Neurological Assessment

History Headache Head injury Dizziness/Vertigo Seizures Tremors Weakness Incoordination

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

Physical Exam Mental Status, Pyschiatric Cranial Nerves Sensory exam Motor exam https://www.youtube.com/watch?v=7h5o-FJUDRA

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

Facing Cranial Nerve Assessment, Barbara Bolek, American Nurse Today, November 2006

Cranial Nerves 1. Olfactory – have patient identify smell 2. Optic – Eye chart, visual fields 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

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”

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

Sensation Posterior Column Tract Vibration sense- tuning fork to bony prominence Position- grasp toe or finger and move it up/down or side/side Tactile discrimination- fine touch Stereognosis- place object in hand to identify (coin or paperclip) Graphesthesia- trace a letter or number on palm to identify Two point discrimination Point location

Motor Muscle Cerebellar Size Strength Tone Involuntary Movement Balance: Gait, Tandem walking Romberg test- have pt stand feet together arms at side eyes closed

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

DTRs

Biceps – C5 The biceps reflex is elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement.

Brachioradialis – C6 The brachioradialis reflex is observed by striking the brachioradialis tendon directly with the hammer when the patient's arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Repeat and compare to the other arm.

Triceps – C7, 8 The triceps reflex is measured by striking the triceps tendon directly with the hammer while holding the patient's arm with your other hand.

Patellar – L3,4 With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer.

Achilles – S1,2 The ankle reflex is elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion.

Babinski Reflex The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe. The normal reflex is toe flexion. If the toes extend and separate, this is an abnormal finding called a positive Babinski's sign.

Reflexes Deep Tendon Reflexes Biceps, triceps, brachioradialis, patellar, achilles Superficial Reflexes Epigastric, abdominal, cremasteric, gluteal, plantal, bulbocavernous, superficial anal Brain Stem Reflexes Pupillary reaction, corneal, oculocephalic, oculovestibular, gag Pathological Reflexes Babinski, grasp

DTR Reflex Scale 0 : absent reflex    1+: trace, or seen only with reinforcement    2+: normal 3+: brisk    4+: nonsustained clonus (i.e., repetitive vibratory movements) 5+: sustained clonus

Glasgow Coma Scale

Summary Neurological assessment includes: Mental status Cognitive assessment Cranial nerves Motor Functions & Muscle tone Sensory Function Cerebellar Function DTR & superficial cutaneous reflexes