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 deúess
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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