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THE NEUROLOGICAL EXAMINATION

THE NEUROLOGICAL EXAMINATION. NEUROLOGICAL EXAM. MENTAL STATUS CRANIAL NERVES MOTOR EXAM STRENGTH GAIT CEREBELLAR REFLEXES SENSATION. MENTAL STATUS. Level of Consciousness. Awake and alert Agitated Lethargic Arousable with Voice Gentle stimulation Painful/vigorous stimulation

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THE NEUROLOGICAL EXAMINATION

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  1. THE NEUROLOGICAL EXAMINATION

  2. NEUROLOGICAL EXAM • MENTAL STATUS • CRANIAL NERVES • MOTOR EXAM • STRENGTH • GAIT • CEREBELLAR • REFLEXES • SENSATION

  3. MENTAL STATUS

  4. Level of Consciousness • Awake and alert • Agitated • Lethargic • Arousable with • Voice • Gentle stimulation • Painful/vigorous stimulation • Comatose

  5. LANGUAGE • FLUENCY • NAMING • REPETITION • READING • WRITING • COMPREHENSION Aphasia vs. dysarthria

  6. MEMORY • IMMEDIATE • REALLY A MEASURE OF ATTENTION RATHER THAN MEMORY • REMOTE • 3 OBJECTS AT 0/3/5 MINUTES • HISTORICAL EVENTS • PERSONAL EVENTS

  7. ORIENTATION • PERSON • NOT WHO THEY ARE BUT WHO YOU ARE • PLACE • TIME

  8. OTHER COGNITIVE FUNCTIONS • CALCULATION • ABSTRACTION • SIMILARITIES/DIFFERENCES • JUDGEMENT • PERSONALITY/BEHAVIOR

  9. CRANIAL NERVES

  10. CRANIAL NERVE EXAM • I - OLFACTORY • DON’T USE A NOXIOUS STIMULUS • COFFEE, LEMON EXTRACT • II - OPTIC • VISUAL ACUITY • VISUAL FIELDS • FUNDOSCOPIC EXAM

  11. CRANIAL NERVE EXAM • III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS • PUPILLARY RESPONSE • EYE MOVEMENTS • 9 CARDINAL POSITIONS • OBSERVE LIDS FOR PTOSIS • V - TRIGEMINAL • MOTOR - JAW STRENGTH • SENS - ALL 3 DIVISIONS

  12. CRANIAL NERVES • VII - FACIAL • OBSERVE FOR FACIAL ASYMMETRY • FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER • VIII - VESTIBULAR • ACUITY • RINNE, WEBER

  13. CRANIAL NERVES • IX/X - GLOSSOPHARYNGEAL, VAGUS • GAG • XI - SPINAL ACCESSORY • STERNOCLEIDOMASTOID M. • TRAPEZIUS MUSCLE • XII - HYPOGLOSSAL • TONGUE STRENGTH • RIGHT XII THRUSTS TONGUE TO LEFT

  14. MOTOR EXAMINATION

  15. STRENGTH • STRENGTH • GRADED 0 - 5 • 0 - NO MOVEMENT • 1 - FLICKER • 2 - MOVEMENT WITH GRAVITY REMOVED • 3 - MOVEMENT AGAINST GRAVITY • 4 - MOVEMENT AGAINST RESISTANCE • 5 - NORMAL STRENGTH

  16. STRENGTH EXAM • UPPER AND LOWER EXTREMITIES • DISTAL AND PROXIMAL MUSCLES • GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH • SUBTLE WEAKNESS • TOE WALK, HEEL WALK • OUT OF CHAIR • DEEP KNEE BEND

  17. Motor exam, cont • Subtle signs of weakness on a cortical/subcortical basis • Pronator drift • Orbiting

  18. Gait evaluation • Include walking and turning • Examples of abnormal gait • High steppage • Waddling • Hemiparetic • Shuffling • Turns en bloc

  19. MUSCLE OBSERVATION • ATROPHY • FASCIULATIONS

  20. ABNORMAL MOVEMENTS • TREMOR • REST • WITH ARMS OUTSTRETCHED • INTENTION • CHOREA • ATHETOSIS • ABNORMAL POSTURES

  21. CEREBELLAR FUNCTION • RAPID ALTERNATING MOVEMENTS • FINGER TO FINGER TO NOSE TESTING • HEEL TO SHIN • GAIT • TANDEM

  22. Romberg Sign • Stand with feet together - assure patient stable - have them close eyes • Romberg is positive if they do worse with eyes closed • Measures • Cerebellar function • Frequently poor balance with eyes open and closed • Proprioception • Frequently do worse with eyes closed • Vestibular system

  23. REFLEXES

  24. MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES) • GRADED 0 - 5 • 0 - ABSENT • 1 - PRESENT WITH REINFORCEMENT • 2 - NORMAL • 3 - ENHANCED • 4 - UNSUSTAINED CLONUS • 5 - SUSTAINED CLONUS

  25. MSR / DTR • BICEPS • BRACHIORADIALIS • TRICEPS • KNEE • ANKLE

  26. OTHER REFLEXES • Upper motor neuron dysfunction • BABINSKI • present or absent • toes downgoing/ flexor plantar response • HOFMAN’S • JAW JERK • Frontal release signs • GRASP • SNOUT • SUCK • PALMOMENTAL

  27. TONE • INCREASED, DECREASED, NORMAL • COGWHEELING • CLASP KNIFE

  28. SENSORY EXAM

  29. SENSORY EXAM • VIBRATION • 128 hz tuning fork • JOINT POSITION SENSE • PIN PRICK • TEMPERATURE Start distally and move proximally

  30. HIGHER CORTICAL SENSATIONS • GRAPHESTHESIA • STEREOGNOSIS • DOUBLE SIMULTANEOUS STIMULATION • BAROSTHESIA • TEXTURES

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