1. Neurological Examination Physical Diagnosis III Steve Sager, MPAS, PA-C

14. Abnormal Movements

15. Abnormal Movements

16. Abnormal Movements

17. Abnormal Movements

19. Key components of H&P Complaint Hx P.E. Altered mental status Associated seizure activity; recent trauma or infection; illicit drug use; exposure to toxic substances Mental status exam; pupillary reaction; corneal reflexes; gag reflexes; posturing/motor asymmetry; Babinski Vertigo Differentiate between true vertigo and lightheadedness! Present at rest; affected by positional changes CN VIII function; Dix-Hallpike maneuver; nystagmus Headache Thorough hx; “worst headache ever?”; associated sx’s; neck pain/stiffness CN function; pupillary reaction; fundoscopic exam; palpate temporal artery; Marcus-Gunn Seizures Previous hx; frequency; motor activity; aura; LOC; post-ictal confusion; external etiology Search for focal deficits; signs of trauma; hyperreflexia Weakness Generalized or focal; loss of strength; pain; progressive or recurrent fatigue Asymmetry7; atrophy; sensory deficits; fasciculations; DTRs

33. Glasgow Coma Scale

45. Abnormalities of Thought Processes Circumstaniality Indirection and delay in reaching a point because of unnecessary detail. Loose Associations Person shifts from one unrelated subject to another. Flight of Ideas Almost continuous flow of accelerated speech with abrupt topic changes. Incoherence Incomprehensible because of illogic, lack of meaningful connections, abrupt topic changes, or disordered word use/grammar. Confabulation Fabrication of facts or events to fill in gaps in impaired memory. Perseveration Persistent repetition of words or ideas. Echolalia Repetition of the words or phrases of others. Neologisms Invented or distorted words. Blocking Sudden interruption in mid-sentence or before completion of an idea. Clanging Person chooses a word based on sound instead of meaning.

46. Abnormalities of Thought Content Obsessions Recurrent, uncontrollable thoughts, images, or impulses that a persons considers unacceptable or strange Compulsions Repetitive acts that a person feels driven to perform to prevent or produce some unrealistic future state of affairs. Delusions False, fixed, personal beliefs that are not shared by other members of the person’s culture. Phobias Persistent, irrational fears; accompanied by a compelling desire to avoid the stimulus. Anxieties Apprehensions, fears, or tensions that may be free-floating or focused (i.e. phobia). Feelings of Unreality A sense that things in the environment are strange, unreal, or remote. Feelings of Depersonalization A sense that one’s self is different, changed, or unreal. Identity is lost.

53. Dix-Hallpike maneuver

56. Testing for Aphasia Word Comprehension Comprehension of spoken language through recognition (“point to your nose”) or understanding (“Can dogs fly?”). Repetition Repeat items of increasing complexity. Note the fluency and accuracy of the responses. Naming Name a series of objects or colors. Gradually increase difficulty. Note the fluency and accuracy of the responses. Reading Comprehension Have the patient follow several simple written commands. Writing Ask the patient to make up and write a sentence.

68. Neuro Exam - Shoulder Nerve Motor Sensory Reflex C5 abduct arm, flex biceps lateral arm (axillary n.) biceps C6 extend wrist, flex biceps lateral forearm, 1 st & 2 nd digits (musculocutaneous n.) brachioradialis C7 flex wrist, extend fingers, extend forearm middle finger triceps C8 hand instrinsics, finger flexors Medial forearm/ 4 th & 5 th digits (medial antebrachial cutaneous n.)

69. Neuro Exam - Spine Nerve Motor Sensory Reflex T1 hand intrinsics, finger abduction finger adduction medial Arm (medial antebrachial cutaneous n.) L1 inversion of foot medial aspect of foot/calf Patellar L5 dorsiflexion of big toe dorsum of foot and lateral calf S1 eversion of foot lateral aspect foot and sole Achilles S5 anal sphincter tone

82. EOM Innervations Muscle Innervation Primary action Secondary action Tertiary action Medial rectus CN III Adduction Superior rectus CN III Elevation Intortion Adduction Inferior rectus CN III Depression Extortion Adduction Inferior oblique CN III Extorsion Elevation Abduction Superior oblique CN IV Intorsion Depression Abduction Lateral rectus CN VI Abduction

83. CN III: Clinical correlation

86. Left Trochlear (CN IV) palsy

88. Abducens Nerve (CN VI) Palsy

98. Aphasia Broca’s Wernicke’s Word comprehension Fair Impaired Repetition Impaired Impaired Naming Impaired Impaired Reading comprehension Fair Impaired Writing Impaired Impaired

108. Common Gait Abnormalities

109. Function and Innervations 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

110. Function and Innervations Motor Function Muscles Primary Nerve Origin KNEE EXTENSION Quadriceps L2, L3, L4 KNEE FLEXION Hamstrings L4, L5, S1, S2 FOOT DORSIFLEXION Tibialis Anterior Deep peroneal L4, L5 ANKLE PLANTAR FLEXION Gastrocnemius mainly S1 EXTENSION OF GREAT TOE Extensor hallicus longus L5

111. Grading Muscular Response Grade Muscular Response 0 No contraction detected 1 Barely detectable flicker or trace of contraction 2 Active movement with gravity eliminated 3 Active movement against gravity 4 Active movement against gravity and some resistance 5 Active movement against resistance without evident fatigue - “Normal”

114. Peripheral Nerve Injuries Nerve Motor function impaired Radial (C5-C8) Elbow & wrist extension (wrist drop); extension of the fingers at the MCP joints; triceps reflex Median (C6-T1) Wrist flexion and radial deviation; flexion of thumb and index/middle fingers; thumb opposition; forearm pronation Ulnar (C8-T1) Wrist flexion and ulnar deviation; flexion of the ring & little fingers; abduction/adduction of the fingers Musculocutaneous (C5-6) Elbow flexion; forearm supination; biceps reflex Axillary (C5-6) Abduction, flexion and extension of the shoulder Femoral (L2-L4) Hip flexion; knee extension; patellar reflex Obturator (L2-L4) Hip adduction Sciatic (L4-S3) Knee flexion Tibial (L4-S3) Foot inversion; ankle plantarflexion; Achilles reflex Common peroneal (L4-S2) Foot eversion; ankle & toe dorsiflexion (foot drop)

119. Testing the nerves of the upper extremity

121. Sensory distribution of the hand

122. Testing the nerves of the upper extremity