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  2. • Personal H: – Handness – Occupation (driver) • C/O: – Onset, course & duration • Family H: – Heredofamilial ataxia – Familial periodic paralysis – Peroneal mus. atrophy • Past H: 2 T Trauma, TB 2 S Syphilis, Similar attack 2 H HTN, Heart disease 2 D DM, Drugs 1 E ENT 1 F Fever • HPI: – 12 items History
  3. HPI • Motor • Sensory • Trophic • Cranial n • ↑ ICT • Fits • Speech • Sphincter • Gait • Mental • Hypoth • Other
  4. Motor • Involuntary: extra ∆ , fasiculation • State • Tone • Weakness • Ataxia (cerebellum) •Dist or prox •Stat or Kinetic •Disappear e sleep or Not •UL or LL •Rt or Lt •Dist or Prox •Flexor or Extensor •Abductor or Adductor •Drunken gait •Intension tremors •dysdidoko •+ve romberge •Improve on bed
  5. Sensory • Superficial: Pain, Temp, Touch • Deep: Position, Mov., Vibr. • Cortical: Steriog, T. loc., T. discr. • Ulcers: (N.B. : painless) If +ve : pattern •Sensory level •hemihypoth •Glove & stock •Jacket loss Trophic changes or deformities
  6. Cranial n • ①: • Anosmia • ②: • Acuity • Field • ③,④,⑥: • Diplopia • Ptosis • Squint • ⑤: • Sensory • Pain,Temp • Motor • Masticat. • ⑦: • Sensory • Tast ant ⅔ • Motor • Eey clos. • Mouth clos. • ⑧: • Deaf • Tinitus • Vertigo • ⑨, ⑩: • Dysph (phar) • N. regur (palat) • N. tone (palat) • Hoarsn (lary) • ⑪: • Shoulder elev • neck side mov • ⑫: • Tounge mov
  7. ↑ ICT • Papilledema • Headache • Vomiting • Aura • Post effect • Cons. Loss • Gener. Or local • March Fits
  8. Speech • Aphasia: (higher neurolo. center lesion): – Receptive(sensory): • Spoken(Auditory)(aud recogn area lesion) • Written(Visual)(visual recogn area lesion) – Expressive(motor): • Spoken (broca’s area lesion) • Written(Agraphia)(exner’s area lesion) • Dysarthria: (articul system lesion): – ∆: bilateral→ slurred (psudobulbar) – Extra ∆ → slow monotonus – Cerebellar → stacatto – Cr n → slurred (true bulbar)
  9. Sphincters • Consciousness • Hallucination • Memory Gait Mental
  10. Hypothalamus • D.I. • Polyphagia • Hypogonadal • Hypersomnia • Hyperpyrexia Other systems affection
  11. Examination • Motor • Sensory • Trophic • Cranial n • ↑ ICT • Fits • Speech • Sphincter • Gait • Mental • Hypoth • Other • General examination • Neurological examination:
  12. Mental • Consciousness • Memory • Mode • Orientation • Behavior • Intelligence
  13. EXAMINATION – LEVEL OF CONSCIOUSNESS (AROUSAL) Level of Consciousness (Arousal): Techniques and Patient Response Level Technique Abnormal Response Alertness Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact). Lethargy Speak to the patient in a loud voice. For example, call the patient’s name or ask, “How are you?” A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep. Obtundation Shake the patient gently, as if awakening a sleeper. An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. Stupor Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli are needed.) A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment. Coma Apply repeated painful stimuli. A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.
  14. Glasgow Coma Scale
  15. Speech Read Sorat El Fateha • Aphasia: (higher neurolo. center lesion): • Dysarthria: (articul system or Cr n. lesion): Trophic changes or deformities
  16. Motor • Involuntary: extra ∆ , fasiculation • State • Tone • Weakness • Ataxia (cerebellum) • Reflexes •Dist or prox •Stat or Kinetic •Disappear e sleep or Not •UL or LL •Rt or Lt •Dist or Prox •Flexor or Extensor •Abductor or Adductor •Drunken gait •Intension tremors •dysdidoko •+ve romberge •Improve on bed •Rapid alternating movem •Finger-to-Nose /Finger •Heel-to-Knee Test •Romberg’s Test •Gait Sensory or Cerebellar ataxia: •-ve romberg •Intension tremors
  17. Tone • 6 joints + don’t forget support before joint • Tone is the resistance appreciated when moving a limb passively • “Normal Tone” • Hypotonia – “Central Hypotonia”:shock UMNL, cerebellar – “Peripheral Hypotonia”: LMNL, myopathy • Hypertonia – Spasticity (Corticospinal Tract = ∆ ) – Rigidity (Basal Ganglia, Parkinson’s = extra ∆ )
  18. Flexion at the elbow (C5, C6, biceps) Extension at the elbow (C6, C7, C8, triceps) Extension at the wrist (C6, C7, C8, radial nerve) Squeeze 2 fingers as hard as possible ("grip," C7, C8, T1) Finger abduction (C8, T1, ulnar nerve) Oppostion of the thumb (C8, T1, median nerve) Flexion at the hip (L2, L3, L4, iliopsoas) Adduction at the hips (L2, L3, L4, adductors) Abduction at the hips (L4, L5, S1, G. medius and minimus) Extension at the hips (S1, gluteus maximus) Extension at the knee (L2, L3, L4, quadriceps) Flexion at the knee (L4, L5, S1, S2, hamstrings) Dorsiflexion at the ankle (L4, L5) Plantar flexion (S1) Weakness: examine the following
  19. Muscle(s) Function Primary Nerve Origin DELTOID Shoulder abduction Axillary C5-C6 BICEPS Elbow flexion Musculocutaneous C5, C6 TRICEPS Elbow extension Radial C6, C7, C8 WRIST EXTENSORS Radial C6, C7, C8 WRIST FLEXION Median C6, C7 HAND GRIP Grasp Fingers Median C7, C8, T1 FINGER ADDUCTION Median C7-T1 FINGER ABDUCTION Ulnar C8, T1 THUMB OPPOSITION Median C8, T1 HIP FLEXION Iliopsoas L2, L3, L4 HIP EXTENSION Gluteus maximus S1 Quadriceps Knee extension L2, L3, L4 Hamstrings Knee flexion L4, L5, S1, S2 Tibialis anterior Foot dorsiflexion Deep peroneal L4, L5 Gastrocnemius Ankle plantar flex mainly S1 Ext hallicus longus Extens of great toe L5 Weakness: examine the following
  20. Upper limb: Shoulder: Adduction Abduction Flexion Extension Lat rotation Med rotation serratus ant. Elbow: Flexion Extension Wrist: Flexion Extension Weakness: examine the following Hand Thumb Oppon pollicis Abd pollicis Add pollicis Flexor pollicis Exte pollicis Other fingers: Abductors Adductors Flexion Extension Lumbricalis Abdom. mus: Flexion Lower limb: Hip: Flexion Extension Adduction Abduction Knee: Flexion Extension Ankle: Dorsiflexion Planter flexion Trunk mus: extension C4 C5 C5 C6 C7 C7 C8 C8 T1 T7- T12 L1,2 L2,3,4 L4,5 L5, S1 S1,2 S1,2
  21. Grading Motor Strength Grade Description 0/5 No muscle movement 1/5 Visible muscle movement, but no movement at the joint 2/5 Movement at the joint, but not against gravity 3/5 Movement against gravity, but not against added resistance 4/5 Movement against resistance, but less than normal 5/5 Normal strength
  22. Deep (tendon jerks) UL • BICEPS • BRACHIORADIALIS • TRICEPS LL • KNEE + clonus • ANKLE + clonus Reflexes & clonus Superficial reflexes • Corneal • Grasp • Gag (palatal) • Planter • Abdominal • Cremastric • Anal C5,6 C6,7 L2,3,4 S1,2 S1,2 T6-12 L1 S3,4,5 Abnormal Deep reflexes • Jaw jerk • Wartenberg • Finger jerk • Hofman • Patelal jerk • Adductor jerk Technique Babiniski Scratsh From below up- lat to medial Chaddock The skin under and around the lateral malleolus is stroked in a circular fashion. Gonda’s Flex 3 rd & 4 th toes 7 release suddenly Oppenheim press to the anterior surface of the tibia, stroking down to the ankle. Gordon Compressing the calf muscles Schaefer Pinching the Achilles tendon enough to cause pain. Sure signs of ∆????
  23. EXAMINATION – REFLEXES: SCALE FOR GRADING Reflexes are usually graded on a 0 to 4+ scale 4+ Very brisk, hyperactive, with clonus 3+ Brisker than average; possibly but not necessarily indicative of disease (no clonus) 2+ Average; normal 1+ Somewhat diminished; low normal 0 No response
  24. Sensory • Superficial: Pain, Temp, Touch (one ⅟2, Rt & Lt, derm) • Deep: Position, Mov., Vibr., N & M • Cortical: Steriog, T. loc & discr., Graph. If +ve : pattern •Sensory level •hemihypoth •Glove & stock •Jacket loss
  25. Cranial n • ① - smell • ② - Acuity: ( Snellen chart, Counting finger, Hand mov., Light perception) - Fields ( confrontation) - Fundus - Colour vision • ③,④,⑥- Ocular mov. - Ptosis, Myosis or Mydriasis - Reflexes: • Light: (direct & consensual) • Accomodation • Ciliospinal Partial ptosis+ Miosis+ Anhdrosis+ Enophthalm = ?? Complete ptosis+ Mydriasis+ Diverg squint = ??
  26. Cranial n • ⑤ - Sensory: (ophth., maxillary, mandibular) - Motor: (massiter, temporalis, tregoid) - Reflexes: • Corneal • Jaw : if +ve = bilateral ∆ lesion above pons (above ⑤ nc.) • ⑦ - Sensory: (Tast ant ⅔ of tounge) - Motor: (frontalis, orbic occul., buccinator, retractor angulii, orbic oris) - Reflexes: • glabellar • ⑧ - Nystagmus - Hearing ⑤→⑦ ⑤→⑤ ⑦→⑦ Rapid phase toward H pendular occular H fix i.e. (lesion) cerebel H Away from (norm) vestib V vertical stem
  27. Cranial n • ⑨,⑩ -Say AHH = palatal movement ⑩ Move up = normal deviate to healthy = LMNL Move No movement -Palat reflex -Pharyn reflex ⑤→⑩ ⑨→⑩ Exag bilat= Bilateral UMNL Lost bilateral= Bilateral LMNL
  28. Cranial n • ⑪ - Shoulder elev (trapezius) - Neck side mov (sternomastoid) • ⑫ - Observation ( atrophy, fascic) - Midline protrusion (Deviation, invol. movem ) - Power Sphincters ↑ ICT
  29. Gait Other systems affection Classical Patterns of Abnormal Gait •Parkinsonism Gait •Hemiparetic Gait •Ataxia Gait •Waddling Gait (Hip Girdle Weakness) •High Stepping Gait