Neurological Assessment

- help identify pathology/gather baseline data - seizures - Parkinson's disease - Peripheral neuropathy - Cerebrovascular disease - assess effectiveness of medications - assess toxicity of medications

What are the various components of a neurological assessment?

• mental status

• cranial nerve

• motor

• reflexes

• sensory

**May not be all performed at one, usually targeted based on the patient’s complaint or eval of drug therapy

What should be assessed for mental status?

• appearance

  • poor hygiene or lack of concern of appearance

• mood

  • sustained emotions

• affect (expressiveness)

• speech

  • pattern, rate, volume

• thought process

  • answers questions appropriately

• recall

  • immediate → name 3 things back to me in a few minutes

  • recent → what was for breakfast?

  • remote → what are the provinces in Canada?

• orientation

• level of consciousness

How to assess for orientation?

• tell me your name

• tell me where you are

• tell me the date

  • month, day, year

Oriented x3 (person, place and time)

Why might you want to assess orientation?

• quick way to assess if patient has confusion

  • due to medical (e.x. UTI) or side effect of a medication (e.x anticholinergics, benzodiazepines)

How to assess level of consciousness?

• how awake and aware the patient is

• Use the Glasgow Coma Scale

What is the Glasgow Come Scale?

• universal tool to assess level of consciousness

• consists of 3 main areas

  • eye opening

  • best verbal response

  • best motor response

Why might there be abnormalities in a cranial nerve exam?

• compression

  • hemorrhage

  • tumour

• Stroke

• Inflammation

  • MS

• Head trauma

• Medications

  • nystagmus (involuntary eye movement → side to side) with phenytoin

What are the various components of a motor exam?

• strength

• gait

• balance

• coordination

• other movements

What could you assess for strength in a motor assessment? and why?

• grip strength

• move against resistance

• look for cogwheel rigidity

• assess medication effective

  • dose for Parkinson’s meds working?

• assess medication safety

  • any extrapyramidal effects (seen with antipsychotics)

What is cogwheel rigidity?

• starts and stops

  • cannot press uniformly

• associated with Parkinson’s

What could you assess for gait in a motor assessment?

• walk away from and towards you as normal

• walk towards on tiptoes and/or on heels

• observe positions and arm movements

Why are the deviations of normal gait you would be looking for?

• Festinating gait

  • short shuffling, stooped posture

  • may indicate Parkinson’s disease

• Ataxia

  • wide based, staggering gait

  • inability to coordinate muscle movements

  • drug (phenytoin or barbiturates) or alcohol induced

What could you assess for balance in a motor assessment?

• Romberg test

  • stand with feet together and eyes open

  • close eyes for 20-30s without support

  • normal → no/minimal sway

  • positive test → sways or moved feet to keep balance

What might a positive Romberg test be indicative of?

• vestibular dysfunction

• cerebellar dysfunction

• intoxication

What could you assess for coordination in a motor assessment?

• rapid alternating movements

  • touch thumb to each finger of same hand

  • pat thigh and alternate hand back to front

Why would you want to assess coordination?

assess cerebellum controls motor coordination of voluntary movement, equilibrium and muscle tone.

What could you assess for abnormal movements in a motor assessment? and why?

• tremors

  • resting, postural or intention tremors

• dyskinesia

  • involuntary, uncontrollable movemoents

  • oral → rhythmic, repetitive movements of face, mouth, jaw, tongue

What medications may cause tremors?

• antipsychotics

• B-agonists

• caffeine

• theophylline

• many more

What medications may cause Dyskinesia?

• phenothiazines (antipsychotics)

What could you assess for in a reflex assessment?

• plantar reflexes

  • dorsiflexion of big toe → Babinski reflex (flex up = positive)

What might cause a positive Babinski reflex?

• CNS lesion

• unconscious state from drug or alcohol intoxication

What could you assess for in a sensory assessment?

• close eyes and distinguish between sharp and dull sensations

• determine when a tuning fork is vibrating as it touches wrists or feet