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Chapter 22
Neurologic System
Neurologic System
• The nervous system
• Central and peripheral divisions
• Maintains and controls all body functions by its voluntary and
autonomic responses
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Neurologic System (Cont.)
• The physical examination of the nervous system assesses the
following elements:
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Motor
Sensory
Autonomic
Cognitive
Behavioral
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Anatomy and Physiology
• Central nervous system
• Main network of coordination and control for the body
• Brain
• Spinal cord
• Peripheral nervous system
• Carries information to and from the central nervous system
• Cranial nerves
• Spinal nerves
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Anatomy and Physiology (Cont.)
• Autonomic nervous system
• Coordinates and regulates the internal organs of the
body
• Two divisions that balance the impulses of each other
• Sympathetic
• Parasympathetic
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Brain (Cont.)
• Three major units
• Cerebrum
• Cerebellum
• Brainstem
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Cerebrum (Cont.)
Uses sensory data for reflexive control of muscle tone,
equilibrium, and posture
Frontal lobe
 Voluntary skeletal movement
Parietal lobe
 Interpretation and recognition of body parts and awareness of body
position (proprioception)
 Senses
Occipital lobe
 Vision
Temporal lobe
Perception and interpretation of sounds
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Brainstem
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Involuntary functions
12 cranial nerves
Medulla oblongata
Midbrain
Pons
• Transmits information between the brainstem and the cerebellum
• Diencephalon
• Thalamus: perception of various sensations (pain)
• Hypothalmus: Controls temperature
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Cranial Nerves
• 12 nerves that rise from brain
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I- Olfactory
II- Optic
III- Oculomotor
IV- Trochlear
V- Trigeminal
VI- Abducens
VII- Facial
VIII- Acoustic
IX- Glossopharyngeal
X- Vagus
XI- Spinal acessory
XII- Hypoglossal
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Spinal Cord and Spinal Nerves
Each of 31 pairs supply and receive information from specific
body parts
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Infants and Children
Major brain growth and myelinization in first year of life
Brain growth continues until 12 to 15 years
of age
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Older Adults
• The number of cerebral neurons decreases with aging, but this
is not necessarily associated with deteriorating mental
function.
• Velocity of nerve impulse conduction declines.
• Slowed response time
• Diminished touch and pain perception
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History of Present Illness
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Seizures
Pain
Gait coordination
Weakness/ parasthesia
Tremor
Trauma
Circulatory function
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Family History
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Hereditary disease
Alcoholism
Mental disabilities
Epilepsy, seizure disorder, or headaches
Alzheimer disease or other dementia
Learning disorders
Weakness or gait disorders
Medical or metabolic disorder
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Personal and Social History
• Environmental or occupational hazards
• Ability to care for self
• Use of alcohol and drugs
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Infants
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Prenatal history
Birth history
RespiCongenital anomalies
Developmental delay
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Children
• Developmental milestones
• Hyperactive or impulsive behavior
• Health problems
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Older Adults
• Pattern of increased stumbling, falls, unsteadiness, or
decreased agility
• Interference with performance of ADLs
• Hearing loss, vision deficit
• Transient neurologic deficits
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Neurologic Examination
• Components
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Cranial nerves
Proprioception and cerebellar function
Sensory function
Reflex function
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Cranial Nerves
• 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
• Oculomotor(CN III), Trochlear (CN IV), and Abducens (CN VI)
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Inspect eyelids for drooping
Inspect pupils for size and equality
Consensual response and accomadation
Extraocular eye movements
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Cranial Nerves (Cont.)
• Trigeminal (CN V)
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Muscle tone and sensation
Inspect face for atrophy or tremors
Palpate jaw for tone and strength
Assess for pain
Corneal reflex
• Facial (CN VII)
• Facial symmetry
• Taste (salty and sweet)
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Cranial Nerves (Cont.)
• Acoustic (CN VIII)
• Hearing
• Bone and air conduction
• Sound lateralization
• Glossopharyngeal (CN IX)
• Sour and bitter taste
• Gag reflex and swallowing
• Vagus (CN X)
• Uvula symmetrical
• Swallowing
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Cranial Nerves (Cont.)
• Spinal accessory (CN XI)
• motor and muscle strength in trapezius and sternocleidomastoid
• Shrug shoulder
• Hypoglossal (CNXII)
• Tongue strength
• Speech sounds
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Proprioception and Cerebellar
Function
• Coordination and fine motor skills
• Touching thumb to finger
• Finger to nose
• Heel to shin
• Balance
• Equilibrium
• Romberg
• Stand on one foot
• Gait
• Heel to toe walking
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Sensory Function
• Test with the patient’s eyes closed.
• Observe all sensory function tests
• Superficial touch and pain
• Vibration
• Position of joints
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Sensory Function (Cont.)
• Cortical sensory function
• Stereognosis
• Familiar object (key, coin)
• Tactile agnosia is an inability to recognize objects by touch
• Graphesthesia
• Draw letter on palm of hand
• Point location
• Where they are being touched
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Reflexes
• Superficial reflexes (Cont.)
• Plantar reflex
• Babinski
• Deep tendon reflexes
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Biceps: elbow flexion
Brachioradial: forearm pronation and elbow flexion
Triceps: elbow extension
Patellar: lower leg extension
Achilles: foot flexion
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Reflexes (Cont.)
• Deep tendon reflexes (Cont.)
• Symmetric visible or palpable responses should be noted.
• Clonus
• Involuntary movemnt
• Associated with stroke
• Scoring deep tendon reflexes:
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0 No response
1 Sluggish or diminished
2 Active or expected response
3 More brisk than expected, slightly hyperactive
4 Brisk, hyperactive, with intermittent or transient clonus
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Additional Procedures
Meningeal signs (Cont.)
 Brudzinski
• Involuntary flexion of the hips and knees when flexing the neck is a
positive Brudzinski sign.
 Kernig
• Pain in the lower back and resistance to straightening the leg at the
knee constitute positive Kernig sign
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Infants
• Cranial nerves indirectly assessed by observing:
• CN II, III, IV, and VI
• Optical blink reflex
• Gaze and tracking
• CN V
• Rooting and sucking
• CNVII
• Smile
• CN VIII
• Acoustic blink
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Infants (Cont.)
• Cranial nerves
• CN IX and X
• Swallow and gag reflex
• CN XII
• Sucking and swallowing ability
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Infants (Cont.)
• Relexes
• Palmar grasp
• Moro
• Stepping
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Older Adults
• Test gait for decreases in speed, balance, and grace
• Check tactile and vibratory sense for impairment
• Check deep tendon reflexes for diminished response
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Abnormalities (CNS)
• Multiple sclerosis
• Progressive autoimmune disorder obstructed transmission of
nerve impulses
• Seizure disorder
• Electrical discharges (excessive concurrent firing) of cerebral
neurons
• Encephalitis
• Inflammation of the brain and spinal cord
• Meningitis
• Inflammation of the meninges
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Abnormalities (CNS)
• Stoke (brain attack or cerebrovascular accident)
• Sudden interruption of blood supply to a part of the brain or the
rupture of a blood vessel, spilling blood into spaces around brain
cells
• Myasthenia gravis
• Disorder of neuromuscular transmission
• Muscle weakness
• Guillain-Barre’
• 1-3 weeks after a virus or or immunization
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Abnormalities (PNS)
• Bell palsy
• Temporary acute paralysis or weakness of one side of the face
• Peripheral neuropathy
• Disorder of the peripheral nervous system that results in motor and
sensory loss in the distribution of one or more nerves
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Diabetes mellitus
B12 or folate deficiency
Lyme disease
HIV infection
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Abnormalities (Children)
• Cerebral palsy
• Permanent disorder of movement and posture development
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Abnormalities (Older Adults)
• Parkinson disease
• Slowly progressive, degenerative neurologic disorder
• Poor communication between parts of the brain that coordinate
and control movement and balance
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