Physical Assessment Class 3

Daily Tasks**Spot Test and assessment 1 (Class materials from1-2)**Goals:• Understand significant features of a neurological history• Know the complete sequence of cranial nerve examinations ,

adding CN VII-XII in addition to last weeks material• Understand the organizing principles of the neurologic

examination: symmetry versus asymmetry and localization of findings to the central nervous system versus peripheral nervous system.

• Learn about examination of the motor system, including bulk, strength, tone and cerebellar function; rapid alternating movements; finger to nose (F-->N); Heel to Shin (H-->S) and features of various gait types.

• Wrap up general assessment of the Central Nervous system and Cranial Nerves

CN VII: What it innervates

Testing CN VII

*CN VII Testing

Sensory: anterior 2/3 of tongue taste buds Motor: facial expression muscles (smile

showing teeth, raise eyebrows, scowl)Parasymp: sublingual and submandibular salivary glands, lacrimal, nasal mucosa

CN VIII

*CN VIII Function

Cochlear Branch: hearing1. Rub fingers on either side of head with patient’s eyes closed. Get a general feel of where and when the sound is heard2. Rinne’s Test3. Weber’s Test

Vestibular Branch: equilibrium testing

*CN VIII Testing

*CN VIII Testing

• Vestibular component is difficult to independently test, but can be tested using cold water flushing in ear canal

• Overall history and assessment of sensory system, cognitive function, cerebellar function can help lead to a diagnosis of vestibular pathology

CN IX: glossopharyngeal nerve

*CN IX

Sensory: posterior 1/3 of tongue; pharynx

Motor: pharyngeal muscles (swallowing), check with swallow and gag reflex (afferent component)

Parasymp: parotid salivary gland

CN IX and X

*CN X: Vagus Nerve

Sensory: from thoracic & abdominal viscera (heart, lungs, GI tract)

Motor: pharynx (check gag reflex: motor component) & larynx (listen to speech)

Parasymp: HT, LU, abd organs

CN IX and X: Testing

*CN XI: Spinal Accessory/Accessory Nerve

CN XI supplies motor and sensory control to the Sternocleidomastoid & Trapezius muscles: Test muscle strength with active and resisted motions

CN XI: Spinal Accessory/Accessory Nerve

CN XI

*CN XII:

• tongue muscles

CN XII: Hypoglossal Nerve

CN XII

*CN XII

• Test by having patient stick out tongue. Look for deviation to one side (side of weakness), fasciculations, atrophy

Spot test and Practice!

• Test each other on cranial nerves I-XII• Perform task at Spot Test when I come around

to you and your partner

*Review: CN VII-XIICN VII: Check smile, frown, scowl, wink. Ask

about lacrimation, salivation, tasteCN VIII: test hearing with finger rub, Rinne’s, and

Weber’s test. Ask about equilibriumCN IX & X: Gag reflex, have patient swallow, ask

about taste, listen to voice and look at soft palate deviation with “AH” sound

CN XI: Test SCM and Trapezius muscle strengthCN XII: Have patient protrude tongue and look

for deviation

Understanding Upper and Lower Motor Neuron Lesion Signs

• Injury to a neuron can be seen on physical exam with various signs which depend upon where the injury is located. If the injured neuron is an upper motor neuron it often has certain signs, just like a lower motor neuron injury has distinct characteristics.

• Review what an upper and lower motor neuron are…

*Understanding Upper and Lower Motor Neuron Lesion Signs

• An upper motor neuron connects the primary motor cortex of the precentral gyrus of a cerebral hemisphere with a synaptic junction to a lower motor neuron cell body (often located )in the ventral horn of the spinal cord

• A lower motor neuron travel then from the ventral horn of the spinal cord, out the ventral root through the spinal nerve (to either ventral or dorsal rami) and then to a named nerve (ex: musculocutaneous nerve) to a specific group of now innervated muscles (the musc. cutaneous nerve supplies the biceps brachii muscle))

*More about UMNL and LMNL

*Upper Motor Neuron Lesion (UMNL) Signs

• Loss of distal extremity strength (ex: weakness in hands)• Loss of distal extremity dexterity (poor hand control, dropping

objects, etc.)• A Babinski sign • Increased muscle tone, either

– Spasticity (clasp knife-like weakness)– Rigidity (feels like bending hard plastic…constant resistance through

range of motion)• Hyperreflexia( increased reflex muscle jerk reactions)• “Clasp-knife phenomena”: giveaway weakness at the end

range of a muscle test (like closing a swiss army knife)

Babinski Reflex

*Lower Motor Neuron Lesion (UMNL) Signs

• Loss of muscle strength and tone• Loss of reflexes due to denervation• Muscle wasting and atrophy• Denervation hypersensitivity noted by

fasciculations (tiny, ongoing contractions of fascicles within a muscle)

*Other Motor System Exams

• Cerebrocerebellar Tests: These test cerebellar coordination with cerebrum

1) Finger-to-nose: have patient close their eyes and try to touch their index finger to their nose

2) Heel-to-shin: have patient with their eyes closed run their heel down their skin (superior to inferior)

3) Rapidly alternating movements: have patient flip both hands from supination to pronation and back again many times in rapid succession

*Other Motor System Exams

• Common abnormal Gaits1) Neuropathic Gait Demonstration2) Myopathic Gait Demonstration3) Parkinsonian Gait Demonstration

• Neuropathic Gait DemonstrationThis type of gait is most often seen in peripheral nerve disease where the distal lower extremity is most affected. Because the foot dorsiflexors are weak, the patient has a high stepping gait in an attempt to avoid dragging the toe on the ground.

• Myopathic Gait DemonstrationWith muscular diseases, the proximal pelvic girdle muscles are usually the most weak. Because of this the patient will not be able to stabilize the pelvis as they lift their leg to step forward, so the pelvis will tilt toward the non-weight bearing leg which results in a waddle type of gait.

• Parkinsonian Gait DemonstrationThis type of gait is seen with rigidity and hypokinesia from basal ganglia disease. The patient's posture is stooped forward. Gait initiation is slow and steps are small and shuffling; turning is en bloc like a statue.

*Muscle Strength Nerve Root Levels

Biceps – C5-6Brachioradialis – C5-6Triceps – C7Finger Flexors – C8Finger abduction and thumb opposition-T1L2 – Hip flexionL3 – Knee extensionL4 – Knee flexionL5 – Ankle dorsiflexonS1 – Ankle plantar flexion

• The next slide is an interesting and helpful chart to help understand and examine a patient with weakness

Putting it together

• A patient that has a larger distribution of pain or neurological symptoms will have a more centralized lesion (closer to the spinal cord, in the spinal cord, or other CNS location). Also metabolic disorders can result in symmetrical loss/change in reflexes (ex: diabetes)

• Ex: compare a patient with numbness along the T1 dermatome verses a patient that has arm and leg numbness

Putting it together

• Similarly, if a patient has unilateral (asymetrically) altered reflexes in the C5 & C6 levels, how is that different from a patient that has bilateral (symetrically) altered reflexes in the C5 & C6 levels?

• What if all reflexes are diminished?

• Muscle testing of all muscle levels will be reviewed in a later class

Epilepsy and other causes of convulsive activity

• Non-epileptic causes of seizure:– Fever– Drug reaction– Hypoxia– Hypoglycemia

Epilepsy and other causes of convulsive activity

• Know causes of epilepsy:– Vascular (AV malformation, aneurysm)– Tumor (glioblastoma)– Head trauma (subdural hematoma)– Metabolic (diabetes)

Review:

• Make sure that you understand the concepts of CN I-XII and how to test these

• Understand the differences between UMNL and LMNL, and be able to write or describe their associated findings

• Be able to test cerebrocerebellar function• Recognize common gait abnormalities and their

significance• Understand common causes of seizure disorders• Start to learn muscle testing nerve root levels