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Neurological Assessment

This overview provides an in-depth look at the anatomy of the nervous system, covering central and peripheral components, including the brain, spinal cord, cranial, and spinal nerves. It discusses the cerebral cortex's functions, motor coordination, and the role of various brain regions such as the thalamus and hypothalamus. The assessment of neurological function involves evaluating mental status, cranial nerves, sensory and motor exams, and reflex arcs. Understanding symptoms like headaches, seizures, or weakness aids in diagnosis, while knowledge of anticholinergic effects is crucial for patient safety.

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Neurological Assessment

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  1. Neurological Assessment

  2. Anatomy of Nervous System • Central • Brain • Spinal cord • Peripheral • Cranial Nerves • Spinal Nerves

  3. Brain • Cerebral cortex (“rind”) – gray matter • Frontal • Parietal • Temporal • Occipital • Wernicke’s area – receptive aphasia • Broca’s area – expressive aphasia

  4. Brain • Basal ganglia: motor function • Thalamus: relay station • Hypothalamus: HR, BP, sleep, etc. • Cerebellum: motor coordination • Brain stem • Midbrain • Pons • Medulla: respiration, heart, GI function, CN 8 - 12

  5. Spinal Cord • Nerve cell bodies arranged in “horns” • Nerve pathways cross in the spinal cord • Eg. Sensation of the left side of the body enters the left dorsal horn, and crosses to the right ventral horn and travels to right hemisphere • Sensation • Spinothalamic tract: pain, temperature, crude and light touch • Posterior columms: does not cross sides; position, vibration, finely localized touch

  6. Spinal Cord • Motor pathways • Corticospinal (Pyramidal) tract: • All go through the medulla’s pyramid • Crossed • Uncrossed • Finer body movements • Extrapyramidal • Cruder movement (walking) • Upper vs Lower motor neurons

  7. Peripheral Nervous System • Reflex arc • Deep tendon reflexes: requires • Intact sensory nerve • Functional synapse • Motor Nerve • Competent Muscle • Superficial • corneal, abdominal • Visceral • Pupillary light, accommodation • Pathologic

  8. Cranial Nerves • Mnemonic: “Oh Oh Oh, To Taste And Feel Very Good Veal Simply Heaven”

  9. Spinal Nerves • Cervical 8 • Thoracic 12 • Lumbar 5 • Sacral 5 • 1 Coccygeal • Sensory in dorsal horns; motor in ventral • Dermatome

  10. Functional Divisions • Autonomic vs. Somatic Nervous System • Sympathetic vs. Parasympathetic • Primary sympathetic neurotransmitter is Norepinephrine, so sympathetic system is called “adrenergic” • Primary sympathetic neurotransmitter is Acetylycholine, so parasympathetic system is called “cholinergic”

  11. History • Headache • Head injury • Dizziness/Vertigo • Seizures • Tremors • Weakness • Incoordination

  12. History Cont • Numbness or tingling • Difficulty Swallowing • Difficulty Speaking • Environmental/occupational hazards • Past Medical History • Social History: smoking, drugs, alcohol • Medications

  13. Anticholinergic Symptoms • Mydriasis • Dry, flushed skin • Hallucinations • Agitation • Hyperthermia • Urinary retention • Delayed intestinal motility (constipation) • Tachycardia • Seizure

  14. Anticholinergic Mnemonic • Blind as a bat • Dry as a bone • Red as a beet • Mad as a hatter • Hot as a hare

  15. Phenobarbital Oxybutynin (20%) Isosorbide dinitrate Hydroxyzine Warfarin Dipyridamole Codeine Ranitidine (10%) Dyazide Furosemide (Lasix) Nortriptyline (3%) Drugs with Anticholinergic Effects • Atropine (100% of maximal anticholinergic effect) • Scopolamine • Tolterodine • Hyoscyamine • Cholinergic Parkinsonism agents • Prednisone (55%) • Diphenhydramine (Benadryl) • Amitriptyline (Elavil) • Digoxin • Nifedipine

  16. Physical Exam • Mental Status, Pyschiatric • Cranial Nerves • Sensory exam • Motor exam

  17. Level of Consciousness Speech Orientation Knowledge of Current events Judgment Abstraction Vocabulary Emotional responses Memory Calculation ability Object recognition Praxis Mental Status

  18. Cranial Nerves • 1. Olfactory – have patient identify smell • 2. Optic – Eye chart, visual fields, fundus • 3,4,6. Oculomotor, Trochlear, Abducens – PERRLA, positions of gaze, nystagmus • 5. Trigeminal Nerve: chewing muscles, facial sensation, corneal reflex • 7. Facial nerve: smile, frown, close eyes, puff cheeks

  19. Cranial Nerves • 8. Test hearing, Weber, Rinne tests • 9, 10. Glossopharyngeal and Vagus Nerves – Soft palate and uvula movement; gag reflex • 11. Spinal Accessory Nerve: head movement; shrug shoulders • 12. Hypoglossal – Tongue movement; “light, tight, dynamite”

  20. Sensation • Eyes closed • Avoid leading questions • In general, if distal is intact, proximal will also be intact • Spinothalamic tract • Pain: sharp or dull • Temperature • Light touch

  21. Sensation • Posterior Column Tract • Vibration sense • Position • Tactile discrimination • Stereognosis • Graphesthesia • Two point discrimination • Extinction • Point location

  22. Motor • Muscle • Size • Strength • Tone • Involuntary Movement • Cerebellar • Balance: • Gait, • Tandem walking • Romberg, • One legged squat

  23. Motor • Cerebellar • Coordination • Rapid alternating movement • Knee slapping • Finger to thumb • Finger to finger • Finger to nose • Heel to shin

  24. Deep Tendon Reflexes • Tests sensory and motor function • Biceps • Brachiradialis • Triceps • Quadriceps (patellar) • Achilles

  25. Additional Tests • Clonus • Superficial reflexes • Abdominal • Cremasteric • Plantar reflexes

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