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Neurological Assessment

Neurological Assessment. Anatomy of Nervous System. Central Brain Spinal cord Peripheral Cranial Nerves Spinal Nerves. Brain. Cerebral cortex (“rind”) – gray matter Frontal Parietal Temporal Occipital Wernicke’s area – receptive aphasia Broca’s area – expressive aphasia. Brain.

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Neurological Assessment

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  1. Neurological Assessment

  2. Anatomy of Nervous System • Central • Brain • Spinal cord • Peripheral • Cranial Nerves • Spinal Nerves

  3. Brain • Cerebral cortex (“rind”) – gray matter • Frontal • Parietal • Temporal • Occipital • Wernicke’s area – receptive aphasia • Broca’s area – expressive aphasia

  4. Brain • Basal ganglia: motor function • Thalamus: relay station • Hypothalamus: HR, BP, sleep, etc. • Cerebellum: motor coordination • Brain stem • Midbrain • Pons • Medulla: respiration, heart, GI function, CN 8 - 12

  5. Spinal Cord • Nerve cell bodies arranged in “horns” • Nerve pathways cross in the spinal cord • Eg. Sensation of the left side of the body enters the left dorsal horn, and crosses to the right ventral horn and travels to right hemisphere • Sensation • Spinothalamic tract: pain, temperature, crude and light touch • Posterior columms: does not cross sides; position, vibration, finely localized touch

  6. Spinal Cord • Motor pathways • Corticospinal (Pyramidal) tract: • All go through the medulla’s pyramid • Crossed • Uncrossed • Finer body movements • Extrapyramidal • Cruder movement (walking) • Upper vs Lower motor neurons

  7. Peripheral Nervous System • Reflex arc • Deep tendon reflexes: requires • Intact sensory nerve • Functional synapse • Motor Nerve • Competent Muscle • Superficial • corneal, abdominal • Visceral • Pupillary light, accommodation • Pathologic

  8. Cranial Nerves • Mnemonic: “Oh Oh Oh, To Taste And Feel Very Good Veal Simply Heaven”

  9. Spinal Nerves • Cervical 8 • Thoracic 12 • Lumbar 5 • Sacral 5 • 1 Coccygeal • Sensory in dorsal horns; motor in ventral • Dermatome

  10. Functional Divisions • Autonomic vs. Somatic Nervous System • Sympathetic vs. Parasympathetic • Primary sympathetic neurotransmitter is Norepinephrine, so sympathetic system is called “adrenergic” • Primary sympathetic neurotransmitter is Acetylycholine, so parasympathetic system is called “cholinergic”

  11. History • Headache • Head injury • Dizziness/Vertigo • Seizures • Tremors • Weakness • Incoordination

  12. History Cont • Numbness or tingling • Difficulty Swallowing • Difficulty Speaking • Environmental/occupational hazards • Past Medical History • Social History: smoking, drugs, alcohol • Medications

  13. Anticholinergic Symptoms • Mydriasis • Dry, flushed skin • Hallucinations • Agitation • Hyperthermia • Urinary retention • Delayed intestinal motility (constipation) • Tachycardia • Seizure

  14. Anticholinergic Mnemonic • Blind as a bat • Dry as a bone • Red as a beet • Mad as a hatter • Hot as a hare

  15. Phenobarbital Oxybutynin (20%) Isosorbide dinitrate Hydroxyzine Warfarin Dipyridamole Codeine Ranitidine (10%) Dyazide Furosemide (Lasix) Nortriptyline (3%) Drugs with Anticholinergic Effects • Atropine (100% of maximal anticholinergic effect) • Scopolamine • Tolterodine • Hyoscyamine • Cholinergic Parkinsonism agents • Prednisone (55%) • Diphenhydramine (Benadryl) • Amitriptyline (Elavil) • Digoxin • Nifedipine

  16. Physical Exam • Mental Status, Pyschiatric • Cranial Nerves • Sensory exam • Motor exam

  17. Level of Consciousness Speech Orientation Knowledge of Current events Judgment Abstraction Vocabulary Emotional responses Memory Calculation ability Object recognition Praxis Mental Status

  18. Cranial Nerves • 1. Olfactory – have patient identify smell • 2. Optic – Eye chart, visual fields, fundus • 3,4,6. Oculomotor, Trochlear, Abducens – PERRLA, positions of gaze, nystagmus • 5. Trigeminal Nerve: chewing muscles, facial sensation, corneal reflex • 7. Facial nerve: smile, frown, close eyes, puff cheeks

  19. Cranial Nerves • 8. Test hearing, Weber, Rinne tests • 9, 10. Glossopharyngeal and Vagus Nerves – Soft palate and uvula movement; gag reflex • 11. Spinal Accessory Nerve: head movement; shrug shoulders • 12. Hypoglossal – Tongue movement; “light, tight, dynamite”

  20. Sensation • Eyes closed • Avoid leading questions • In general, if distal is intact, proximal will also be intact • Spinothalamic tract • Pain: sharp or dull • Temperature • Light touch

  21. Sensation • Posterior Column Tract • Vibration sense • Position • Tactile discrimination • Stereognosis • Graphesthesia • Two point discrimination • Extinction • Point location

  22. Motor • Muscle • Size • Strength • Tone • Involuntary Movement • Cerebellar • Balance: • Gait, • Tandem walking • Romberg, • One legged squat

  23. Motor • Cerebellar • Coordination • Rapid alternating movement • Knee slapping • Finger to thumb • Finger to finger • Finger to nose • Heel to shin

  24. Deep Tendon Reflexes • Tests sensory and motor function • Biceps • Brachiradialis • Triceps • Quadriceps (patellar) • Achilles

  25. Additional Tests • Clonus • Superficial reflexes • Abdominal • Cremasteric • Plantar reflexes

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