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Premium member Presentation Transcript The Neurologic Examination: The Neurologic Examination Hosam atef,MD LECTURER OF ANESTHEIOLOGYThe Neurologic Examination: The Neurologic Examination Pain, a nervous system event, is a presenting symptom in many neurologic disorders. Therefore, a pain practitioner should have a good understanding of the nervous system in regards to anatomy and pathophysiology to safely navigate the waters of patient care.The Neurologic Examination: The Neurologic Examination Lesion localization is the hallmark of neurologic diagnosis The History and Physical are the first and major components of lesion localization.The Neurologic Examination: The Neurologic Examination Cognitive Status Level of arousal Alert - awake, attentive Lethargic - may drift off from attentiveness Obtunded/semicomatose - will arouse to noxious stimuli briefly, inattentive Comatose - does not arouse to any stimuli Orientation to person, place, and time Mini Mental Status Examination, if indicatedThe Neurologic Examination: The Neurologic Examination Cranial Nerve Testing I - (olfactory) smell II - (optic) visual acuity, visual fields, fundi III, IV, VI - (oculomotor, trochlear, abducens) pupillary response, ptosis, eye movements V - (trigeminal) corneal reflex, facial sensation, masseter and temporalis movement VII - (facial) raise eyebrows, close eyes, show teeth, smile, corneal reflex VIII - (acoustic) hearing IX, X - (glossopharyngeal, vagus) midline palate, clear speech XI - (spinal accessory) shoulder shrug, turn head against resistance XII - (hypoglossal) midline tongue protrusionThe Neurologic Examination: The Neurologic Examination Motor Testing pronator drift muscle strength (scale of 1-5) grip strength toe/heel walk specific muscle groups as indicated tone spasticity rigidityThe Neurologic Examination: The Neurologic Examination Radial Nerve - C5-C8 Elbow/wrist extension, finger extension Median Nerve - C6-T1 Wrist, thumb, index & middle finger flexion, thumb opposition (thenar eminence atrophy), bends wrist radially Ulnar Nerve - C8-T1 Wrist, ring, and small finger flexion (claw deformity), adduction/abduction of fingers, hypothenar eminence atrophyThe Neurologic Examination: The Neurologic Examination Musculocutaneous nerve - C5-C6 biceps strength/elbow flexion, forearm supination Axillary nerve - C5-C6 deltoid strength, adduction of arm Long thoracic nerve - C5-C7 elevate arm above horizontal (winging of scapula)The Neurologic Examination: The Neurologic Examination Femoral nerve - L2-L4 Knee extension, hip flexion Obturator nerve - L2-L4 Hip adduction Sciatic nerve - L4-S3 - knee flexion Tibial nerve - L4-S3 - foot inversion, ankle plantar flexion Common Peroneal nerve - L4-S2 - foot eversion, ankle dorsiflexion (foot drop)The Neurologic Examination: The Neurologic Examination Sensory Testing light touch pain temperature vibratory sense position senseThe Neurologic Examination: The Neurologic ExaminationThe Neurologic Examination: The Neurologic Examination Cerebellar Testing Finger-nose-finger Heel-shin Gait Rhomberg - actually, tests 3 systems - proprioception, vestibular sense, and cerebellar functionThe Neurologic Examination: The Neurologic Examination Reflexes grade from I-IV (I=decreased, II=normal, III=increased, IV=pathologic) Biceps - C5 Brachioradialis - C6 Triceps - C7 Knee Jerk - L3/L4 Ankle Jerk - S1 Clonus - more than 2-3 beats of clonus suggest upper motor neuron dysfunction Babinski - upgoing toe on plantar stimulation suggests upper motor neuron dysfunction Hoffman’s - thumb jerk on middle finger flexion suggest upper motor neuron dysfunction Jaw Jerk - if increased, then lesion above the cervical spineThe Neurologic Examination: The Neurologic Examination Testing Neuroimaging CT MRI plain film xrays Ultrasound Neurophysiologic Testing EMG/NCV CPT Evoked Potentials EEG Sleep Studies Autonomic TestingThe Neurologic Examination: The Neurologic Examination Laboratory W/U CBC, platelets Serum chemistry profile, LFTs ESR, C-reactive protein ANA, Rheumatoid factor HIV, Hep C, Lyme, RPR etc, etc, etc…….The Neurologic Examination: The Neurologic Examination Anatomic Localization Localize the lesion to one of the following regions: muscle neuromuscular junction peripheral nerve root spinal cord brainstem cerebellum subcortical brain cortex Begin distally, and work proximally until the lesion location is identified by history and physicalThe Neurologic Examination: The Neurologic Examination Anatomic Localization muscle proximal weakness symmetric weakness normal sensation reflexes normal or slightly reduced muscles usually normal in size without atrophy neuromuscular junction resembles muscle, except fatigability is hallmarkThe Neurologic Examination: The Neurologic Examination Anatomic Localization peripheral nerve distal weakness asymmetric or symmetric weakness denervation changes wasting/shrinking of muscle (atrophy) fasciculations sensory changes diminished reflexes trophic changes to skin?The Neurologic Examination: The Neurologic Examination Anatomic Localization nerve root pain asymmetric weakness denervation (atrophy, fasciculations) proximal or distal possibly decreased reflexes depending on root pain to nerve root stretch (straight leg raising, etc)The Neurologic Examination: The Neurologic Examination Anatomic Localization Spinal cord sensory level distal, symmetric, spastic weakness bowel/bladder dysfunction Extensor weakness > flexor weakness increased tone increased reflexes clonus extensor plantar response no atrophy or fasciculationsThe Neurologic Examination: The Neurologic Examination Anatomic Localization Brainstem Dysfunction cranial nerve palsies long tract signs as in spinal cord disease crossed findings cerebellar findings Cerebellar Dysfunction ataxia of arms (tremor, difficulty with targeted movements) ataxia of legs (wide based, staggering gait) brainstem dysfunctionThe Neurologic Examination: The Neurologic Examination Anatomic Localization subcortical lesions language spared usually hemibody motor dysfunction higher cortical functions spared usually hemibody sensory dysfunction visual field loss cortical lesions language may be involved primary sensations spared, but higher functions requiring sensory processing affected (stereognosis, graphesthesia) hemi motor loss usually incomplete (eg face and arm, not leg; or vice versa) visual processing affected (eg recognizing faces) no visual field cut seizuresThe Neurologic Examination: The Neurologic ExaminationThe Neurologic Examination: The Neurologic ExaminationThe Neurologic Examination: The Neurologic Examination References The Four-Minute Neurologic Examination , Stephen Goldberg Bickerstaff’s Neurologic Examination in Clinical Practice , 6th edition, by John Spillane Dejong’s The Neurologic Examination , 5th edition, byArmin F. 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