1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 1 Welcome to Mosby’s Guide to PHYSICAL EXAMINATION, 6th edition

2. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 2 Chapter 22 Neurologic Systems

3. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 3 Anatomy and Physiology The central nervous system (CNS)—brain and spinal cord—is the main network of coordination and control for the body.

4. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 4 Neurologic System (1)  Peripheral  Parts ● Motor and sensory nerves ● Ganglia outside the CNS  Function ● Carries information to and from CNS Anatomy and Physiology

5. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 5 Neurologic System (2)  Autonomic  Parts ● Sympathetic: prods body to action during periods of physiologic and psychologic stress ● Parasympathetic: functions in a complementary and counterbalancing manner to conserve body resources and day-to-day functions (e.g., digestion and eliminations) Anatomy and Physiology

6. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 6 Neurologic System (3)  Receives sensory stimuli from environment  Identifies and integrates adaptive processes needed to maintain current body functions  Orchestrates body function changes required for adaptation and survival Anatomy and Physiology

7. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 7 Neurologic System (4)  Integrates rapid responsiveness of central nervous system with more gradual responsiveness of endocrine system  Controls cognitive and voluntary behavioral processes  Controls subconscious and involuntary body functions Anatomy and Physiology

8. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 8 Neurologic System (5)  Divisions  Central  Peripheral  Functions  Maintains and controls body functions  Responses  Voluntary  Autonomic Anatomy and Physiology

9. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 9 Neurologic System (6)  Central Nervous System (CNS)  Parts Brain Brain Spinal cord Spinal cord  Function Coordination and control for body Coordination and control for body Anatomy and Physiology

10. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 10 Brain (1)  Brain and spinal cord protected by:  Skull  Vertebrae  Meninges  Cerebrospinal fluid (CSF)  Meninges produce and drain CSF.  CSF circulates in and around brain as shock absorber. Anatomy and Physiology

11. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 11 Brain (2)  Brain Circulation  Arterial Internal carotids Internal carotids Vertebral Vertebral Basilar Basilar  Venous Jugular veins Jugular veins Anatomy and Physiology

12. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 12 Brain (3)  Cerebrum  Frontal lobe Voluntary skeletal movement Voluntary skeletal movement Fine repetitive movement Fine repetitive movement Control of eye movement Control of eye movement  Parietal lobe Processes sensory data Processes sensory data  Occipital lobe Interprets visual data Interprets visual data Anatomy and Physiology

13. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 13 Brain (4)  Cerebrum - continued  Temporal lobe Perception and interpretation of sounds Perception and interpretation of sounds Integration of taste, smell, and balance Integration of taste, smell, and balance  Limbic system Mediates behavior patterns for survival Mediates behavior patterns for survival Sense of smell Sense of smell Anatomy and Physiology

14. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 14 Brain (5)  Cerebellum  Aids in integration of voluntary movement  Processes sensory information  Uses sensory data for reflex control Muscle tone Muscle tone Equilibrium Equilibrium Posture Posture Anatomy and Physiology

15. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 15 Brain (6)  Brainstem  Parts Medulla oblongata Medulla oblongata Midbrain Midbrain Pons Pons Diencephalon Diencephalon  Function Pathway between cerebral cortex and spinal cord Pathway between cerebral cortex and spinal cord Controls many involuntary functions Controls many involuntary functions Anatomy and Physiology

16. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 16 Brain (7)  Cranial Nerves  Twelve nerves originate from brain  Functions ● Motor ● Sensory ● Parasympathetic Anatomy and Physiology

17. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 17 Brain (8)  Basal Ganglia  Function ● Extrapyramidal pathway ● Processing station between motor cortex and upper brainstem ● Gross intentional movement without conscious thought Anatomy and Physiology

18. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 18 Spinal Cord and Spinal Tracts (1)  Spinal cord  Spinal cord begins as a continuation of medulla oblongata.  Fibers grouped into tracts run through spinal cord and carry sensory, motor, and autonomic impulses between higher centers and the body.  Myelin-coated white matter contains ascending and descending tracts.  Gray matter contains nerve cell bodies. Anatomy and Physiology

19. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 19 Spinal Cord and Spinal Tracts (2)  Descending spinal tracts –corticospinal, reticulospinal, and vestibulospinal  Originate in the brain  Convey inhibitory or facilitatory impulses to various muscle groups Corticospinal tract permits skilled, delicate, and purposeful movements. Corticospinal tract permits skilled, delicate, and purposeful movements. Vestibulospinal tract causes extensor muscles to contract suddenly when falling. Vestibulospinal tract causes extensor muscles to contract suddenly when falling. Corticobulbar tract innervates the motor functions of the cranial nerves. Corticobulbar tract innervates the motor functions of the cranial nerves. Anatomy and Physiology

20. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 20 Spinal Cord and Spinal Tracts (3) ● Upper motor neurons  Comprise descending pathways from brain to spinal cord.  Influence, direct, and modify spinal reflex arcs and circuits.  Can affect movement only through the lower motor neurons.  Injury results in initial paralysis followed by partial recovery over an extended period. Anatomy and Physiology

21. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 21 Spinal Cord and Spinal Tracts (4) ● Lower motor neurons  Cranial and spinal – originate in the anterior horn of spinal cord and extend into peripheral nervous system.  Transmit neural signals directly to the muscles to permit movement.  Injury often results in permanent paralysis. Anatomy and Physiology

22. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 22 Spinal Cord and Spinal Tracts (5)  Ascending spinal tracts  Mediate sensations  Facilitate signals for complex discriminations tasks  Transmit precise information on types of stimulus and location Anatomy and Physiology

23. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 23 Spinal Cord and Spinal Tracts (6)  Ascending spinal tracts - continued  Posterior (dorsal) column tract carries fibers for discriminatory sensations of touch, deep pressure, vibration, position of joints, stereognosis, and two-point discrimination.  Spinothalmatic tracts carry fibers for sensations of light and crude touch, pressure, temperature, and pain. Anatomy and Physiology

24. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 24 Spinal Nerves  Parts  31 pairs  Exit at each intervertebral foramen  Ventral and dorsal roots  Function  Sensory and motor fibers that supply and receive information in dermatome  Reflex actions Anatomy and Physiology

25. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 25 Infants and Children  Major brain growth and myelinization in first year of life  Primitive reflexes present in newborn  Motor maturation in cephalocaudal direction  Brain growth continues until 12 to 15 years of age Anatomy and Physiology

26. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 26 Pregnant Women  Hypothalamic-pituitary neurohormonal changes  Common alterations  Headaches  Numbness or tingling in hands  Does not feel rested after sleep  Inability to sleep Anatomy and Physiology

27. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 27 Older Adults  Changes are physiologic rather than anatomic.  Cerebral neurons decrease.  Velocity of nerve impulse conduction declines:  Slowed response time  Diminished touch and pain perception Anatomy and Physiology

28. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 28 Review of Related History

29. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 29 History of Present Illness (1)  Seizures or convulsions  Sequence of events  Character of symptoms  Aura  Level of consciousness  Automatism Review of Related History

30. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 30 History of Present Illness (2)  Seizures or convulsions - continued  Muscle tone  Postictal behavior  Relationship of seizure to other events  Frequency of seizures  Medication Review of Related History

31. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 31 History of Present Illness (3)  Pain  Onset  Quality  Location  Associated manifestations  Efforts to treat  Medications Review of Related History

32. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 32 History of Present Illness (4)  Gait coordination  Balance  Falling  Legs simply give way  Associated problems  Medications Review of Related History

33. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 33 History of Present Illness (5)  Weakness or paresthesia  Onset: sudden, or with initiation of or following sustained activity  Character: generalized or specific body area affected (face, extremity).  Associated symptoms  Concurrent chronic illness (HIV, nutritional or vitamin deficiency)  Medications: zidovudine, diaminodiphenylsulfone, dideoxyinosine, amphotericin B; Review of Related History

34. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 34 History of Present Illness (6)  Tremor  Onset: sudden or gradual  Character: worse with rest, intentional movement, anxiety Unilateral or bilateral; body location: distal extremities, head Unilateral or bilateral; body location: distal extremities, head Interference with daily activities Interference with daily activities Review of Related History

35. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 35 History of Present Illness (7)  Tremor – continued  Associated problems: hyperthyroidism, familial tremor, liver or kidney disorder, consumption of alcohol, multiple sclerosis  Relieved by rest, activity, alcohol  Medications: Neuroleptics, valproate, phenytoin, albuterol, pseudoephedrine, antiarrhythmics, corticosteroids, caffeine (all may cause essential tremor) Review of Related History

36. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 36 Past Medical History  Trauma  Meningitis, encephalitis, plumbism  Deformities, congenital anomalies  Cardiovascular or circulatory problem  Neurologic disorder, brain surgery, and residual effects Review of Related History

37. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 37 Family History  Hereditary disease  Medical or metabolic disorder  Alcoholism  Mental retardation  Epilepsy, seizure disorder, or headaches  Alzheimer disease  Learning disorders  Weakness or gait disorders Review of Related History

38. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 38 Personal and Social History  Environmental or occupational hazards  Hand, eye, foot dominance  Ability to care for self  Sleeping and eating patterns  Use of alcohol and drugs Review of Related History

39. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 39 Infants  Prenatal history  Birth history  Respiratory status at birth  Neonatal health  Congenital anomalies  Multiple handicapping conditions Review of Related History

40. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 40 Children (1)  Developmental milestones  Age attained  Loss of previously achieved function Review of Related History

41. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 41 Children (2)  Performance of self-care activities  Health problems  Headaches  Seizure activity  Clumsiness or unsteady gait  Muscular weakness or falling Review of Related History

42. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 42 Pregnant Women  Weeks of gestation or estimated date of delivery  Convulsions or headache  Seizure activity  Headache  Nutritional status Review of Related History

43. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 43 Older Adults  Increased stumbling or falls  Decreased agility  Safety modification at home  Interference with performance of ADLs  Hearing loss, vision deficit, or anosmia  Development of tremor  Fecal or urinary incontinence  Transient neurologic deficits Review of Related History

44. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 44 Examination and Findings

45. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 45 Equipment  Penlight  Tongue blades  Sterile needles  Tuning forks  Familiar objects  Cotton wisp  5.07 Monofilament  Reflex hammer  Vials of aromatic substances  Vials of solutions  Test tubes of hot and cold water  Denver II Examination and Findings

46. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 46 Screening Examination  Components  Cranial nerves  Proprioception and cerebellar function  Sensory function  Deep tendon reflexes Examination and Findings

47. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 47 Cranial Nerves (1)  Olfactory (CN I) Sensory and smell  Test for odor identification.  Optic (CN II) Sensory and visual acuity  Test for visual acuity.  Test visual fields.  Perform ophthalmologic examination. Examination and Findings

48. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 48 Cranial Nerves (2)  Oculomotor, trochlear, and abducens (CN III, IV, and VI) Motor and eye movement, pupil size, eyelid opening  Inspect eyelids for drooping.  Inspect pupils for size and equality.  Test consensual response and accommodation.  Test extraocular eye movements. Examination and Findings

49. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 49 Cranial Nerves (3)  Trigeminal (CN V) Mixed: muscle tone and sensation  Inspect face for atrophy or tremors.  Palpate jaw for tone and strength.  Test for pain and sensation.  Test corneal reflex. Examination and Findings

50. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 50 Cranial Nerves (4)  Facial (CN VII) Mixed: facial expressions and taste  Inspect facial symmetry.  Test tongue for salt and sweet.  Acoustic (CN VIII) Sensory, hearing, and balance  Test hearing.  Compare bone and air conduction.  Test for sound lateralization. Examination and Findings

51. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 51 Cranial Nerves (5)  Glossopharyngeal (CN IX) Mixed: taste and swallowing  Test tongue for sour and bitter.  Test gag reflex and swallow.  Vagus (CN X) Mixed: swallowing and speech  Inspect palate and uvula for symmetry.  Inspect for swallow difficulty.  Evaluate guttural speech sounds. Examination and Findings

52. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 52 Cranial Nerves (6)  Spinal accessory (CN XI) Motor and muscle strength  Test trapezius and sternocleidomastoid muscle strength.  Hypoglossal (CN XII) Motor and tongue strength  Inspect tongue for symmetry/tremors/atrophy.  Test tongue movement.  Test tongue strength.  Evaluate lingual speech sounds. Examination and Findings

53. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 53 Coordination and Fine Motor Skills  Test rapid rhythmic alternating movements:  Evaluate rhythm, flow, and speed.  Test accuracy of movements:  Evaluate accuracy, speed, and rhythm.  Test balance:  Evaluate equilibrium.  Observe gait. Examination and Findings

54. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 54 Gait Patterns  Spastic hemiparesis  Spastic diplegia  Steppage  Waddling  Tabetic  Cerebellar  Sensory ataxia  Parkinsonian  Ataxia  Antalgic limp Examination and Findings

55. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 55 Sensory Function (1)  Primary functions  Superficial touch  Superficial pain  Temperature  Deep pressure  Vibration  Joint position Examination and Findings

56. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 56 Sensory Function (2)  Cortical functions  Stereognosis  Two-point discrimination  Extinction phenomenon  Graphesthesia  Point location Examination and Findings

57. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 57 Sensory Function (3)  Observe all sensory function tests for:  Side-to-side differences  Interpretation of sensation  Discrimination  Location  If impairment are found, map boundaries by dermatome. Examination and Findings

58. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 58 Reflexes (1)  Superficial reflexes  Upper abdominal  Lower abdominal  Cremasteric  Plantar Examination and Findings

59. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 59 Reflexes (2)  Deep reflexes  Biceps  Brachioradial  Triceps  Patellar  Achilles Examination and Findings

60. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 60 Reflexes (3)  Observe superficial reflex tests for:  Abdominals: equal movement of umbilicus  Cremasteric: rising of testicle and scrotum  Plantar: fanning of toes or dorsiflexion of great toe Examination and Findings

61. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 61 Reflexes (4)  Observe deep tendon reflex tests for:  Biceps: elbow flexion  Brachioradial: forearm pronation and elbow flexion  Triceps: elbow extension  Patellar: lower leg extension  Achilles: foot flexion  Clonus Examination and Findings

62. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 62 Additional Procedures  Monofilament test  Protective sensation on foot  Meningeal signs  Nuchal rigidity  Brudzinski  Kernig Examination and Findings

63. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 63 Infants (1)  Cranial nerves indirectly tested  CN II, III, IV, and VI  Optical blink reflex  Gaze and tracking  Doll’s eye  CN V  Rooting  Sucking Examination and Findings

64. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 64 Infants (2)  CN VII  Facial expressions  Forehead wrinkling  Smile  CN VIII  Acoustic blink reflex  Doll’s eye maneuver Examination and Findings

65. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 65 Infants (3)  CN IX and X  Swallow and gag reflex  CN XII  Sucking and swallowing ability  Tongue position with pinch test  Observe movement  Spontaneity  Symmetry Examination and Findings

66. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 66 Infants (4)  Evaluate primitive reflexes:  Palmar  Plantar  Moro  Placing  Stepping  Asymmetric tonic neck  Inspect and palpate muscle for strength and tone. Examination and Findings

67. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 67 Children (1)  Observe neuromuscular development progress and skills displayed during physical exam.  Evaluate developmental level.  Modify CN examination according to age.  Observe at play:  Gait and fine motor coordination  Heel-to-toe walking, hopping, jumping  Deep tendon reflexes are not routinely tested in young children. Examination and Findings

68. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 68 Children (2)  Soft signs  Unexpected findings in school-age child considered normal in younger child  Soft signs can be found in gross motor, fine motor, sensory, and reflex functional areas Examination and Findings

69. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 69 Pregnant Women  (Same as for adult)  Deep tendon reflexes on initial examination serve as baseline Examination and Findings

70. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 70 Older Adults  (Same as for adult)  Medications can impair CNS function:  Slowed reaction time, tremors, and anxiety  Test gait for decreases in speed, balance, and grace,  Check tactile and vibratory sense for impairment.  Check deep tendon reflexes for diminished response. Examination and Findings

71. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 71 Common Abnormalities

72. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 72 Disorders of the Central Nervous System  Disorders of the central and peripheral nervous systems often fall into groups.  Static problems develop at any age and do not get better or worse (e.g., nerve deafness and some trauma).  Degenerative problems occur when function is lost and it progressively worsens.  Some problems are intermittent, whereas others are genetic or related to a metabolic disorder. Common Abnormalities

73. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 73 Central Nervous System (1)  HIV encephalopathy  Multiple sclerosis  Generalized seizure disorder  Meningitis Common Abnormalities

74. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 74 Central Nervous System (2)  Encephalitis  Lyme disease  Intracranial tumors  Cerebrovascular accident Common Abnormalities

75. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 75 Peripheral Nervous System  Myasthenia gravis  Guillain-Barré syndrome  Trigeminal neuralgia  Peripheral neuropathy Common Abnormalities

76. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 76 Children  Cerebral palsy  Shaken baby syndrome  HIV encephalopathy  Rett syndrome Common Abnormalities

77. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 77 Pregnant Women  Maternal obstetric palsy Common Abnormalities

78. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 78 Older Adults  Parkinson disease  Normal-pressure hydrocephalus  Post-polio syndrome Common Abnormalities

79. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 79 Summary of Examination (1)  Test Cranial Nerves I through XII:  Cerebellar Function and Proprioception  Evaluate coordination and fine motor skills by the following: ● Rapid rhythmic alternating movements ● Accuracy of upper and lower extremity movements

80. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 80 Summary of Examination (2)  Test Cranial Nerves I through XII:  Cerebellar Function and Proprioception  Evaluate balance using the Romberg test  Observe the patient’s gait ● Posture ● Rhythm and sequence of stride and arm movements

81. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 81 Summary of Examination (3)  Test Cranial Nerves I through XII:  Sensory Function  Test primary sensory responses to the following: Superficial touch Superficial touch Superficial pain Superficial pain  Test vibratory response to tuning fork over joints or bony prominences on upper and lower extremities.  Evaluate perception of position sense with movement of the great toe or a finger.

82. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 82 Summary of Examination (4)  Sensory Function - continued  Assess ability to identify familiar object by touch and manipulation.  Assess two-point discrimination.  Assess ability to identify letter or number “drawn” on palm of hand.  Assess ability to identify body area when touched.

83. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 83 Summary of Examination (5)  Superficial and Deep Tendon Reflexes  Test abdominal reflexes.  Test cremasteric reflex in male patients Test the following deep tendon reflexes: ● Biceps ● Brachioradial ● Triceps ● Patellar ● Achilles

84. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. Slide 84 Summary of Examination (6)  Superficial and Deep Tendon Reflexes -continued  Test for ankle clonus.  Test plantar reflex.