The Neurological Exam 9/30/2012 10:00:00 PM
Neurologist:
1. ask patient about the problem (HISTORY)
2. make general assessment of patient condition
3. possibly recommend additional tests
4. write case summary
The Patient’s History
-Info on patient’s background
-History of disease, accidents, occurrence of symptoms
-Family background reviewed as well: many diseases genetic
-Observe patient’s behavior (assess mental status, look for abnormalities in
speech/facial features, posture)
-Facial expression and behavior reveal mental status
-Handedness: which hemisphere controls speech
Physical Examination
*Tools:
-measuring tape: measure head and body size, skin lesions, etc
-stethoscope: listen to heart/blood vessels
-otoscope: examine auditory canal/eardrum
-flashlight: elicit pupillary reflexes
-tongue blades: elicit gag/abdominal/plantar reflexes
-vial of coffee: assess smell
-salt & sugar: taste
-tuning fork: test vibratory sensation & hearing
-cotton wisp: elicit corneal reflex, test sensitivity to light touch
-plastic tubes: temperature
-pins: pain
-hammer: elicit muscle stretch reflexes
-coins/keys: recognition of objects through touch and sound
-blood pressure cuff: measure blood pressure
*MOST IMPORTANT PART of study: HEAD
-cranial-nerve malfunctions discovered : important clues to location and
nature of neural damage *Motor system: examined to assess muscle bulk, tone, power, occurrence of
involuntary movement reflexes), coordination, head-to-toe Vascular Disorders 9/30/2012 10:00:00 PM
•CNS functioning can be affected by vascular problems
-Blood-vessel disease or damage can greatly reduce OXYGEN and
GLUCOSE to brain region
-longer than 10 min interference: DEATH to cells in region
-Most develop in arterial system
Stroke
-Among the most common causes of death/injury in Western world
-Interruption of bloody flow
-Sudden appearance of neurological symptoms
-Can be insidious, spanning over period of time
-Produce infarct, an area of dead/dying tissue (from insufficiency of blood
flow to region)
*Capillaries: effects are more limited compared to
*Large vessels: often devastating consequences
*One restricted part of vessel: surrounding healthy vessels supply blood to
at least some of deprived area
*Region supplied by weak/diseased vessels: more serious, no possibility of
compensation
Cerebral Ischemia
-Symptoms caused by vessel blockage preventing sufficient supply of blood
to brain
-Thrombosis: blood coagulated to form clot or plug that remained at the
place of formation
-Embolism: clot or other plug brought through blood from larger vessel and
forced into smaller one: obstructs circulation (blood clot, air bubble, oil/fat
deposit, small mass of cells from tumor) MOST OFTEN AFFECT MIDDLE
CEREBRAL ARTERY
-Cerebral arteriosclerosis: thickening and hardening of arteries
-transient ischemia: temporary, recurring
Migraine Stroke:
-May lead to infarcts and permanent neurological deficits
-Young people, especially women -Vasopasm: constriction of blood vessels, but unknown cause
-Posterior cerebral artery most commonly affected
-symptoms similar to transient ischemia
Cerebral Hemorrhage:
-Massive bleeding into substance of brain
-Cause: most frequently high blood pressure, hypertension Neurological Assessment 9/30/2012 10:00:00 PM
-People with closed-head traumatic brain injuries often have little or no sign
of cerebral injury visible on neuroimaging, but still have significant cognitive
deficits
-1980s heyday of neuropsychological assessment
The Changing Face of Neuropsychological Assessment
-Roots lie in neurology and psychiatry
-Began to diverge from medicine in 1940s
-First tests designed to identify people suffering from cerebral dysfunction
(organic diseases) rather than “functional disorders” linked with behavior
-3 factors that enhanced the rate of change:
Functional imaging:
-Perhaps the biggest change in both neurology and neuropsychology
-Neuroimaging: allowed investigators to identify changes in cerebral
functioning
-Main role of clinical neuropsychologists: from diagnostician to participant in
rehabilitation (esp. chronic disease; stroke/head trauma)
-Even the most sophisticated functional-imaging techniques don’t predict
extent of behavioral disturbance
-People with closed-head injury: way to document nature & extent of
disability is through neuropsychological assessment
Cognitive Neuroscience:
-Diversification of methods used by individual neuropsychologists
•Choice of tests: disorder being investigated & question being asked
-Halstead-Reitan Battery:
•retain concept of cutoff scores
➜DIFFICULTIES OF CUT OFF SCORES
•performance below particular levels don’t always indicate brain damage
•Cerebral organization varies with factors: sex, handedness, age,
education, experience, etc.
•Test problems can be solved using different strategies -> entail different
cortical regions
•Vary with intelligence: many tests require problem solving
-Handicap in development of test batteries: absence of neurological theory -Knowledge of brain function largely based on clinical observation
Cognitive Neuroscience (ctd.)
•1990s-modern theoretical understanding of brain/cognition
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