Physiology Lab THE NEUROLOGICAL EXAMINATION " Three stations will be from this tutorial "

1- MENTAL STATUS 2- CRANIAL NERVES 3- MOTOR EXAM - Tone - Strength (Power) - Reflexes - Cerebellum ( Gait ) 4- SENSATION

Tools: A. The reflex hammer. B. The tuning fork. It is used to illicit deep tendon reflexes throughout the body. B. The tuning fork. It is used to test vibration sense throughout the body. C. The ophthalmoscope. It is used to examine the interior of the eye. D. Visual acuity card. E. Q-tip. The tip is used to test the corneal reflex.

* SEARCH FOR OTHER PICTURES. D B A E C

EXANINATION RULES: 1. Start with upper limb DISTAL  PROXIMAL. ) Ex: joints. “wrist – elbow – radioulnar” ) *no examination for the shoulders because there are lots of muscles. 2. Compare right  left . )Ex: right wrist  left wrist( *do not move to the other joint until you compare 3.Lower limb DISTAL  PROXIMAL. )Ex: joints: ankle – knee – hip( )Ex: right ankle  left ankle(

Physical examination steps: Inspection or Observation. Palpation or Touching. Percussion. Auscultation.

MOTOR examination 1. Inspection or Observation. Look for any twitches, tremors, abnormal movements or postures. Look carefully for hypokinesia , decreased eye blinking or staring which could be indicative or an extrapyramidal disorder such as Parkinson’s disease. In suspected lower motor neuron disorders , look for muscle wasting or fasciculation. 2. Palpation or Touching. Tone and power of muscles in cases of suspected myopathy to check for muscle tenderness. 3. Percussion. By the hammer. Passively move each limb to check muscle tone. Ask the patient to relax before beginning. * no auscultation for motor examination.

Tremor ( at rest – or with arms outstretched – or intention tremor (. 1- Inspection (MUSCLE OBSERVATION( Total of inspection 1 minute Choose big muscle Atrophy (wasting( Abnormal movements: Tremor ( at rest – or with arms outstretched – or intention tremor (. Chorea ( dance like movement( Athetosis. Deformity: Drop wrist. Drop foot. Fasciculation: Abnormal twitching of the muscle. *Normally occur after exercising of changing weather.

2) Palpation: (TONE: normal resistance ) Passively move the joint: A- Upper limb first then lower limb. B- Start from distal  proximal. Choose single joint Observe for 20 sec C- compare.(zigzag movement) D- You will see : Normal. Hypotonia (Flaccid): lower motor neuron lesion. ( from anterior horn cell of spinal cord goes to muscles( Hypertonia (spasticity): upper motor neuron lesion.( cerebral cortex to anterior horn cell of spinal cord )

A- Wrist. B- Elbow. C- Radioulnar )by shake hand ( D- shoulder Upper joints: A- Wrist. B- Elbow. C- Radioulnar )by shake hand ( D- shoulder

Lower joints: A- ankle. B- Knee. C-Hip.

GRADING( 0-5) 0- NO MOVEMENT 1- FLICKER 2- MOVEMENT WITHOUT GRAVITY 3- MOVEMENT AGAINST GRAVITY 4- MOVEMENT AGAINST RESISTANCE 5- NORMAL STRENGTH

The first action you do when assess or examine strength (power) is asking the patient to raise his hand or foot GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH Example of OSPE questions : 60 years old patient , you asked him to move his hands then he moves it to left and right without moving his hand against gravity. What is the grade of his power ? Answer : grade 2

3 - Enhanced (hyper reflexia) The last two grades for later stages (GRADED 0–5) 0 – Absent. 1 - Present with reinforcement. ( يعني تبين ردة الفعل اذا كان المريض يفكر بشيء ثاني ومو مركز على الاهتزاز اللي يسويه الدكتور ) 2 - Normal 3 - Enhanced (hyper reflexia) The last two grades for later stages 4 – Unsustained clonus 5 - Sustained clonus

Biceps (tap on your finger) Brachioradialis Root : C5-C6 you should mention 5 - flexion and extension of elbow sometimes called pronation and supination Triceps - flexion and extension of semi pronation Root : C6-C7 you should mention 7 Knee Root : L2-L4 Ankle : S1

Achilles deep tendon reflex

Upper motor neuron dysfunction (cervical spinal cord) BABINSKI HOFMAN’S JAW JERK Frontal release signs (lumbosacral spinal cord) GRASP SNOUT SUCK PALMOMENTAL

Test the plantar response by scraping an object across the sole of the foot beginning from the heel, moving forward toward the small toe, and then arcing medially toward the big toe. The normal response is downward contraction of the toes. The abnormal response, called Babinski's sign, is characterized by an upgoing big toe and fanning outward of the other toes. The presence of Babinski's sign is always abnormal in adults, but it is often present in infants, up to the age of about 1 year.

Gait ( TANDEM ) RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING HEEL TO SHIN Gait ( TANDEM )

RAPID ALTERNATING MOVEMENTS

FINGER TO FINGER TO NOSE TESTING

HEEL TO SHIN

Include walking and turning Examples of abnormal gait High steppage Waddling Hemiparetic Shuffling

Tandem gait

Romberg is positive if they do worse with eyes closed Measures: 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

Romberg sign (Sensory ataxia) Posterior column disease

The sensory exam relies to a large extent on the ability or willingness of the patient to report what he is feeling. It can therefore often be the most difficult and unreliable part of the neurologic exam Posterior column of spinal cord

- Superficial: •Light touch (umbilicus T10, nipple T4) •Pinprick •Temperature - Deep: •Vibration •Joint position

Start distally and move proximally PIN PRICK TEMPERATURE VIBRATION ( 128 HZ TUNING FORK ) JOINT POSITION SENSE

PIN PRICK

TEMPERATURE sensory examination

Vibration sensory examination Put the tuning fork on prominent bony area : Lower limb : medial malleolus , tuberosity of tibia, superior iliac spine Upper limb : styloid process

Upper limb joint position sense

Lower limb joint position sense

GRAPHESTHESIA STEREOGNOSIS DOUBLE SIMULTANEOUS STIMULATION BAROSTHESIA TEXTURES

Sterognosis : recognizing objects while eyes closed Graphesthesia : recognizing letter or number in the hand while eyes closed Sterognosis : recognizing objects while eyes closed Double Simultaneous Stimulation Intact primary sensation with deficits in cortical sensation such as agraphesthesia or astereognosis suggests a lesion in the contralateral sensory cortex. Note, however, that severe cortical lesions can cause deficits in primary sensation as well. Extinction with intact primary sensation is a form of hemineglect that is most commonly associated with lesions of the right parietal lobe. Extinction can also be seen in right frontal or subcortical lesions, or sometimes in left hemisphere lesions causing mild right hemineglect

graphesthesia

Stereognosis