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The Neurologic Exam

The Neurologic Exam. Rachel Hindin Department of Medical Education Washington University School of Medicine April 16, 2008. Outline. Central vs. peripheral nervous system CNS Brain Spinal cord PNS 12 pairs of cranial nerves Spinal/peripheral nerves Pathways Motor Sensory

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The Neurologic Exam

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  1. The Neurologic Exam Rachel Hindin Department of Medical Education Washington University School of Medicine April 16, 2008

  2. Outline • Central vs. peripheral nervous system • CNS • Brain • Spinal cord • PNS • 12 pairs of cranial nerves • Spinal/peripheral nerves • Pathways • Motor • Sensory • Neurologic exam • Mental status • Cranial nerves • Motor system • Sensory system • Deep tendon reflexes

  3. CNS: Brain • Four regions • Cerebrum • Diencephalon • Brainstem • Cerebellum • Cerebrum: Two hemispheres, four lobes each • Frontal • Parietal • Temporal • Occipital

  4. CNS: Brain function

  5. CNS: Gray vs. white matter • Gray matter • Aggregations of neuronal cell bodies • Rims the surface of the cerebral hemispheres -> cerebral cortex • White matter • Neuronal axons coated with myelin • Myelin sheaths allow nerve impulses to travel more rapidly

  6. CNS: Spinal cord • Cylindrical mass of nerve tissue protected by bony vertebral column • Pathways • Motor • Sensory • Five segments • Cervical (C1-8) • Thoracic (T1-12) • Lumbar (L1-5) • Sacral (S1-5) • Coccygeal

  7. PNS: Cranial nerves • Twelve pairs of special nerves emerge from within the skull • Functions • Motor • Sensory • Specialized (smell, vision, hearing)

  8. PNS: Cranial nerves

  9. PNS: Peripheral nerves • Nerves that carry impulses to and from the spinal cord • Thirty-one pairs of nerves • Nerve structure • Anterior (ventral) root – motor fibers • Posterior (dorsal) root – sensory fibers • Anterior and posterior roots merge to form spinal nerve • Spinal nerves join with nerves from other levels to form peripheral nerves • Spinal cord structure • Gray matter (nerve cell bodies) surrounded by white matter (nerve fibers connecting brain to peripheral nervous system)

  10. PNS: Peripheral nerves

  11. Motor pathways • Motor pathways: regulate motor activity • Corticospinal (pyramidal) tract • Mediates voluntary mvmt and integrates skilled mvmt • Basal ganglia system • Maintains muscle tone, controls gross autonomic mvmts • Cerebellar system • Coordinates motor activity, maintains equilibrium and posture

  12. Sensory pathways • Sensory pathways • regulate reflexes, conscious sensation, regulate internal autonomic functions (BP, HR, respiration) • Sensory fibers sense stimuli (pain, temperature, position, touch) -> stimuli pass through peripheral nerves to spinal cord -> peripheral nerve synapses with neuron that then relays impulse to brain • Spinothalamic tract • Pain, temperature, crude touch • Posterior columns • Position, vibration, fine touch

  13. Neurologic exam • Mental status • Cranial nerves • Motor • Sensory • Deep tendon reflexes

  14. Mental Status • Level of consciousness • Alert • Lethargic • Obtunded • Stuporous • Comatose

  15. Mental status • Cognition

  16. Mental status • Dementia: decline in cognition • Delirium: acute and relatively sudden decline in attention-focus, perception, and cognition • Aphasia: disorder in producing or understanding language • Wernicke’s • Broca’s • Agnosia: inability to recognize and identify known objects or persons • Amnesia: memory loss • Apraxia: inability to do simple or routine tasks

  17. Cranial nerve functions (I-IV)

  18. Cranial nerve functions (V-VII)

  19. Cranial nerve functions (VIII-XII)

  20. Cranial nerve functions (XI-XII)

  21. Motor system • Body position - observe • hemiplegia • Involuntary movements - observe • tremors, fasciculations, chorea, oral-facial dyskinesia • Muscle bulk – inspect muscle contour • atrophy • Muscle tone – assess resistance to passive stretch • spasticity, rigidity, flaccidity • Upper motor neuron - spasticity • Lower motor neuron - flaccidity • Muscle strength - test • grading scale

  22. Muscle strength grading scale

  23. Motor system: coordination • Rapid alternating movements • Clumsy, slow movements • Point-to-point movements • Clumsy, unsteady movements • Gait • Stance (Romberg test) • Loss of balance that appears when eyes are closed

  24. Sensory system • Pain • Temperature • Light touch • Vibration • Position • Discriminative function

  25. Deep tendon reflexes • Reflex grading: • Reflex: involuntary stereotypical response involving as few as two neurons, one sensory (afferent) and one motor (efferent) across a single synapse • Relayed over structures of both PNS and CNS

  26. Deep tendon reflexes • Biceps (C5, C6) • Triceps (C6, C7) • Brachioradialis (C5, C6) • Knee (L2, L3, L4) • Ankle (S1) • Plantar response (L5, S1)

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