexes

The deep tendon response

• Reflex: involuntary response

• Briskly tap the tendon of partially stretched muscle

• Tapping tendon activates special sensory fibers

• For the reflex to work- sensory, spinal cord, motor, and muscular fibers must be intact

• Each deep tendon involves specific spinal segments, can help locate a pathologic lesion

Physical examination equipment

• Sensory examination

  • Objects to feel (coin, paper clip)

  • Tuning fork

  • Hot and cold water in test tubes/glass

  • Cotton swab

• Reflexes

  • Reflex hammer

  • Tongue blade

Physical examination of Motor system

• Coordination

  • Requires four areas of the nervous system:

  • Motor system

  • Cerebellar system

  • Vestibular system

  • Sensory system

• Observe performance

  • Rapid alternating movements

  • Point-to-point movements

  • Gait and other related body movements

  • Standing in specific ways

• Rapid alternating movements

  • Arms

  • Legs

• Point-point movements

  • Arms: fingers-to-nose-test

  • Legs: heels-to shin test

    

Gait physical examination

• Ataxia- lacks coordination

• Cerebellar Dfx

• *Normal Gait

• *Tandem Walk

• Cerebellar Ataxia

• Sensory Ataxia

  

Stance physical examination

*The Romberg test

*Pronator drift

The sensory system (Physical Examination)

• Test the following:

  • Pain and temperature

  • Position and vibration

  • **Light touch

  • Discriminative sensations

• Correlate abnormal findings with motor and reflex activity

• Underlying lesion central or peripheral?

• Sensory loss bilateral or unilateral?

• Pattern suggest dermatomal distribution, a polyneuropathy, spinal cord syndrome?

• Loss of pain and temperature sensation?

• Patterns of testing

  • Can fatigue patient, causing produce unreliable results

  • Pay special attention to:

    • Where there are symptoms such as numbness or pain

    • Where there are motor or reflex abnormalities

    • Where there are abnormal findings

    • Compare symmetric areas

    • Compare distal with proximal areas

    • Test fingers and toes first for vibration and position

    • Vary the pace of your testing

    • Map out boundaries if sensory loss or hypersensitivity is detected

Discriminative sensations

• *Stereognosis

• *Graphesthesia

• **Two-point discrimination

• Point localization

• Extinction

  

Pattern of testing physical examination

• Pain

• Use broken tongue blade/cotton swab.

• Sharp and dull

• Apply lightest pressure needed for stimulus to feel sharp; do not draw blood.

• Temperature

  • Water, tuning fork

• *Light touch

  • Cotton, avoid pressure

• Vibration

  • Tuning fork

• Pattern of testing (cont’d)

  • Proprioception (position)

    • Moving big toe up and down***

Deep tendon reflexes

*Deep tendon reflexes

• Equipment: properly weighted reflex hammer

• Encourage patient to relax.

• Hold reflex hammer loosely between thumb and finger.

• With wrist relaxed, strike tendon briskly .

• Note the speed, force, and amplitude of reflex response.

Reflexes include:

• biceps reflex

• triceps reflex

• supinator or brachioradialis reflex

• knee reflex (patellar reflex)

• ankle reflex (achilles reflex) (primarily S1)

• Clonus

Deep tendon reflexes Reinforcement

Uses isometric contraction of other muscles

Deep tendon reflexes Bicep reflex

Deep tendon reflexes Triceps reflex

Deep tendon reflexes Supinator or brachioradialis reflex

Deep tendon reflex The knee reflex

AKA patellar relex

Deep tendon reflexes Ankle reflex

Achilles reflex

Primarily S1

Deep tendon reflex Clonus

Cutaneous stimulation reflexes

Superficial reflexes

Plantar response (L5, S1)

Abbreviated Neurological assessment For comatose patient

• Assessment for comatose patient

  • ABCs

  • Level of consciousness

  • Metabolic or structural cause for LOC?

  • Interview relatives, friends, witnesses

• “Don’ts” when assessing the comatose patient

  • Don’t dilate the pupils.

  • Don’t flex the neck if any question of trauma to the head or neck.

Pupils in Comatose Patients

Small or pinpoint pupils Misposition Fixed Pupils

Large pupils One large pupil

Level of consciousness for comatose patient

• Alertness: Alert patient opens eyes, looks at you, and responds fully and appropriately.

• Lethargy: Patient appears drowsy but opens eyes, looks at you, responds to questions, and falls asleep.

• Obtundation: Patient opens eyes, looks at you, responds slowly, and is somewhat confused.

• Stupor: Patient arouses from sleep only after painful stimuli. Verbal responses are slow or absent. Patient lapses into unresponsive state when stimulus ceases and has minimal awareness of self or environment.

  Coma: Patient is unarousable and eyes are closed. There is no evident response to inner need or external stimuli.

Glasgow Coma Scale

Neurological evaluation of comatose patient

• Respirations

• Pupils

• Ocular movement

• Oculocephalic reflex

• Posture and muscle tone

• If no there is spontaneous movement, apply painful stimuli.

• Classify results:

  • Normal/avoidant: pushes the stimulus away

  • Stereotypic: evokes abnormal response

  • Flaccid paralysis or no response

Neurological evaluation for comatose patient

Decorticate Rigidity

Hemiplegia (Early)

Decerebrate Rigidity

Recording Your Findings

• Mental status

• Cranial nerves

• Motor

• Sensory

• Reflexes

Health Promotion and Counseling

• Important topics for health promotion and counseling

  • Preventing strokes or transient ischemic attack

  • Reducing risk of peripheral neuropathy

Preventing stroke and transient ischemic attack Health Promotion and Counseling

• Stroke

  • Third leading cause of death

  • Leading cause of long-term disability

  • Symptoms and signs depend on vascular territory affected in brain.

  • Most common: middle cerebral artery

Stroke warning signs

• Sudden numbness or weakness of the face, arm, or leg

• Sudden confusion or trouble speaking or understanding

• Sudden trouble walking, dizziness, or loss of balance or coordination

• Sudden trouble seeing in one or both eyes

• Sudden severe headache

Stroke risk factors: primary prevention

• Hypertension

• Smoking

• Hyperlipidemia

• Diabetes

• Excess weight

• Lack of exercise

• Heavy alcohol use

Stroke risk factors: secondary prevention

• After a TIA, focus on any secondary risk factors.

  • Atherosclerotic large vessel disease

  • Cardiac emboli secondary to atrial fibrillation

  • Small vessel lacunar disease

  • Idiopathic

Reducing risk of peripheral neuropathies

• Diabetes is the most common cause of peripheral neuropathies.

• Distal symmetric sensorimotor polyneuropathy

• Autonomic dysfunction

• Mononeuritis multiplex

• Diabetic amyotrophy