Anatomy: The brain has four regions: the cerebrum, diencephalon, brain stem, and the cerebellum. The brain and spinal cord are protected by the meninges. Cranial nerves supply the motor and sensory tracts for the head and neck.
The Cerebrum interprets sensory input and is concerned with all voluntary muscular activity. It controls consciousness and is the center of memory, reasoning, intelligence and emotions.
The Cerebellum is concerned with coordination of voluntary muscular movement making it possible to walk or touch your nose with a finger.
The Diencephalon or the thalamus is a relay center of all sensory input from the body to the cerebrum. It activates or arouses the brain to consciousness. Example: You are asleep, the fire alarm goes off -sensory input hits the thalamus - it then activates the brain (turns on the computer) to action. If this area is injured, coma can result.
The Brain Stem connects the brain to the spinal cord. The cranial nerves branch off of it. Vital areas for the control of heart rate, blood pressure and respiration are found in the part of the midbrain called the medulla. The medulla is located above the first vertebrae. With swelling or bleeding in the skull pressure pushes the medulla down, damaging it against the vertebrae causing death due to loss of control to the heart, lungs and blood pressure. First signs of this problem are noticed in the cranial nerves - this is the reason they are checked following head injury.
Meninges are the fibrous and vascular coverings of the brain & spinal cord. If the skull is hit, the bone protects the brain from direct injury. But indirect injury can result if the brain is bounced against the hard bony inner surface of the skull. In between the skull and the brain are the meninges. This 'PAD' (Pia mater, Arachnoid, & Dura mater) protects the brain. The pia mater is a thin sheet that hugs the brain.
The arachnoid is the middle layer and is separated from the pia mater by the subarachnoid space, which is filled with cerebrospinal fluid. Cerebrospinal fluid acts to cushion the soft cranial and spinal cord tissue within their hard bony protective cases.
The dura mater is the tough fibrous sheath; it covers the arachnoid and lies against the skull. While the meninges protect the brain they can also be damaged and if bleeding occurs pressure can be exerted against the brain stem.
The 12 Cranial Nerves are motor, sensory or both. Knowing the function of each cranial nerve and how to examine them helps to identify the location of lesions in the brain and brain stem. The 12 cranial nerves and their functions must be memorized.
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CN |
Name |
Function |
M/S/B |
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I |
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II |
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III |
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IV |
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V |
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VI |
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VII |
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VIII |
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IX |
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X |
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XI |
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XII |
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THE NEUROLOGIC EXAMINATION:
ORIENTATION:
Person, Place & Time
CRANIAL NERVES
CNII-XII intact or report deficiencies
SENSORY
Dermatomes are areas of sensation and autonomic function in the skin which are served by CN V and specific nerve roots which comes off each of the vertebrae. The area of skin supplied by each nerve forms a band that can be mapped out on the skin. It is possible to localize the level of damage in the spinal cord and brain stem with the aid of a dermatome map. The types of sensation are Pinprick ( present, absent or increased/decreased with respect to other normal side), Light Touch (present or absent), Proprioception/Vibratory sense (present or absent), and 2 Point Discrimination (reported in mm. NORMAL is 5mm at finger tips).
MOTOR
Muscles are graded from five to zero and are reported as a number over the maximum possible ie 5/5 or 1/5. A "+" or "-" is added to denote slight differences the grades below.
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Normal |
+5/5 |
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Incompletely resists Examiner |
4/5 |
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Moves joint through a Range Of Motion against gravity |
3/5 |
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Moves joint through a Range Of Motion w/gravity removed |
2/5 |
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Muscle contracts but, no joint movement is achieved |
1/5 |
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No Movement |
0/5 |
Shoulder Abduction, C5
Elbow Flexion, C5,6
Wrist Extensors, C6
Wrist Flexors, C7
Finger Extensors, C7
Finger Flexors, C8
Finger Abductors, T1
Hip Flexors, T12-L3
Hip Adductors L2-L4
Hip Abductors, L4-S1
Knee Extensors, L2-L4
Foot Inversion, L4
Toe Extensors, L5
Foot Eversion, S1
Foot Plantarflexion, L5-S2
DTR’S
Deep tendon reflexes are used to evaluate the sensory and motor units of a particular spinal cord level. Reported as a fraction of the maximum (4). NORMAL is 2/4, ABSENT is 0/4 and HYPER-REFLEXIA is 4/4.
Biceps, C5
Brachioradialis, C6
Triceps, C7
Patellar, L4
Achilles, S1
CEREBELLAR FUNCTION
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Gait/Posture
Note the patient’s type of gait and ability to maintain their posture while sitting and or standing.
Finger-Nose Test:
The test begins with the patient’s upper arms in a horizontal plane with the elbows in full extension and eyes closed. The patient is instructed to alternately touch their index fingers to their nose. The sequence may be performed at varying rates and horizontal starting positions.
Nose-Finger-Nose Test:
The patient is instructed to alternately touch the tip of their index finger to the tip of their nose and the tip of the examiner’s finger. The examiner moves his/her finger about during several sequences. The examiner should ensure full extension of the patient’s elbow during this test.
Rapid Alternating Movements:
Pat knees alternating palms and the back of hands or touch fingers to the thumb rapidly
Romberg test:
Ask the patient to stand, feet together with arms at their sides, first with their eyes open then closed. Loss of balance indicates a cerebellar problem and is a positive Romberg sign.
OTHER TESTS
Babinski:
Using a pointed object stroke the plantar side of the foot from the heel to the ball of the foot. Dorsiflexion of the great toe, fanning of the toes or both dorsiflexion of the great toe and fanning of the toes constitutes a positive Babinski, ie loss of brain inhibition of a spinal reflex.
Pronator Drift:
With the patient in the Romberg’s position have the patient raise their arms in front of them palms up. Note whether the supinated hands slowly pronate once the eyes are close. If only one hand pronates an intra cranial lesion is possible.
Head
Tension Headaches:
The most common type of headache, usually the result of involuntary muscle contraction of the head, neck or shoulder. Occurs daily and is associated with depression, anxiety, tension or fatigue. Headaches that are worse on arising in the AM are usually related to depression. They may persist for days, weeks, or months.
S: Dull persistent headache that circles the head in a "hat band" & "feels like a tight band around my head." May be alternatively located in the occiput.
O: Normal neurologic examination. May have TTP over the Occiput, Neck and/or Shoulder muscles.
A: Tension HA
P: Tylenol (Acetaminophen) 325 mg, 2 TAB PO Q4 D#24
FFD, f/u PRN
If depressed, refer to Physician.
Migraine Headaches:
S: Periodic, throbbing, severe, frequently unilateral, pain maybe triggered by specific foods (chocolate), EtOH, menstruation, oral contraceptives, stress or fatigue. Associated with nausea, vomiting, photophobia and sensitivity to sound. Classic migraines are preceded by a visual prodrome such as flashing lights, blind spots, or hemianopsia. Common migraines don’t have a prodrome. Relieved by sleep.
O: Normal neurologic examination.
A: Migraine HA
P: Refer to physician.
Cluster Headaches:
S: Severe unilateral periocular, throbbing pain occurs at the same time every day lasting from minutes to a few hours. They come in clusters and last weeks to months and then subside. f Relief with sleep. Usually G.
O: Autonomic dysfunction, miotic pupil, ptosis, red eye, and/or Uni-lateral nasal congestion
A: Cluster HA
P: Refer to physician.
Meningitis/Encephalitis:
S: Unrelenting HA, stiff neck, backache, fever, nausea, vomiting or irritability and confusion.
O: Fever, nuchal rigidity, Brudzinski’s sign (attempt to flex the neck results in reflex flexion of the knee and hip), Kerning’s sign (with thigh flexed on the abdomen patient resists knee extension <135o). Increased
WBC. Mental status change (confusion to coma), seizures, focal neurologic signs such as paralysis indicate encephalitis.
A: Meningitis or Encephalitis
P: Immediate Referral to physician.
Seizures
S: Altered level of consciousness, postictal confusion or fatigue, paresis, H/O seizures or head trauma
O:
A:
P: Protect the Patient
Immediate referral to physician.
Closed Head Trauma:
S: HA and/or painful scalp/face. f LOC, neurologic signs or neck pain. H/O blunt trauma.
O: TTP w/o bone pain or step off, Soft tissue swelling, ecchymosis, normal ocular, jaw and neck ROM. Normal neurologic exam including mental status.
A: Closed Head Trauma or Facial Contusion
P: LLD x 2 days, f/u PRN
Tylenol (Acetaminophen) 325 mg, 2 TAB PO Q4 D#24
Head trauma education/sheet
Immediate Referral to physician if FX, LOC or abnormal ROM or neurologic signs/exam
Open Head Trauma:
S: HA, painful scalp and/or face/neck pain,
O: Laceration, hemorrhage or bony step off
A: Open head trauma
P: Control hemorrhage
Immediate referral to physician.
Facial Laceration:
S: Sharp or blunt trauma with resultant pain.
O: Laceration, hemorrhage or bony step off
A: Facial Laceration
P: Control hemorrhage
Immediate referral to physician.
Eyes
Blepharitis:
Hordeolum (stye):
Chalazion:
Conjunctivitis:
Corneal Abrasions:
Burns:
Retinal Detachment:
Glaucoma:
Iritis:
Ears
Otitis Externa:
Otitis Media:
Serous Otitis Media:
Nose
Rhinitis:
Sinusitis:
Nasal Fracture:
Epistaxis:
Throat
Pharyngitis:
Peritonsillar Abscess (PTA):
Neck
Fracture:
Cervical Sprain/Strain:
Hyperthyroidism:
Hypothyroidism:
Lymphadenopathy:
Chest Wall
Rib Fracture:
Flail Chest:
Chostochondritis:
Strained Muscle:
Lungs
Asthma:
Bronchitis:
Pneumonia:
Simple Pneumothorax:
Open Pneumothorax:
Tension Pneumothorax:
Hemothorax:
Cardiovascular
Hypertension:
Angina Pectoris:
Myocardial Infarction:
Varicose Veins:
Superficial Venous thrombophlebitis:
Deep Venous Thrombophlebitis:
Gastrointestinal & Abdomen
Umbilical Hernia:
Abdominal Strain:
Gastroesophageal Reflux:
Ulcer:
Gastritis:
Gastroenteritis:
Enteritis:
Hepatitis:
Pancreatitis:
Cholelithiasis:
Appendicitis:
Constipation:
Rectum
Internal Hemorrhoids:
External Hemorrhoids:
Anal Fissure:
Perirectal Abscess:
Genital Urinary System
Urolithiasis:
Pyelonephritis:
Cystitis:
Prostatitis:
Epididymitis:
Urethritis:
Inguinal Hernia:
Hydrocele, Spermatocele, Varicocele:
Testicular CA:
Cryptorchidism:
Back
Fracture:
Thoracic or Lumbar Sprain/Strain:
Radiculitis:
Cauda Equina Syndrome:
Extremities
Fractures:
Dislocations:
Tendonitis:
Sprain/Strain:
Compartment Syndrome:
Osgood Schlatter’s Disease:
Patellar — Femoral Syndrome:
Acute Arthritis:
Dorsal Wrist Ganglion:
Subungual Hematoma:
Paronychia:
Skin
Urticaria:
Acne:
Folliculitis, Furuncle, Carbuncle:
Abscess:
Impetigo:
Cellulitis:
Pityriasis Rosea:
Psoriasis:
Tinea pedis:
Tinea cruris:
Tinea versicolor:
Eczema:
Seborrhea:
Atopic Dermatitis:
Scabies:
Verrucae:
Pediculosis pubis:
Skin CA:
