Assessment Neuro, Muskulo, Respi in Word

8/8/2019 Assessment Neuro, Muskulo, Respi in Word

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Assessment:

The Neurologic Exam A. HEALTH HISTORY

INTERVIEW

onset, character, severity, location,duration, and frequency of symptoms and signs; associated complaints; precipitating, aggravating, and relieving factors; progression, remission,and exacerbation; and the presence or

absence of similar symptoms among family members

OBSERVATION

appearance, mental status, posture,movement and affect.

Review of the Medical History

System-by-system evaluation

B. C LINI C AL MANIFESTATIONS

1.1 PAIN

considered an unpleasant sensory perception and emotional experienceassociated with actual or potential tissuedamage or described in terms of suchdamage .

1.2 Seizures

1.3 Abnormal Sensation

1.4 Dizziness

1.5 Visual Disturbances

1.6 Weakness

S eizures are the result of abnormalparoxysmal discharges in the cerebralcortex, which then manifest as analteration in S ensation, B ehavior,

M ovement, P erception, or C onsciousness(SMBPC )

ex. tonic-clonic grand mal seizure, high fever ,alcohol or drug withdrawal, or hypoglycemia . Aseizure may also be the first obvious sign of abrain lesion .

Vertigo , a specific form of dizziness, isdefined as a sensation that is usually a

manifestation of vestibular dysfunction. Itcan be so severe as to result in spatialdisorientation, loss of equilibrium,

andnausea and vomiting.

Normal vision depends upon functioningvisual pathways through the retina andoptic chiasm and the radiations into the

visual cortex in the occipital lobes. ex.Nystagmus - associated with multiplesclerosis.

W eakness , specifically muscle weakness, isa common manifestation of neurologicdisease.

Numbness, abnormal sensation , or loss of sensation is a neurologic manifestation of both

central and peripheral nervous system disease.Numbness and weakness can significantly affectbalance and coordination.


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5 COMPO NENTS OF NEUROLOGIC ASS ESSM ENT

1 . Cerebral function, 2. Cranial nerves,

3. Motor system,

4. Sensory system, and

5. Reflexes

C erebral abnormalities may causedisturbances in mental status ,intellectual functioning, and thought content and in patterns of emotional behavior. There may also bealterations in perception, motor and language abilities, as well as lifestyle.

E xamination of the motor systemincludes an assessment of muscle size,tone, and strength, coordination, and

balance.

Assessing Cerebral Function

1 ) M ENTAL S TATUS

observing the patient s appearance and

behavior, noting dress, grooming, andpersonal hygiene, posture, gestures,movements, facial expressions, and motor

activity, speech and level of consciousness

2) INTELLECTUAL FUNCTIO N

Assessing thru serial 7s. Interpret well-known proverbs tests

abstract reasoning. Ability to recognize similarities. C an the patient make judgements

about situations .3) THO UG HT CO NTENT4) MO TO R ABILI TY 5) EMO TIO NAL S TATUS 6) P ERC EP TIO N7) LANG UAG E ABILI TY8) IMP ACT O N LIF ES TYLE

FG

Q UES TIO NS TO ASK ..

Is the patient s speech clear and coherent? Isthe patient alert and responsive, or drowsyand stuporous?

Assessing orientation to time, place, and

person assists in evaluating mental status.

Does the patient know what day it is, whatyear it is, and the name of the president of

the United States?

Is the patient aware of where he or she is?

Is the patient aware of who the examiner isand of his or her purpose for being in theroom?

Is the capacity for immediate memory

intact?

A person with an average IQ can repeatseven digits without faltering and can recitefive digits backward. The examiner might askthe patient to count backward from 100 or tosubtract 7 from 100, then 7 from that, and soforth (called serial 7s).


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C ranial Nerves and Its Function

Examining the C ranial Nerves


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Examining the M otor S ystem

Assessment of M USCL E SIZ E, TO NE(spasticity increased muscle tone,rigidity resistance to passive stretch), and FLACCIDI TY. S TRENG HT, COO RDI NATIO N andB

ALAN

CE.

MO TO R S YS TEM

The patient is instructed to walk across the room while the examiner observes postureand gait . The muscles are inspected, and palpated if necessary, for their size and symmetry.

Coordination in the hands and upper extremities is tested by having the patient performrapid, alternating movements and point-to-point testing .

F irst, the patient is instructed to pat his or her thigh as fast as possible with eachhand separately. T hen the patient is instructed to alternately pronate and supinate thehand as rapidly as possible.

Lastly, the patient is asked to touch each of the fingers with the thumb in aconsecutive motion. Speed, symmetry, and degree of difficulty are noted. Point-to-pointtesting is accomplished by having the patient touch the examiner s extended finger andthen his or her own nose. This is repeated several times. This assessment is then carriedout with the patient s eyes closed.

Romberg test is a screening test for balance.T

he patient stands with feettogether and arms at the side, first with eyes open and then with both eyes closed for20 to 30 seconds . S light swaying is normal , but a loss of balance is abnormal and isconsidered a positive Romberg test .

A stick figure may be used to record M USCL E S TRENG HT

5, full range of motion against gravity

and resistance;4, full range of motion against gravity and a

moderate amount of resistance;

3, full range of motion against gravity only;

2, full range of motion when gravity is

eliminated;

1 , a weak muscle contraction when muscle is

palpated, but no movement;

0, complete paralysis.


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TRIC EPS REFL EX-The examiner supports the patient s arm and identifies the tricepstendon by palpating 2.5 to 5 cm ( 1 to 2 in) above the elbow. A direct blow on the tendonnormally produces contraction of the triceps muscle and extension of the elbow.

B RACHI0RADI ALIS REFL EX-A gentle strike of the hammer 2.5 to 5 cm ( 1 to 2 in) abovethe wrist results in flexion and supination of the forearm.

P ATTELAR REFL EX- C ontractions of the quadriceps and knee extension are normalresponses.

ACHILL ES REFL EX-This reflex normally produces plantar flexion.

CLO NUS - When reflexes are very hyperactive, a phenomenon called clonus may beelicited. If the foot is abruptly dorsiflexed, it may continue to beat two or three timesbefore it settles into a position of rest.

CO RNEALREFL EX-is tested carefully using a clean wisp of cotton and lightly touching theouter corner of each eye on the sclera. The reflex is present if the action elicits a blink.C onditions such as a cerebrovascular accident or coma might result in loss of this reflex,either unilaterally or bilaterally. Loss of this reflex indicates the need for eye protectionand possible lubrication to prevent corneal damage.

G ag reflex- is elicited by gently touching the posterior pharynx with a cotton-tippedapplicator; first on one side of the uvula and then the other. Positive response is anequal elevation of the uvula and gag with stimulation.

P lantar reflex -is elicited by stroking the lateral side of the foot with a tongue blade orthe handle of a reflex hammer. Stimulation normally causes toe flexion. T oe fanning(positive B abinski ) is an abnormal response. Reflex indicative of central nervous systemdisease affecting the corticospinal tract.

Examining the Reflexes

1. Deep Tendon Reflexes ( biceps, brachioradialis, triceps,

patellar, and ankle reflexes or

achilles reflex)

2. Superficial or C utaneous reflexes corneal, gag or swallowing,

upper/lower abdominal,

cremasteric ( men only), plantar,

and perianal.

The motor reflexes are involuntary contractions of muscles ormuscle groups in response to abrupt stretching near the site of themuscle s insertion.

Testing these reflexes enables the examiner to assess involuntaryreflex arcs that depend on the presence of afferent stretchreceptors , spinal synapses , efferent motor fibers , and a variety of modifying influences from higher levels.


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G RADI NG OF D EEP TENDO N REFL EX

Assessment:

The M USK ULOSK ELETAL EXAMI NAT IO N

S cale of 0 to 4+4+ indicates a hyperactivereflex, often indicatingpathology;3+ indicates a responsethat is more brisk thanaverage but may be normalor indicative of disease;2+ indicates an averageor normal response;1 + indicates a hypoactiveor diminished response;and

0 indicates no response

D ERM ATOM ES

Reflexes S pinal cord

B iceps - C 5 ,C6 Triceps - C7,C 8

B rachio radialis - C 3,C6 P attelar - L2, L3, L4Achilles - S 1, S 2

A. HIS TO RY 1 . Interview

P atient s health status (onset of the problem, patient s perceptions andexpectations, concurrent health conditions, familialor genetic abnormalities, medication use andresponse to pain.2. Assessment D ata

pain, tenderness, tightness, and abnormalsensations(EX. P aresthesias) BO NE P AIN is characteristically describedas a dull, deep ache that is boring innatureM USC ULAR P AIN is described as sorenessor aching and is referred to as musclecramps.FRACTURE P AIN sharp and piercing and isrelieved by immobilizationBO NE INFECTIO N Sharp pain, with musclespasm or pressure on a sensory nerveJoint sprain or muscle strain Pain thatincreases with activityInfectious process (osteomyelitis), amalignant tumor, or neurovascularcomplications steadily increasing pain .


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B . P HYSIC AL ASS ESSM ENT

P osture- normal curvature of the spine is convex through the thoracicportion and concave through the cervical and lumbar portion.

AB NO RM AL CURVATURE N O RM AL CURVATURE

Inspection and palpation are used to evaluate the patient s posture, gait,

bone integrity, joint function, and muscle strength and size . In addition,assessing the skin and neurovascular status.

S pinal curves and trunk symmetry from posterior and lateral views. Gluteal

folds are normally symmetric, shoulder and hip symmetry.

When larger amounts of fluid are present, the patella becomes elevated

from the femur during knee extension and the ballottement test is

positive .

C . G AIT assessed by having the patient walk away from the examiner for a short

distance.

AB NO RM AL- unsteadiness or irregular movements (frequently noted

in elderly patients), limping motion, spastic hemiparesis gait (stroke),steppage gait (lower motor neuron disease), and shuffling gait (Parkinson s

disease).


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D. B one Integrity assessed for deformities and alignment.E. Joint Function evaluated by noting range of motion, deformity, stability, and nodular

formation.deformity may be caused by contracture (shortening of surrounding joint structures),

dislocation (complete separation of joint surfaces), subluxation (partial separation of

articular surfaces), or disruption of structures surrounding the joint. Slightly roughenedsurfaces, as in arthritic conditions , result in crepitus (grating, crackling sound orsensation) as the irregular joint surfaces move across one another.

F . M uscle S trength and S ize i. M uscle tone -palpating the muscle while passively moving the relaxed extremity.ii. M uscle strength - the patient perform certain maneuvers with

and without added resistance.AB NORMAL--clonus (rhythmic contractions of a muscle) in the ankle or wrist by

sudden, forceful, sustained dorsiflexion of the foot or extension of the wrist.F asciculations (involuntary twitching of muscle fiber groups).iii. M uscle size- the girth of an extremity- to monitor increased size due to exercise,

edema, or bleeding into the muscle. Girth may decrease due to muscle atrophy.iv. S kin v. Neurovascular S tatus ( ex.compartment syndrome)

C OMPAR TMENT SYNDROME--caused by pressure within a muscle compartment that increasesto such an extent that microcirculation diminishes, leading to nerve and muscle anoxiaand necrosis. Function can be permanently lost if the anoxic situation continues forlonger than 6 hours.

ASS ESSI NG THE THO RAX AND LUNGS

1 . Inspection (musculoskeletal structure, nutritional status, and the respiratory system, skinover the thorax for color and turgor, symmetry)


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2. P ALP ATIO N (tenderness, masses, lesions, respiratory excursion, and vocal fremitus. )

a) RESPI RATO RY EXCURSIO N- is an estimation of thoracic expansion and may disclose significantinformation about thoracic movement during breathing. Assesses the patient for range and symmetry of

excursion.

b) TA CTILE FREMI TUS - Sound generated by the larynx travels distally along the bronchial tree to set thechest wall in resonant motion. Air does not conduct sound well but a solid substance such as tissuedoes, provided that it has elasticity and is not compressed. Thus, an increase in solid tissue per unitvolume of lung will enhance fremitus; an increase in air per unit volume of lung will impede sound.Patients with emphysema, which results in the rupture of alveoli and trapping of air, exhibit almost notactile fremitus. A patient with consolidation of a lobe of the lung from pneumonia will have increased

tactile fremitus over that lobe. Air in the pleural space will not conduct sound.

3. P ERC USSIO N (to determine whether underlying tissues are filled with air, fluid, or solidmaterial. Also is used to estimate the size and location of certain structures within the thorax (eg,Diaphragm EX CURSION, heart, liver).

D ullness noted to the left of the sternum between the third and fifth intercostal spaces is a normal finding because it is the location of the heart

D ullness (abnormal)over the lung occurs when air-filled lung tissue is replaced by fluid or solid tissue.

DI AGP RHAGMIC EXCURSIO N-Maximal excursion of the diaphragm may be as much as 8 to 10 cm (3 to4 inches) in healthy, tall young men, but for most people it is usually 5 to 7 cm (2 to 2.75 inches).Normally, the diaphragm is about 2 cm ( 0 .75 inches) higher on the right because of the position of the

heart and the liver above and below the left and right segments of the diaphragm, respectively.Decreased diaphragmatic excursion may occur with pleural effusion and emphysema. An increase inintra-abdominal pressure, as in pregnancy or ascites may account for a diaphragm that is positioned

high in the thorax.

4. AUSC ULTATIO N (auscultates for normal breath sounds, adventitious sounds, and voice sounds)

B REATH SO UNDS


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AD VENTITIO US B REATH SO UNDS

Assessment Neuro, Muskulo, Respi in Word

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