NEUROLOGICAL ASSESSMENT

• Outline of Neurological Assessment

  • Mental Status
  • Cranial Nerves
  • Motor System
  • Reflexes
  • Sensory System
  • Cerebellar System
  • Meningeals
• Goals of Neurologic Assessment

  • Know if there are any lesions and where specifically in the nervous system the lesion is located
  • Determine the cognitive state of the patient
• Tools


  • Measuring tape
  • Stethoscope
  • Good penlight
  • Transparent ruler
  • Ophthalmoscope/otoscope
  • Tongue depressors (3)
  • Dark vial with coffee granules/tobacco fibers
  • Dark vial with sugar/salt
  • Tuning fork (256 freq)
  • Cotton balls, cotton buds
  • Pins (large safety pins) or pinwheel
  • Tongue depressor
  • Reflex hammer
  • Coins of various sizes
  • Keys, paper clips
  • BP apparatus
  • Jaeger chart/Newspaper clipping/A picture with a story – laminated
  • Halsted-Wepman chart – laminated
• Keypoints to Remember


  • Learn the complete range of tests
  • Familiarize with the procedure and explain them well beforehand
  • Give clear instruction
  • Prepare tools you will need ahead of time
• Mental Status and Level of Consciousness

  Anatomically, this will give you an idea what happens in areas like Cerebral Cortex primarily the frontal lobe, temporal lobe, and we are also looking at the Ascending Reticular Activating System (for level of consciousness)
• Observe level of consciousness

  1. Consciousness – the awareness of the person, self-awareness, as well as awareness of his surroundings

  2. Requisites of consciousness: Arousal (or wakefulness) and Awareness (or content)
• Levels of Consciousness


  • Alert
  • Lethargic (somnolent)
  • Obtunded
  • Stupor
  • Comatose
• Observe for the general behavior

  Acting normally on his age, sex, or occupation? Dressed neatly, slovenly or appropriately for age and occasion? Immobile, catatonic, hyperactive, agitated, quiet?
• Stream of talk and speech

  Flow of speech
• Mood


  Observe facial expressions and display of his emotions
• Content of thought


  Illusions, auditory or visual hallucinations, delusions of grandeur, persecution, paranoia, hypochondriasis
• Intellectual capacity


  General evaluation of patient's intellectual capacity (Bright, average, dull, demented, retarded, or with delayed development or speech)
• Attention span


  Ask the patient to spell a word and then ask them to spell it backwards, or count backwards by 7 from 100 (serial 7's)
• Orientation


  Three spheres (time, place, and person)
• Memory


  Immediate recall, Short term recall, Recent memory, Remote memory
• Fund of information


  Reflects the patient's awareness of current events or what is going on around him
• Calculation


  Serial 7's
• Insight and judgement


  Involves the patient's judgement in given critical situation, and refers to the patient's recognition of his illness and its implications
• Cranial nerves happen in the nucleus primarily in the brainstem
• Cranial Nerves


  • CN 1: Olfactory
  • CN 2: Optic
  • CN 3: Oculomotor
  • CN 4 & 6: Trochlear and Abducens
  • CN 5: Trigeminal
  • CN 7: Facial
  • CN 8: Acoustic
• Olfactory Nerve (CN 1)


  Ask the client to close his/her eyes then sniff and identify aromatic substances (coffee granules or tobacco fibers); one nostril at a time
• Anosmia


  Inability to identify correct scent
• Optic Nerve (CN 2)


  Visual acuity (test one eye at a time), Visual field testing/ visual confrontation test
• Abnormal findings for Optic Nerve

  Difficulty reading Snellen chart, missing letters, squinting, Holds print closer than 14 inches or farther away, Loss of visual fields
• Oculomotor Nerve (CN 3)


  Assess directions of gaze by asking client to follow moving objects, Pupillary light reflex and consensual light reflex, Accommodation
• Abnormal findings for Oculomotor Nerve

  Ptosis, Nystagmus, Strabismus, Dilated (6-7 mm) or constricted pupils, Unilateral response
• Trochlear (CN 4) and Abducens (CN 6) Nerves


  Assess directions of gaze by asking client to follow moving objects
• Trigeminal Nerve (CN 5)


  Corneal reflex, Assess light touch and pain sensation across the face, Opening the mouth against resistance and moving the jaw from side to side
• Facial Nerve (CN 7)

  Ask the client to raise eyebrows, frown, or wrinkle forehead, shut eyes tightly while you try to pry them open, smile, close mouth, puff cheeks, identify sweet tastes on front of the tongue (2/3 of the tongue)
• Acoustic Nerve (CN 8)

  Gross hearing, Weber's test, Rinne's test, Schwabach's test, Air conduction
• Loss of visual fields

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• CN 3: OCULOMOTOR

  • Assess directions of gaze by asking client to follow moving objects
  • Pupillary light reflex and consensual light reflex
  • Accommodation
  • Ptosis
  • Nystagmus
  • Strabismus
  • Dilated (6-7 mm) or constricted pupils
  • Unilateral response
• CN 4 & 6: THROCHLEAR AND ABDUCENS


  • Assess directions of gaze by asking client to follow moving objects
• CN 5: TRIGEMINAL


  • Corneal reflex
  • Assess light touch and pain sensation across the face
  • Opening the mouth against resistance and moving the jaw from side to side
• CN 7: FACIAL


  • Ask the client to: (to check for symmetry)

  Raise eyebrows, frown, or wrinkle forehead

  shut his eyes tightly while you try to pry them open

  smile

  close his mouth

  puff his cheeks

  have client to identify sweet tastes on front of the tongue (2/3 of the tongue)
• CN 8: ACOUSTIC


  • Gross hearing
  • Weber's test
  • Rinne's test
  • Schwabach's test
  • Air conduction must be greater than bone conduction
• CN 9, 10, AND 12: GLOSSOPHARYGNEAL, VAGUS, AND HYPOGLOSSAL NERVE


  • Observe the patient's speech, articulation, tone volume and quality of voice
  • Observe if there are any drooling of saliva
  • Ask him to swallow cough
• CN 11: ACCESSORY


  • Sternocleidomastoid muscle
  • Trapezius muscle
• MOTOR SYSTEM


  • Inspection of the body contours, postures, and gait

  Palpation

  Muscle strength testing
• THE MATCHING PRINCIPLE


  Select movements that are neither too strong for you to overcome nor too weak for you to judge the resistance; match your strength to the strength of the patient