2nd assessment and tests edited .pdf
- 2. INTERVIEW: • Describe the pain. Is it pulsating ,throbbing, pressure ,squeezing or stabbing? ABNORMALITIES : Migraine headaches are described as a pulsating or throbbing pain. Tension headaches as a pressure or squeezing pain. Cluster headaches as a sharp or stabbing pain. INTERVIEW • Do you notice any other symptoms with your headache like Nausea or vomiting, Sensitivity to light or sound , watery eyes ? ABNORMALITIES During cluster headaches, patients can experience watery eyes and rhinorrhea. Nausea, vomiting, photophobia, and phonophobia classically occur with migraine headaches. Subjective informations Headache
- 3. INTERVIEW Have you ever experienced any seizures? If so, Onset and duration: ü When did your last seizure occur? ü How often do they occur? ü How long do they last? Location: ü Where do the seizures begin? ü Do they travel through the body? ü They occur on one or both sides? Symptoms: ü Describe the seizure? ABNORMALITIES The differences between seizure types. Subjective informations Seizure
- 4. INTERVIEW ◦ Do you ever have numbness or tingling in your hands or feet? If so, how long has the numbness and tingling been going on? How frequently does this occur? ABNORMALITIES ◦ Peripheral neuropathies tend to be a chronic numbness and tingling, in which temporary nerve compression can also occur and cause similar symptoms, that resolves in a short period of time. INTERVIEW Location and Symptoms: ü Where are the numbness and tingling occurring? Do you have any other symptoms associated with the numbness and tingling? ü Describe the numbness and tingling. What makes it worse? Relief : ü Does anything make it better or go away? Past history : ü Do you have any past history of neurologic problems? Headaches? Epilepsy? Stroke? High cholesterol? Diabetes? Irregular heartbeat? Any cardiovascular problems? Parkinson’s disease? ABNORMALITIES ü The location of the numbness and tingling can guide the examiner in the physical examination to determine the placement of a nerve injury. Symmetrical distal sensory loss suggests a polyneuropathy. If bilateral, it suggests a “glove and stocking” sensory loss such as that seen with diabetes or alcoholism. Medication history can help rule out a drug-related cause of the paresthesia. Subjective informations Paresthesia
- 5. objective information Cranial nerve I : olfactory Test the relevant cranial nerve, when a sensory loss is suspected. Technique: Test for sense of smell ◦ Use the least irritating odor (e.g., Peppermint) ◦ Ask the patient to close both eyes and to occlude one nostril. ◦ Place the substance beneath the patient’s nose. ◦ Ask the patient to sniff and then identify the smell. Abnormalities Upper respiratory tract infections, tobacco or cocaine use, a frontal lobe lesion, or a fracture in the nasal area can all cause an abnormal sense of smell.
- 6. Cranial nerve II: optic ◦ the optic nerve is generally tested during the eye examination, which includes visual acuity, visual fields, light reflex, and direct inspection Cranial nerve III, IV & VI: oculomotor, trochlear, and abducens ◦ Movement of the eyes through the six cardinal points of gaze; pupil size, shape, response to light.
- 7. Cranial nerve V: trigeminal Technique : step 1 Inspect and palpate the face ◦ Observe the face for muscle atrophy or deviation of the jaw to one side. ◦ While palpating the masseter and temporal muscles, have the patient clench the teeth, and Note the strength of the muscle contraction. ◦ Abnormalities: ◦ Unilateral weakness occurs with a cranial nerve V lesion. ◦ A bilateral weakness can occur with either peripheral nervous system or CNS involvement. step 2 Evaluate Superficial Touch Sensations ◦ Have the patient close his eyes, and touch each side of the face. ◦ Alternate using the sharp and smooth edge of a paper clip or a broken tongue blade. ◦ Ask the patient to report the sensation of dull or sharp. ◦ Repeat with a cotton wisp or brush, and ask when the stimulus is felt. Abnormalities: ◦ Absent touch and pain or paresthesias can be caused by tumor, trauma, trigeminal neuralgia, or sequelae of alcohol ingestion.
- 8. Step 3 test for the corneal reflex ◦ Ask the patient look up and away from you, and approach from the other side. ◦ Lightly touch the cornea of one eye with a cotton wisp. ◦ Repeat with the other side. ◦ A symmetric blink reflex should occur. Caution: ◦ Contact lenses, if worn, should be removed. Patients with contact lenses may have a decreased or absent corneal reflex.
- 9. Cranial nerve VII: facial Technique: Observe motor function have the patient perform the following expressions: ◦ Raise the eyebrows ◦ Squeeze the eyes shut against force ◦ Wrinkle the forehead ◦ Frown ◦ Smile ◦ Observe for unusual facial movements Abnormalities ◦ A peripheral injury affects both the upper and lower face; a central lesion affects the lower face. In unilateral facial paralysis, the mouth droops on the affected side when the patient smiles or grimaces.
- 10. Cranial nerve VIII: acoustic ◦ Hearing ◦ It is evaluated using an audiometer or the simple screening tests. Audiometer hearing test Cranial nerve IX and X: glossopharyngeal and vagus ◦ The glossopharyngeal nerve is tested at the same time with the vagus nerve for gag reflex and motor function of swallowing.
- 11. Cranial nerve XI: spinal accessory Technique : step 1 Observe motor function ◦ Inspect for atrophy or abnormalities from behind the patient. ◦ Ask the patient to shrug both shoulders upward against your hands while applying a light pressure, then turn his head to each side against your hand. ◦ Observe the contraction of the sternocleidomastoid muscle. Abnormalities ◦ Weakness with atrophy and fasciculation indicates a peripheral nerve disorder. step 2 perform the romberg test ◦ Ask the patient to stand up, with his feet together and arms to the side. ◦ Once the patient is in a stable position, ask the patient to close his eyes and then hold that position. ◦ Wait 20 to 30 seconds. ◦ A person should be able to maintain posture and balance even without visual orientation. Abnormalities ◦ A positive romberg sign (i.e., Swaying, falling, or widening the base of the feet to avoid falling) occurs in cerebellar ataxia, multiple sclerosis, alcohol intoxication, and vestibular dysfunction.
- 12. Step 3 Assess the patient’s balance ◦ Have the patient stand in front of you. ◦ Pull backward on the patient’s shoulders. Abnormalities: ◦ Retropulsion, or falling backward when you pull on the patient’s shoulders, is a sign of parkinson’s disease. Coordination ◦ Coordination requires that four areas of the nervous system work in an integrated way. These areas include: ◦ ● The motor system ● The cerebellar system ◦ ● The vestibular system ● The sensory system
- 13. Sensory testing toaccuratelyassessthesensorysystem,patientsmustbecalm,alert,andcooperative. Ø The following is the guidelines when assessing sensory function: v Assess body symmetry v When assessing position, perception, or vibration, examine the knuckles v When assessing touch, temperature, or pain, evaluate distal and proximal sensations in relation to each other v Avoid repetition to ensure true patient response Technique : Test the response to pain Using a safety pin or broken tongue blade, apply pressure of varying degrees with both the sharp and dull ends of the pin. Ask the patient, “is this sharp or dull? Does this feel the same as this?”
- 14. Reflex testing Reflex response partially depends on the force of the stimulus. Use only the force needed to elicit a definite response. It is easier to assess differences between sides than it is to assess symmetric changes in reflexes. Reflexes are usually graded on a 0 to 4 scale: ◦ 4: very brisk, hyperactive ◦ 3: more active than average ◦ 2: average, normal ◦ 1: somewhat diminished ◦ 0: no response
- 15. Technique: step 1 ◦ Assess for deep tendon reflexes evaluation for deep tendon reflexes. ◦ Persuade the patient to relax and to position properly and with the limbs relaxed and the muscles partially stretched. ◦ Swing the rubber hammer freely between your thumb and index finger, and strike the tendon briskly, using a rapid wrist movement. ◦ The strike should be quick and direct. Abnormalities Deep tendon reflexes can be diminished in patients with hypothyroidism and spinal cord injuries. Step 2 ◦ Evaluation of plantar reflex. ◦ Have the patient sit or lie down, with the leg stretched out on the table in front. ◦ With an object such as a wooden end of an applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball. Abnormalities ◦ Dorsiflexion of the big toe, which is generally accompanied by fanning of the other toes, is a positive babinski sign
- 16. Laboratory and diagnostic tests: o A computed tomography (CT) scan, to identify areas of atrophy, trauma, hemorrhage, and tumors. o An electroencephalogram (EEG), to identify seizure disorders and focal neurologic deficits. o Magnetic resonance imaging (MRI), to identify hemorrhage, ischemia, and other pathologies. o A lumbar puncture, For the diagnosis of meningitis and cancer.