Neurological Examination in psychiatry

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Neurological Examination in psychiatry
Introduction:
 "Neuropsychiatry" it deals with the study of psychiatric problems in neurological disorders and the neurologic problems in the classical psychiatric disorders.
The purpose of the neurological examination is to determine the presence or absence of disease in the nervous system,
Components of Neurological examination
l. Patient History
2. Level of consciousness
3. Mental status examination
4. Cranial nerve function          
5. Motor power
6. Sensory power
7. Cerebellar functions
l. Patient History: An accurate and detailed history should be collected. Special attention should be paid to several details such as age of onset of symptoms.
2. Level of Consciousness
·         Alert: The patient is awake, responds immediately and appropriately to verbal stimuli
·         Lethargic: The patient is drowsy, inattentive but easily arousal
·         Stuporous: The patient sleeps most of the time, He can be aroused with great difficulty and co-operates minimally when stimulated
·         Semi-Comatose: There is no response to verbal stimuli. Non-purposeful motor activity is seen when the patient is stimulated with pain
·         Comatose: There is no response to verbal or painful stimuli. No motor activity is seen
Glasgow Coma Scale
l .Best eye opening response:
·         Spontaneously: 4
·         To verbal command: 3
·         To pain: 2
·         No response: 1
2. Best Verbal Response:
·         Oriented, Converses: 5
·         Disoriented, Converse: 4
·         Inappropriate words: 3
·         Incomprehensible sounds: 2  
·         No response: 1
3.Best Motor response:
·         To verbal command - Obeys: 6
·         To painful stimulus –
o   Localizes pain: 5
o   Withdrawal: 4
o   -Flexion : 3
o   -Extension: 2
o   -No response: 1
A score of 15 indicates best level of consciousness and a score of 3 the least level of consciousness
3. Mental status examination
·         General Appearance and behavior
·         Mood and affect
·         Speech
·         Perception
·         Thought process
·         Cognitive functions
·         Attention and concentration
·         Orientation
·         Memory
·         General knowledge
·         Judgment
·         Impulse control
·         Insight
4. Assessment of Motor function
Assessing for:
·         Muscle size
·         Muscle strength
·         Muscle tone
·         Muscle coordination
·         Gait
·         Movement.
Motor power grading
·         5/5: Full range of motion against gravity with extreme resistance
·         4/5: Full range of motion against gravity with some resistance
·         3/5: Full range of motion against gravity with no resistance
·         2/5: Full range of motion against gravity eliminated
·         1/5: Slight contraction visible
·         No movement
5. Assessment of sensory function:
Testing for:
·         Touch
·         Pain
·         Vibration
·         Position
·         Discrimination.
6. Assessment of cerebellar functions
·         Finger to finger test
·         Finger to nose test
·         Patting test
·         Romberg test
·         Tandom walking test
7. Cranial Nerve Function
Olfactory Nerve(i):
Controls the sense of smell.
·         Close the eyes
·         Occlude one nostril
·         Identify the odor (coffee, lemon etc.)
Repeat the above for the opposite nostril
Optic Nerve (ii):
·         This nervte controls the visual activity and the visual field.
·         Gross visual activity may be assessed by having the patient close one eye and count number of fingers shown by the examiner and repeat using the opposite eye
Visual field:
·         Instruct the patient to close one eye
·         The examiner closes his or her opposite eye
·         The examiner then positions her fingers off to the side at eye level at the same distance the patient and herself
·         The examiner's moving finger is then brought in to the main boundaries of the visual field
·         The patient states when the moving finger is seen
·         This exercise is repeated for the opposite eye
Oculomotor (iii), Trochlear (v) and Abducens (vi):
·         The oculomotor nerve controls pupillary reaction.
·         Instruct the patient to fix his eyes on an object
·         Shine the beam of torch directly in to each pupil
·         Note the size, shape and reaction of the pupils to the light stimulus.
·         The pupil size should be noted before and after the light is directed in to the eye.
·         The three newes (iii, v, and vi) together function by controlling extra ocular movements
·         To assess ocular movements, ask the patient to follow an moved systematically in various directions-up, down, to the right and to the left, Note for diplopic, limited eye movement, and the presence or absence of nystagmus
Trigeminal nerve (iv):
·         It controls facial sensation and jaw movements(Motor)
Sensory function: The patient is asked to close his eyes while a wisp of cotton is passed gently over various parts of his face. The patient is asked to identify where the cotton is applied each time.
Motor function: Tell the patient to open his mouth wide and hold tightly. The examiner then attempts to close the patient's mouth using hands
Facial nerve (vii):
·         The nerve controls the facial muscles and supplies taste fibers to the anterior two third of the tongue
Sensory: The patient is asked to identify the taste of sugar, after which a sip of water is given. The same procedure is followed using a salty, sour, and bitter substance
Motor: Tell the patient to her forehead, smile, showing his teeth and winking his eyes. Asymmetrical movement or facial drooping has to be noted
Auditory or Acoustic neree (viii):
·         This nerve controls hearing and the sense of balance hearing can be tested by using a tuning fork, hearing in both the left and right ears should be compared.
·         The Weber test and Rinne test may be done to differentiate between conduction deafness and nerve deĂșess
Glossopharyngeal (ix) and Vagus (x):
·         Controls swallowing- gag reflexes, articulation, and phonation
·         Insnlct the patient to open his mouth and say 'ah'. If there is paralysis, uvula deviates to the side
·         Use the tip of a tongue depressor, very gently, stimulate the back of the pharynx, note any asymmetrical contractions of the palate, uvula, and pharynx
·         Test for swallowing reflex by asking the patient to drink clear fluid and note the reaction
·         Spinal Accessory Nerve (xi)
·         This nerve controls the trapezius and stemo-cleidomastoid muscle, which assist in shoulder shrugging, head and neck movements
·         Assess the trapezius muscle function by instructing the patient to raise both shoulders and hold tightly while the exaniiner applies resistance to both shoulders using hands. 
·         Evaluate the sterno-cleidomastoid muscle function by asking the patient to turn his/her head against resistance applied by the examiner's hands
Hypoglossal Nerve (xii):
·         This nerve controls the tongue movement and strength
·         This function is evaluated by asking the patient to protrude her tongue. Normally it protrudes in the midline
·         To assess the tongue strength, instruct the patient to move her tongue to the right and to the left,


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