Dr. Juan Ramón Meriño Smith. MSc Consultant Neurologist ASSESSMENT OF THE NEUROLOGICAL SYSTEM Dr. Juan Ramón Meriño Smith. MSc Consultant Neurologist The Gambia 2009

A complete Neurological assessment include: Assessment of mental status and level of consciousness Sensation Cranial nerves Motor and cerebellar function Reflex

Assessment parameter Assessment skill Comments Mental status. Level of consciousness Note general appearance, affect, speech content, logic, memory, judgment and speech patterns during the history If any abnormality or Inconsistencies are evident, perform full mental status assessment Perform GCS with Motor and pupil assessment If GCS < 15 perform full assessment of mental status and consciousness If motor assessment is abnormal or asymmetrical, perform complete motor and sensory assessment

Assessment parameter Assessment skill Comments Sensation Assess pain and vibration in The hands and feet, light Touch on the limbs If deficits are identified, perform a complete sensory assessment Cranial nerves Assess CN II, III, IV, VI: Visual acuity, gross visual fields, funduscopy examination, pupillary reaction and EOM If any abnormalities exist, perform a complete assessment of all XII CN Assess CN VII, VIII, IX, X, XII: Facial expression, gross hearing, voice and tongue

Assessment parameter Assessment skill Comments Motor system Muscle tone and strength, Abnormal movements, grasps If deficits are noted, perform a complete motor system assessment Cerebellar function Observe the patient’s: Gait on arrival Ability to: Walk heel-to-toe Walk on toes Walk on heels Hop in place 3. Check Rhomberg’ s sign If any abnormalities exist, perform a complete cerebellar assessment

Assessment parameter Assessment skill Comments Reflexes Assess the muscle stretch reflex and the plantar response If an any abnormal response is elicited, perform a complete reflex assessment

GLASGOW COMA SCALE (GCS) An international method for grading neurological response of the injured or severely ill patients. It is used for patients who have the potential for rapid deterioration. The GCS assess three parameters of consciousness: eye opening, verbal response and motor response. Verbal response Eyes open Motor response Oriented ---------------- 5 Confused -------------- 4 Inappropriate --------- 3 Incomprehensible --- 2 None --------------------- 1 Obey commands --------- 6 Localize pain -------------- 5 Withdrawal ---------------- 4 Flexion abnormal--------- 3 Extension abnormal ---- 2 None -------------------------- 1 Spontaneously ------ 4 To speech ------------- 3 To pain ----------------- 2 None -------------------- 1

LEVEL OF CONSCIOUSNESS (LOC) Response to stimuli Pupil response Pathophysiology Prognosis Confusion GCS=14 Spontaneous but may be inappropriate. Memory faulty. Reflex intact Normal Metabolic derangement. Diffuse brain dysfunction Good chance of recovery. Must treat primary cause Lethargy GCS=13-14 Requires stimulus to respond (verbal, touch). Reflex intact Normal to unequal Metabolic derangement. Medications, Increased ICP Superficial Stupor GCS=12-13 Requires vigorous continuous stimuli to respond unequal or sluggish

Responds to pain . No cognitive response. Reflexes abnormal Normal LEVEL OF CONSCIOUSNESS (LOC) LOC Response to stimuli Pupil response Pathophysiology Prognosis Deep Stupor GCS=8-10 (Permanent Vegetative state) Responds to pain . No cognitive response. Reflexes abnormal Normal Anoxic ischemic insults Irreversible Superficial Coma GCS=6-8 Locked-in syndrome Awake and aware respond with eyes only Lesion in pons All four extremities and cranial nerves paralyzed. Myasthenia Gravis. Acute polyneuritis Poor prognosis

LEVEL OF CONSCIOUSNESS (LOC) Response to stimuli Pupil response Pathophysiology Prognosis Moderate coma GCS=3-6 Abnormal. Varied response to pain. Reflex abnormal or absent Abnormal dilated or pinpoint Anoxia. Traumatic injury. Space- occupying lesion. Cerebral edema Prognosis depend on length of time in coma Brain Death GCS<3 No response Reflexes abnormal or absent Anoxia. Structural damage Irreversible

Cranial Nerves Olfatory Optic Oculomotor Trochlear Trigeminal Abducens VII. Facial Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal accessory XII. Hypoglossal Cranial Nerves

REFLEXES Deep tendon reflexes Biceps Triceps Brachioradialis Patellar Achilles Superficial or cutaneous reflexes Abdominal Cremasteric Plantar Bulbocavernosus

C. Triceps D. Patellar

CEREBELLAR FUNCTION Coordination: Gait Station: Rhomberg’s Test Fingertip-to- Nose Touch Rapid Alternating Hand Movement Heel Slide Figure eight Gait Station: Rhomberg’s Test

THANK YOU