Neurological System/assessment

Front 1

Four Brain Lobes and primary functions

Back 1

1. Frontal: Personality, behaviour, emotions & intellectual functioning
- Pre-central gyrus = Voluntary movement

2. Parietal: Post-central gyrus = Primary center for sensation

3. Occipital: Primary visual receptor center

4. Temporal: Primary Auditory receptor center

Front 2

Other Parts of the Brain:
- Basal Ganglia
- Thalamus
- Hypothalamus
- Cerebellum

Back 2

1. Basal Ganglia: Additional bands of grey matter that form the subcortical associated motor system (Autonomic movement of body)

2. Thalamus: Main relay station for sensory pathways

3. Hypothalamus: Regulatory centre
- Regulates HR, BP, temp, sleep, appetite, coordination of ANS & pituitary glands

4. Cerebellum: Under occipital lobe, concerned with motor coordination of voluntary movements (Equilibrium & posture/position)

Front 3

Brain Stem: The central core of the brain

Back 3

1. Midbrain: Motor nerve fibres merge into thalamus and hypothalamus

2. Pons: Contain ascending/descending fibre tracts

3. Medulla: Contains all ascending/descending fibre tracts connecting brain and spinal cord
- Has vital autonomic centres (Resp, Cardio, GI)

Front 4

Sensory Pathways

Back 4

1. Lateral spinothalamic Tract (Pain & Temperature)
2. Anterior Spinothalamic Tract (Crude touch & pressure)
- Spinothalamic Tracts enter dorsal root of the spinal cord, synapse with second sensory neuron and the second order neuron then crosses to the oppisite side and ascends to the thalamus

3. Posterior/Dorsal Tract: Fine tough, position & vibration
- Fibres enter dorsal root, proceed up the same side as the spinal cord to the brain stem where it synapses at the medulla with the second sensory neuron, crosses to the opposite side and travels to the thalamus, synapses there and proceeds to the sensory cortex

Front 5

Motor Pathways

Back 5

1. Corticospinal or Pyramindal Tract: Voluntary movement
- Motor nerve fibres originate in motor cortex, travel to brain stem and crosses to the opposite side (May not always cross) then passes down the lateral column of the spinal cord

2. Extrapyramidal Tract: Muscle tone & gross movements
- Motor nerve fibres originate from motor cortex, brain stem, basal ganglia and spinal cord instead

Front 6

Cues to Neuro deficits or distrubances

Back 6

- Headaches
- Seizures/convulsions
- Altered cognition
- LOC
- Vertigo
- Aura
- Tremor
- Paresis
- Paralysis
- Paraesthesia
- Dysmetria
- Dysphagia
- Dysphasia
- Dysarthia

Front 7

Epilepsy

Back 7

A paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle movements and sensory disturbances. Seizures generally also occur.

Front 8

Vertigo

Back 8

Feeling of rotational spinning or severe dizziness

Front 9

Aura

Back 9

Subjective sensation the precedes seizure (may by auditory, visual, olfactory or motor)

Front 10

Tremor

Back 10

Involuntary shaking, vibrating or trembling

Front 11

Paraesis

Back 11

Weakening of the muscles/impaired movement

Front 12

Paralysis

Back 12

Loss of motor function due to lesion in the neurological or muscular system/ loss of sensory innervation

Front 13

Parasthesia

Back 13

Abnormal sensations (ex. Burning or tingling)

Front 14

Dysmetria

Back 14

Inability of controlling/coordinating muscle motion

Front 15

Dysphagia

Back 15

Difficulty swallowing

Front 16

Dysarthia

Back 16

Difficulty forming words

Front 17

Dysaphasia

Back 17

Difficulty with language comprehension

Front 18

Parkinson's Disease

Back 18

Chronic, degenerative, Neurological disorder affecting sensori-motor functioning
- Depletion of dopamine
- Loss of neurons in area responsible for dopamine production
- Initiation/coordination of smooth movement requires dopamine

Front 19

MS

Back 19

Chronic neurological disorder affecting motor, sensory and cerebellar functioning
- Inflammatory demyelination
- Progressive loss of myelin sheath

Front 20

Alzheimer's Disease

Back 20

Chronic neurological disorder affecting neural integration (Most common form of dementia).
- Plaques surround nerve/brain cells resulting in progressive brain cell death due to the tangling

Front 21

Huntington's Chorea

Back 21

Chronic neurological disorder affecting neural integration.
- Affects the neurons in the basal ganglia and cerebral cortex which then affects movement, coordination and thought processes (Commonly mistaken for as being "drunk")

Front 22

Patterns of motor system dysfunction

Back 22

- Cerebral palsy
- Muscular dystrophy
- Hemiplegia
- Parkinsonism
- Cerebellar
- Paraplegia
- Multiple sclerosis

Front 23

Cerebral Palsy

Back 23

Results from damage to cerebral cortex caused by a developmental defect, intrauterine meningitis or encephalitis, birth trauma, anoxia or kernicterus

Front 24

Muscular Dystrophy

Back 24

Chronic, progressive wasting of skeletal muscle, producing weakness, contractures and in severe cases, respiratory dysfunction and death

Front 25

Hemiplegia

Back 25

Damage to corticospinal tract (ex. stroke, CVA)
- Upper motor neuron damage occurs so motor impairment is on the opposite side

Front 26

Parkinsonism

Back 26

Defect of extrapyramidal tracts, in the region of the basal ganglia with the loss of dopaminee

Front 27

Cerebellar

Back 27

A lesion in one hemisphere produces motor abnormalities on the other

Front 28

Paraplegia

Back 28

Lower motor neuron damage caused by spinal cord injury (Spinal shock - No movement of reflex activity below level of lesion)

Front 29

Hydrocephalus

Back 29

Blocked Ventricle

Front 30

Glascow Coma Scale

Back 30

The rapid assessment of LOC
- Tests Eye opening response (1-4), Best verbal response (1-5) & Best Motor Response (1-6)
- Lowest score possible = 3 (Dead)
- Highest score possible = 15 (Fully alert)

Front 31

Examination: Mental status

Back 31

1. LOC (highest level of alertness or arousal to stimuli)
- Alertness to spontaneous, verbal, tactile and pain stimuli

2. Behaviour/ Appearance (Is it out of norm for patient)

3. Cognitive functioning (Memory, Knowledge)
- Orientation = Date, Place, Time

4. Language/Speech (Carry out normal conversation?)
- Pace, quality, articulation, word choice

Front 32

Examination: Cranial Nerves

Back 32

Cranial Nerve I = Olfactory
Cranial Nerve II = Optic
Cranial Nerve III = Oculomotor
Cranial Nerve IV = Trochlear
Cranial Nerve V = Trigeminal
Cranial Nerve VI = Abducens
Cranial Nerve VII = Facial
Cranial Nerve VIII = Acoustic
Cranial Nerve IX = Glossopharyngeal
Cranial Nerve X = Vagus
Cranial Nerve XI = Spinal Accessory
Cranial Nerve XII = Hypoglossal

Front 33

Cranial Nerve I

Back 33

Olfactory (Sensory) = Smell: Generally do not test

1. Sniff out of one nostril at a time
2. Closed eyes, sniff aromatic substance with each nostril

Front 34

Cranial Nerve II

Back 34

Optic (Sensory) = Visual Acuity and fields

1. Snellen Eye Chart
- Position person at 20 ft from chart, hand person opaque card to cover an eye at a time, remove only reading glasses, get them to read the smallest print possible = record fraction at end of last successful line read and indicate any missed letters /lenses were uses) Ex. 20/30-1, with glasses
- Near vision acuity: Cover eye with opaque card, Person hold page with writing 14 inches away, proceed like eye chart. Ex. 14/14 for each eye

2. Peripheral vision tested (BUNNY EARS!)
- Confrontation test:
(Position at eye level - 60 cm away from person, person covers one eye with card and other eye looks straight at you, cover your opposite eye that person is covering with card and use bunny ears

Front 35

Cranial Nerve III, IV & VI (PERRLA)

Back 35

Oculomotor (Motor) = Pupil rxn & eye movement
Trochlear (Motor) = Eye movement
Abducens (Motor) = Eye movement

1. Check pupils for size, regularity, symmetry, accomadation and dilation/constriction (Brisk)

2. Eye movements follow ranges of "Beetle legs"

Front 36

Cranial Nerve V

Back 36

Trigeminal (Both) = Teeth Clenth, open jaw and sensation on forehead, cheek & chin

1. Motor function: Palpate when teeth clenching (Masseter/temporal are equally strong) and palpate when person opens mouth and moves mandible side to side (Look for cracks)

2. Sensory Function: Use a cotton ball, person's eyes closed, test light touch on forehead, cheek and chin getting them to indicate when they feel the touch

3. Corneal reflex: Get person to remove lenses, bring in cotton wisp from the side while person is looking straight and lightly touch cornea

Front 37

Cranial Nerve VII

Back 37

Facial (Both) = Facial movement

1. Motor function:
- Focus on mobility and symmetry when person responses to requests of smiling, frowning, showing teeth, lift eyebrows, close eyes tightly and puff cheeks
- Press cheeks & note equality of air escape from both sides)

2. Sensory Function: Do not test, only when suspect facial nerve injury
- Taste test on tongue with cotton applicator soaked in solution of sugar, salt, or lemon juice and get person to identify taste

Front 38

Cranial Nerve VIII

Back 38

Acoustic (Sensory) = Hearing

1. Test hearing acuity through:
- Normal conversation
- The whisper test (moving person's tragus on one side and whispering 2-syllable words into the other)
- The Weber (Place fork on midline of skull and ask person if the hear tone in both ears or better in one) and/or Rinne (Air C > Bone C) tuning fork tests

Front 39

Cranial Nerve IX & X

Back 39

Glossopharyngeal (Both) = Uvula/palate movement
Vagus (Both) = Gag relfex

1. Motor Function:
- Use tongue depressor, note pharyngeal movement when person says "ahhhh"; uvula/palate should rise in midline and tonsillar pillars move medially.
- Touch posterior pharyngeal wall and note gag reflex, and voice sounds smooth not strained

2. Sensory function:
- Nerve IX does mediate taste on posterior 1/3 of tongue but too difficult to test

Front 40

Cranial Nerve XII

Back 40

Spinal Accessory (Motor) = Muscle tension/resistance

1. Check equal strength by asking person to rotate head forcibly against resistance applied to chin and do the same but with the shoulders

Front 41

Cranial Nerve XII

Back 41

Hypoglossal (Motor) = Tongue movement

1. Inspect tongue for symmetry and signs of atrophy and note the midline thrust as person sticks out tongue.
2. Ask person to say "Light, tight, dynamite" and note the sounds of letters L, T, D & N is clear/distinct

Front 42

Examination: Cerebellar Function

Back 42

- Coordination & balance

Front 43

Test Balance

Back 43

Be sure to demonstrate first
- Ask person to walk naturally across room and access gait (posture, movement, rhythm, symmetry and balance)
- Ask person to walk heel-to-toe (Tandem walking)
- Ask person to walk on heels
- Ask person to walk on toes

Front 44

Romberg Test

Back 44

Demonstrate first & stand near person to prevent any falls:
- Ask person to stand straight with their feet together and arms to the side (Note any swaying/unsteadiness)
- In same position, ask person to close eyes for 20 secs (Noting any imbalance)

Front 45

Test Coordination

Back 45

1. Finger nose movement:
- Ask person to touch tip of their nose with the tip of their finger then to touch your fingertip testing each hand separately

2. Finger to Finger test
- Ask person to touch their fingertip with the tip of you finger and test each hand separately, repeating this several times whilst moving your finger each time

3. Rapid alternating movements
- Ask person to slap their thigh with their palm first the back of the hand as fast as possible (PATTY-CAKE)
- Ask person to slide heel of their foot down the opposite side shin whilst sitting or lying down and repeat with the other heel and other shin

Front 46

Examination: Motor Function

Back 46

1. Observe and palpate muscle groups for atrophy

2. Assess strength and tone independently and against resistance (Note any involuntary movement tics or tremors

Front 47

Examination: Sensory Function

Back 47

Remember that:
- Spinothalamic tract = Pain, Temperature and light touch
- Posterior/dorsal tract = Vibration, Position and Fine touch

Front 48

Test Sensation

Back 48

With their eyes closed: Ask person to identify they feel sensation allowing 2 sec between each stimulation
1. Light Touch: Use cotton ball/kleenex to touch person

2. Superficial Pain Sensation: Use blunt and sharp ends of an object and get person to discriminate b/w to the 2

3. Motion/Position Sense: Move person's distal joints of the fingers/toes up and down and ask person to identify movements
- Get person to wiggle fingers and toes

4. Tactile Discrimination:
- Stereognosis (Give person common objects and identifies the item
- Graphesthesia (Tract # onto palm of person's hand facing toward them and person identifies # written)
- Two-point discrimination (Have 2 sharp point objects and touch person with either 1 sharp end or 2 and alternate between the two with each stimulation and ask person to identify if it's one or two points

Front 49

Examination: Reflexes

Back 49

Deep tendon reflexes: If diminished, get person to clench teeth or interlock fingers when performing other reflexes
- Score reflexes 0-4+ (2+ being average)
- Limbs should be relaxed and muscles partially stretched