Exam Abnormalities

1
Exam Abnormalities

• Part I

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Neurodysfunction

• Trauma
• Vascular lesions
• Infection
• Inflammation
• Tumors
• Toxic substances
• Secondary damage

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Intracranial Hypertension

• Skull rigid enclosure
• Contents nearly constant volumes
• Brain tissue 80, blood 10, CSF 10
• Normal ICP 0 to 15mm Hg
• Intracranial hypertension continued elevation
  above 20mm Hg

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Cranial Vault
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ICP Compensation

• Shrinkage of brain tissue through loss of
  intracellular fluid
• Reduction of CSF volume
• Narrowing ventricular system sub-arachnoid
  spaces
• Increased venous absorption of CSF
• Reduction of cerebral blood volume

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Herniation Syndromes

• 1. Subfalcine
• 2. Uncal
• 3. Central or diencephalic
• 4. Cerebellar upward
• 5. Tonsillar

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Neuronal Death

• Primary injury
• Secondary hypoxia, ischemia or mechanical
  displacement of tissue
• Hypoxia leads to decreased ATP and anaerobic
  metabolism
• Prolonged anoxia leads to cellular edema and
  nerve death

8
Ionic Changes

• Abnormal ion concentrations may alter resting
  membrane potential, interfering with action
  potential propagation
• High extracellular potassium levels and low
  extracellular calcium levels increase nerve
  excitability

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Other Influences

• Excessive magnesium levels have a general
  depressant effect on neuro-logical function
• Disruption of the sodium-potassium pump
  diminishes or prevents ionic activity

10
Neurochemical Changes

• Hypoxia and ischemia reducing neuro-transmitter
  levels or production
• Dopamine in Parkinsons disease
• Interference with neurotransmitter synthesis,
  transport, storage, release and receptor
  interactions

11
Peripheral Nerve Injury

• Degenerative changes distal to injury (Wallerian
  Degeneration)
• Swollen, irregular axon first day
• Axon fragmentation by fourth day
• Myelin sheath degeneration
• Only the neurilemma remains (outermost sheath)

12
Exam Abnormalities

• Grooming personal hygiene may deteriorate in
  dementia, depression schizophrenia
• One-sided neglect may result from a lesion in the
  non-dominant parietal cortex
• Apathy (dulled affect with detachment
  indifference) in dementia

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General Appearance

• Dysmorphic features
• Low-set ears, wide-set eyes, small mandible,
  mongoloid facies
• Chorea sudden, ballistic movements
• Athetosis writhing, repetitive movements
• Dystonia sudden, tonic muscle contractions

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Involuntary Movements

• Athetosis
• Slow, twisting/ writhing with large amplitude
  may see with spasticity(CP)
• Chorea
• Brief, rapid, jerky, irregular, unpredict-able
  at rest or interrupting motion

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Chorea
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Athetosis
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Dystonia
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Dyskinesia and Dystonia
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Abnormal Movements

• Tardive dyskinesia lip smacking, chewing or
  teeth grinding
• Tremor
• At rest and less during sleep and volitional
  movements
• With movement

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Tardive Dyskinesia
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Tremors

• Resting/static prominent at rest, may
  de-crease/disappear with voluntary movement
• Postural appear when affected part is actively
  maintaining a posture
• Intention worsens as target is neared

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Resting Tremor
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Postural Tremor
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Intention Tremor
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Dysmetria

• An intention tremor that appears at the end of
  the movement
• Finger may initially overshoot its mark, but
  finally reach it
• Movements are clumsy, unsteady and
  inappropriately varying in speed, force and
  direction

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Other Dysfunction

• Past pointing
• Repetitive and consistent deviation to one side,
  worse with eyes closed
• Vestibular or cerebellar disease
• Incoordination may get worse with eyes closed
• Inaccuracy that appears with eyes closed suggests
  loss of position sense

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Dysdiadochokinesis

• Abnormal alternating movements
• One movement cannot be followed quickly by its
  opposite
• Movements are slow, irregular and clumsy
• UMN weakness and BG disease may impair rapid
  alternating movements, but differently

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Heel to Shin Test

• In cerebellar disease, the heel may overshoot the
  knee then oscillate from side-to-side down the
  shin
• When position sense is lost, the heel is lifted
  too high and the patient tries to look
• With eyes closed, performance is poor

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Facies
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Eyelid Variations
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Abnormal Gait

• Asymmetrical gait or limp
• Hemiparesis
• Leg joint arthritis
• Old fractures
• Balance disorders
• Leg pain
• Gait apraxia
• Frontal disorders, NPH

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Hemiparetic Gait
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Antalgic Gait
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Other Gait Abnormalities

• Abnormal tandem gait
• Inner ear dysfunction
• Abnormal position sense in feet
• Vestibular, brainstem or cerebellar dysfunction
• Orthopedic leg problems
• Decrease in arm swing
• Upper extremity weakness, basal ganglia

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Mild Cerebellar Ataxia
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Incoordination

• Tandem walking may reveal an ataxia that was not
  previously obvious
• Difficulty hopping may be due to weakness, lack
  of position sense or cerebellar dysfunction
• Disturbances in coordination and gait also can
  be caused by lesions in other systems (sensory,
  motor, basal ganglia)

37
Spastic Hemiparesis

• Corticospinal tract disease (stroke)
• Flexed, immobile upper extremity
• Extended lower extremity
• Foot drag or circumduction

38
Scissors Gait

• Bilateral spastic leg paresis
• Stiff gait, short steps
• Thighs tend to cross forward on each other at
  each step

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Steppage Gait

• Associated with foot drop (LMN disease)
• Appear to be walking up stairs
• Unable to walk on heels
• May be uni- or bi- lateral

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Steppage Gait
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Parkinsonian Gait

• Basal ganglia defects
• Stooped posture, hips knees flexed arms flexed
  at elbows wrists
• Slow initiation
• Short, shuffling steps decreased arm swing
• Turn en-bloc (all in one piece, stifly)

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Parkinsonian Gait
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Gait of Old Age

• Speed, balance and grace decrease
• Short, uncertain steps may shuffle
• Lower limbs may be flexed at hips and knees

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Cerebellar Ataxia

• Cerebellum or associated tracts
• Staggering, wide-based, unsteady
• Exaggerated diffi-culty on turns
• Cannot stand with feet together

45
Sensory Ataxia

• Loss of position sense in the feet legs
• Unsteady, wide-based, double tap as heels then
  toes slap the ground
• Watch the ground for guidance