two cerebral hemispheres each divded into lobes the cerebrum and the cerebral cortex

Commissural fibers (corpus callosum) interconnect the counterpart areas in each hemisphere, permitting the coordination of activities between the hemispheres

frontal- contains the motor cortex associated with voluntary skeletal movement and fine repetitive motor movements as well as control of eye movements

parietal lobe- primarily responsible for processing sensory data as it is recieved. It assists with theinterpretation of tactile sensations (temperature, pressure, pain, size, shape, texture, and two-point discrimination) as well as visual, taste smell, and hearing sensations. Recognition of body parts and awareness of body positioning (proprioception) are dependent on the parietal lobe.

Occipital- primary vision center and provides interpretation of visual data

temporal lobe-responsible for the perception and interpretation of sounds and determination of their source. Also involved in the integration of taste, smell, and balance. The reception and interpretation of speech is located in the Wrenicke area

basal ganglia- extrapyramidal pathway and processing station between the cerebral motor cortex and upper brainstem. Through its interconnectinos with the thalmus, motor cortex, reticular formation, spinal cord, basal ganglia refine motor movements.

pathway between the cerebral cortex and the spinal cord- controls many involuntary functions

 Medulla oblongata, pons, midbrain, and diencephalon

Thalmus is major integrating center for perception of various sensations such as pain and temperature (along with the cortical processing for interpretation) The thalmus also relays sensory aspects of motor information between the basal ganglia and cerebellum. The pons transmits information between the brainsteam and the cerebellum, relaying motor information from the cerebral cortex to the contralateral cerebellar hemisphere. The medulla oblongata is the site where the descending corticospinal tracts decussate

Olfactory (I) sensory- smell reception and interpretatio

Optic (II)- sensory- visual acuity and visual fields

Oculomotor(III) Motor- Raise eyelids, most exraocular movements

Parasympathetic: Pupillary constriction, change lens shape

Trochlear (IV)- Motor-downward, inward eye movement

Trigeminal (V)- Motor- jaw opening and clenching, chewing, and mastication

Sensory- sensation to cornea, iris, lacrimal glands, conjuctiva, eyelids, forehead, nose, nasal, and mouth mucosa, teeth, tongue, ear, facial skin

Abducens (VI)- Motor- Lateral eye movement

Facial (VII)- Motor- movement of facial expression muscles except jaw, close eyelids, labial speech sounds

Sensory- taste-anterior two thirds of tongue, sensation to pharynx

Parasympathetic-secretion of saliva and tears

Acoustic (VIII)- Sensory- hearing and equilibrium

Glossopharyngeal (IX)- Motor: voluntary muscles for swallowing and phonation

Sensory- sensation of nasopharynx, gag reflex, taste-posterior 1/3 of tongue

Parasympathetic- secretion of salivary glands, carotid reflex

Motor- voluntary muscles of phonation (glutteral speech sounds) and swallowing

Vagus (X)- Sensory- sensation behind ear and part of external ear canal

Parasympathetic- secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

Spinal Accessory (XI)- Motor- turn head, shrug shoulders, some action for phonation

Hypoglossal (XII)- Motor- Tongue movement for speech sound and articulation and swallowing

Respiratory-Circulatory-and vasomotor activities

reflexes of swallowing, coughing, vomiting, sneezing, and hiccupping

relay center for major ascending and descending spinal tracts that decussate at the pyramid

Reflexes of pupillary action and eye movement

regulates respiration; houses a portion of the respiratory center

controls voluntary muscle action with corticospinal tract pathway

Midbrain (CN III & IV)

Oculomotor & Trochelear

reflex center for eye and head movement

auditory relay pathway

coricospinal tract pathway

Diencephalon

CN I and II Thalmus-

Olfactory & Optic

Relays impulses between cerebrum, cerebellum, pons, and medulla

conveys all sensory impulses except olfactory

Controls state of conciousness, conscious perceptions of sensations and abstract feelings

integrates impulses between motor cortex and cerebrum, influencing voluntary movement and motor response

Houses the pineal body

sexual development and behavior

Major processing center of interal stimuli for autonomic nervous system

maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity

ascending spinal tracts- spinothalmic, spinocerebllar mediate various sensations

manage sensory signals necessary to perform complex discrimination tasks

The posterior dorsal tract carries the fibers for the sensations of find touch-two point discrimination, and proprioception. spinothalmic tracts carry the fibers for the sensations of light and crude touch, pressure, temperature, and pain

corticospinal, reticulospinal, vestibulospinal

coney impulses from the brain to the various muscle groups by inhibiting or exciting spinal activity. control of muscle tone, posture, and precise motor movements

the corticospinal (pyramidal tract permits skilled, delicate, and purposeful movements.

vestibulospinal tract causes the extensor muscles to suddenly contract when an individual starts to fall.

corticobulbar tract innervates motor functions of the cranial nerves

The major portion of brain growth occurs in the first year of life, along with myelination of the brain and nervous system. any event that disrupts brain development and growth during this period (infection, trauma) can have profound effects on eventual brain function. At birth, the neurologic impulses are primarily handled by the brain stem and the spinal cord such as the following- sucking, rooting, yawn, sneeze, hiccup, blink at bright light, and withdrawal from painful stimuli. Some primitive reflexes are at birth (Moro, stepping, palmar and plantar grasp, and as the brain develops these reflexes are inhibited as more advanced cortical function and voluntary control take over.

Motor maturation proceeds in a cephalocaudal direction. Motor control of the head and neck develops first, followed by the trunk and extremities. Motor development progresses enabling more complex and independent functioning.

The number of cerebral neurons decreases with aging, but this is not necessarily associated with deteriorating mental function.

The vast number of reserve neurons inhibits the appearance of clinical signs. the velocity of nerve impulse conduction declines, so responses to various stimuli take longer

Risk factors for Stroke

HTN

Obesity

Sedentary Lifestyle

Smoking tobacco products

Stress

Increased levels of serum cholesterol, lipoprotein, and triglyercides

Use of oral contraceptives,sickle cell disease

Family history of diabetes mellitus, cardiovascular disease, htn, and increased cholesterol levels

congenital cerebrovascular anomalies

Infants

Prenatal and maternal history: mother's health, medications taken, intrauterine infections such toxoplasmosis, syphilis, tuberculosis, rubella, cytomegalovirus, herpes, fetal movememnt, prior history of htn, preeclampsia, bleeding, history of trauma or stress, perisistent vomiting, htn, drug or alcohol use

Birth History: Apgar score, gestational age, prematurity, birth weight, presentation, use of instruments to assist in delivery, prolonged or precipitate labor, fetal distress

Respiratory status at birth: resuscitation needed, apnea, cyanosis, need for oxygen and mechanical ventilation

one or more falls in the past year

past history of a stroke

neurologic condition such as Parkinson disease, dementia, or peripheral neuropathy

disorder of gait or balance

lower extremity weakness or sensory loss

impaired vision

use of an assistive device

Cranial Nerves- cranial nerves 11 through x11 are routinely tested; however taste is not tested unless some aberration is found

Proprioception and cerebellar function- one test is administered for each of the following- rapid rhythmic alternating movements, accuracy of movements, balance (Romberg) and gait and heel to toe walking

Sensory function- Superficial pain and touch at a distal point in each extremity are tested; vibration and position senses are assessed by testing the great toe

Deep Tendon Reflexes- All deep tendon reflexes are tested, excluding the plantar reflex and the test for clonus

Tested when their is a concern exists with the patient to discriminate odors . Use the least irritating aromatic substance first so that the patient's perception of weaker odors is not impaired. Make sure the patients nasal passages are patent - Occlude one nare at a time and ask the patient to breath in and out

Ask the patient to close his or her eyes and to occlude one naris. Hold an opened vial under the nose. The sense of smell may diminish with age

Ansomnia, the loss of sense of smell or an inability to discriminate odors can be caused by trauma

Visual Acuity and visual fields

Oculomotor III Trochlear IV Abducens VI

Movement of the eyes through the six cardinal points of gaze, pupil size, shape, response to light and accommodation and opening of the upper eyelids

The VI Abducens is the most likely to lose function with increased intercranial pressure- therefore ask the patient to look laterally for absence

Trigeminal V

Evaluate motor function by observing the face for muscle atrophy deviation of the jaw to one side, and fasciculations (muscle twitches) Have the patient tightly clench the teeth as you palpate the muscles over the jaw, evaluating tone,

Evaluate for sharp, dull, and light touch sensations

Corneal wisp

Temperature sensation- hot and cold

observe a series of expressions you ask the patient to make- Check for muscle weakness (Bell's Palsy)

Taste test- bitter, salty, savory, sweet

taste is rarely evaluated in the routine exam- taste acuity decreases with advanced againg, but the extent of decline varies

most individuals that complain of taste loss actuallly have olfactory loss

sensory function of taste of the posterior third of the tongue- can be tested during VII (facial) , simutaneously tested during vagus nerve for nasopharyngeal sensation (gag reflex) and the motor functioning of swallowing

Vagus X

to evaluate nasopharyngeal sensation, tell the patient you will be testing the gag reflex. Touch the posterior wall of the patient's pharynx with an applicator as you observe for upward movement of the palate and ocntraction of the pharyngeal muscles. Except the uvula to remain in the midline. Drooping or absense of an arch on either side of the soft palate is unexpected

Evaluate motor function by insepction of the soft palate for symmetry. Have the patient say "ah" and observe for movement of the soft palate and uvula for symmetry. If the vagus of glossopharyngeal nerve is damaged and the palate fails to rise, the uvula will deviate from the midline.

Have the pt. sip and swallow water.

Coordination and fine motor skills

observe for involuntary movements such as tremors

Rapid Rhythmic Alternating Movements: Ask the seated patient to pat his or her knees with both hands, alternating turning up and down the palms of the hands and increasing in speed.

Have the patient touch thumb to alternating fingers in sequence from index to little and back.

Stiff- slowed-nonrhythmic, or jerky movements are unexpected

The finger to nose test is performed with the patients eyes open. Ask the patient to use an index finger and alternately touch his or her nose and your index finger. Move your finger several times during the test. Repeat the procedure with the other hand. Consistent past pointing (missing the examiners finger) may indicate cellebellar disese

An alternate finger to nose test involves asking the patient to close both eyes and touch his or her nose with the index finger of each hand. Alternate the hands and increase the speed gradually

The heel to shin test is another alternate method, performed with the patient standing sitting, or supine, ask the patient to run the heel of one foot up and down the shin - expect the leg to be in a straight line

Balance is evaluated with the Romberg test- ask the patient to stand with eyes open then closed- slight swaying is expected but not to when their is a danger of falling

Falling indicates cerebellar ataxia, vestibular dysfunction or sensory loss

Ask the patient to stand on one foot and the opposite foot

Have the patient (eyes open) hop in place first on one foot and then on the other.

Superficial Touch- touch the skin with a cotton wisp or with your fingertip, using light strokes, do not deperess the skin and avoid stroking areas with hair

Superficial Pain - Alternating the sharp and smooth edges of a broken tongue blade or paper clip

Change in sensation

Temperature & Deep Pressure- Temperature and deep pressure sensation tests are performed only if superficial pain is not intact- roll test tubes of hot and cold water against the skin, alternating in an upredictable pattern.

Deep pressure is tested by squeezing the trapezius, calf, or biceps muscle- patient should feel uncomfort

Vibration- Place the stem of a tuning fork against several bony prominences

Position of Joints- Assess the great toe of each foot and a finger on each hand. Hold the joint to be tested by the lateral aspects to avoid giving a clue. Raise or lower the digit and ask the patient which was the joint waws moved. Loss of sensory modalities may indicate peripheral neuropathy

test cognitive ability to interpret sensations

*May indicate a lesion in the sensory cortex or the posterior columns of the spinal cord . eyes should be closed

Sterogenesis- hand the patient a familiar object to identify- tactile agnosia- inability to recognize objects by touch suggests a parietal lobe lesion

Two point discrimination- use two sterile needs or ends of a paper clip and alternate touch. Ask the patient how many points are felt. On the fingertips and toes- two points are felt at 2mm otherwise greater distance

Extinction Phenomenon- Simutaneously touch two areas on each side of the ody (cheek and hand) with a sharp edge of a broken tongue blade. Ask the patient to tell you how many stimuli there are and where they are

Graphesthesia- draw a letter or a number

Point location- Touc an area of the patients skin and withdraw the stimulus. ask the patient to point to the area touched

Superficial reflexes-

Plantar reflexes- Use the end of a reflex hammer to stroke the lateral side of the foot from the heel to the ball and then across the all of the foot to the medial side. Expect plantar flexion of all toes-The babinski sign is present when there is a dorsiflexion of the great toe with or without fanning of other toes and indicates a pyramidal tract disease. expected in children younger than 2 yo

Abdominal Reflex- With the patient supine, stroke each quadrant of the abdomen- expect the abdomen umbilicus toward each area of stimulation- corticospinal tract lesion if not

Cremasteric Reflex- Stroke the inner thigh of the male patient (proximal to distal) to eleict the reflex, expect the testicle and scrotum to rise on the stroked side

Ascending Tracts- for Lower Motor Neuron Disorders

Posterior Column-Vibration deep pressure, position sense, stereognosis (familiar object) point location, two point discrimination

proprioception

Upper Motor- descending tracts

Rapid rhythmic alternating movements, voluntary movement, deep tendon reflexes, plantar reflex, posture and romberg, gait, motor reactions

Superficial-

Upper Abdominal T8, T9, and T10

Lower Abdominal T10, T11, T12

Cremasteric T12, L 1, and L2

Plantar L5, S1, and S2

Deep tendon-

Biceps-C5 and C6

Brachioradial- C5 and C6

Triceps C6, C7, C8

Patellar-L2, L3, and L4

Achilles S1 and S2

Deep Tendon Reflexes

Biceps- Flex the patients arm to 45 degrees at the elbow. Palpate the biceps tendon in the antecubital fossa, place your thumb under the tendon and your fingers under the elbow. Strike your thumb, with the reflex hammer

Brachioradial Reflex- Flex the patient's arm up to 45 degrees and rest his or her forearm on your arm with the hand slightly pronated. Strike the brachioradial tender directly with the reflex hammer, pronation of the forearm and flexion of the elbow should occur

Triceps- Flex the patient's arm at the elbow up to 90 degrees, supporting the arm proximal to the atecubital fossa. Palpate the triceps tendon and strike it directly with the reflex hammer, contraction of the triceps muscle causes visible or palpable extension of the elbow

Patellar Reflex- Flex the patients knee at 90 degrees- Support the upper leg with your hand and allow the lower leg to hand loosely. Strike the patellar tendon just below the patella. Contraction of the quadriceps muscle causes extension of the lower leg

Achilles Reflex- With the patient sitting, flex the knee to 90 degrees and keep the ankle in neutral position, holding the foot in your hand. Strike the Achilles tendon at the level of the ankle malleoli, contraction of the gastocnemius muscle causes plantar flexion of the foot

Clonus- if reflexes are hyperactive- support the patient's knee in partially flexed position and briskly dorsiflex the foot with your other hand. No rhythmic movements between dorisflexion and plantar flexion should occur

Characteristics of Upper and Lower motor neuron disese

Upper- Increased tone, spacicity

Decreased strength

Sensation loss

Hyperactive deep tendon, positive Babinski sign

No fasciculations

Parlysis of voluntary movements

Damage above level of brainstem affects opposite side of body, damage bellow the brainstem affects same side of body

Lower-

Decreased tone, muscle flaccidity

loss of muscle strength-muscle atrophy/wasting

sensory loss follows the distribution of dermatones or peripheral nerves

weak or absent deep tendon reflexes

fasciculations

paralysis of muscles

damage affects muscle on same side of body

0- No response

1+ Sluggish or diminished

2+ Active or expected response

3+More brisk than expected, slightly hyperactive

4+Brisk, hyperactive, with intermittent or transient clonus

Use the 5.07 monofilament tet for sensation on several sites of the foot- DM peripheral neuropathy

Meningeal signs

stiff neck or nuchal rigidity is a sign that may be associated with meningitis and intracranial hemmorhage

With the patient supine, slip your hand under the head and raise it, flexing the neck

Try to make the patient's chin touch the sternum but do not foce it . Pai and a resistance to neck motion are associated with nuchal rigidity, occasionally painful swollen lymph nodes in the neck may cause pain and resistance to neck motion

The Brudzinski sign- involuntary flexion of the hips and knees when flexing the neck- meningeal irritation

Kernig Sign- flexing the leg at the knee and hip when the patient is supine, then attempting to straighten the leg, patient has pain in the lower back and resistance to straightening the leg is meningeal irritation

with patient presenting with fever and headache that leads to disagnosis of meningitis

Ask the patient to move his or head horizontally at a rate of 2 to 3 rotations per second. A positive sign is increased headache over the baseline

Postures that may be found in unresponsive patients are associated with severe brain injury, decorticate or flexor posuring is associated with injury to the coricospinal tracts above the brainstem

A decerbrate or extensor posuring is associated with injury to the brainstem

Infants

Coordinated sucking and swallowing is a function of the cerebellum. Hands are usually held in fists until 3 months old. After 3 months the hands begin to open for longer periods of time. Purposeful movement begins at about 2 months of age. The infant progresses to taking objects with one hand at 6 months, transferring objects hand to hand at 7 months, and purposefully releasing objects by 10 months. A withdrawal of all limbs from a painful timulus provides a measure of sensory integrity. The patellar tendon reflexes are present at birth and Achilles and brachioradial tendon reflexes appear at 6 months of age- use fingertip or stethoscope head

One or two beats of ankle clonus is expected

A positive Babinski is expected until 16-24 mo

Rooting- Touch the corner of the infants mouth- disappears by 3-4 months- open mouth on the side of stimulation

Palmar grasp- infants head is in midline, touch the palm of the infants hand from the ulnar side, 1-2 months- dissapear by 3-4

Plantar grasp- touch the plantar surface of the infant's feet at the base of the toes; the toes shuld curl downward; the reflex should be stron up to 8 months

Moro- allow the head and trunk to drop back to 30 degree angl- observe for symmetric abduction and extnesion of the arms, fingers fan out and thumb and index finger form a c- disappears by 6mo

Placing (4days)- hold the infant upright under the arms touch the dorsal side of foot and observe flexion of the hips and knees and lifting of the foot as if stepping up on the table

Stepping- birth and 8 weeks- hold the infant upright under the arms and allow the soles of the feet to touch the surface, observe for alternate flexion and extension of the legs, stimulating walking

Asymmetric tonic neck or fencing (2-3 mo) lying supin and relaxed, turn his or her head to one side, observe for extnesion of the arm and leg on the side where the head is turned. dissapears by 6 mo

CN II, III, IV, VI- optical blink reflex- Doll's eye maneuver

CN v- rooting reflex, suckling

CN VII- Observe facial expression

CN VIII- Acoustic blink reflex- loudly clap

moves eyes in direction of sound, Doll's eye maneuver- eyes don't move in direction of turning- vestibular problem or muscle eye paralysis

CN IX and X Swallowing and gag reflex

CN XII- Coordinated sucking and swallowing ability Pinch infants nose, mouth will open and tip of tongue will be midline

Delay in sitting or walking can be a cerebellar disorder

heel to toe walking, hopping, and jumping

Use figures rather than numbers when checking cortical sensory

CN II- Snellen, Picture chart, visual fields

CN III, IV, VI- have the child follow an object with eyes, extrocular eye movement

CN V- Observe the child chewing a cookie or cracker, ,touch cheeks forehead

CN VII- Observe expressions, puffed cheeks

CN VIII- Observe child turning to sounds, whisper

CN IX & X Gag reflex

CN XI- and XII- Stick out the tongue and shrug shoulders and raise arms

Modifications: weight reduction, adherence to a diet that is low-fat, low sodium and rich in fruits, vegetables, and dairy products, 30 minutes of aerobic exercise daily, moderate alcohol consumption and no smoking

HTN, A fib, heart disease, DM, Hyperlipidemia and carotid artery stenosis treatment decreases risk

allow more time for performing maneuvers of coordinatio and movement

Medicatinos can impair CNS and caused slowed reaction time, tremors and anxiety

diminished smell and taste sensation, reducted ability to differentiate colors, reduced upward gaze, slower adjustment to lighting, decreased corneal reflex, mid to high frequency hearing loss and reduced gag reflex

Gait with advancing age is charaacterized by shorter steps with less lifting of the feet as proprioception declines, shuffling may occur , arms are more flexed and legs may be flexed at the hips and knees. Tactile and vibratory sensation may be decreased- fine motor skills by taking off clothes

Changes in deep tendon reflexes occur with aging even absent reflexes starting in lower than upper

Increase in benign tremor

Mutiple Sclerosis (MS)

progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin of the brains white matter leading to decreased brain mass and tramission of nerve impulses

Infection- women 20-40 yo

Subjective- Faituge, urinary frequency, urgency, or hesitancy, sexual dysfunction, vertigo, weakness, numbness, blurred vision, diplopia, vision loss, emotional changes

Objective Data- muscle weakness, ataxia, hyperactive deep tendon reflexes, paresthesia, sensory loss, intention tremor, optic neuritis, cognitive changes, MRI show brain lesions

chronic disorder characterized by recurrent, unprovoked seizures secondary to an underlying brain abnormality

Subjective- History of prior seizure, premonition or aura, body stiff and ridgid- followd by jerking movements, loss of bladder or bowel control

Objective- Tonic phase- brief flexion and cry with contraction of abdominal muscles followed by generalized extension for 10 to 15 min; loss of consciousness for 1 to 2 minutes, eyes deviated upward, and dilated pupils

Clonic phase- contractions alternate with muscle relaxtion

Postictal state: coma followed by confusion and lethargy

inflammation of the brain and spinal cord involving the meninges due to virus

mild viral illness with fever

onset of lethargy, restlessness and mental confusion

Objective- Altered mental status, confusion, stupor, voma, photophobia, stiff neck, muscle weakness, paralysis, ataxia

inflammatory process in the meninges, membrane around brain and spinal cord

S- fever chills, ha, stiff neck, lethargy, malaise, vomiting, irritability, seizures

o- altered mental status, confusiom, nuchal rigidity, fever, brudzinski and kernig, petchiae, and purpura

lumbar puncture

abnormal growth within the cranial cavity

s- persistent headache, may awaken patient from sleep, nausea - early morning, unsteady gait, impaired coordination, memory loss and confusion, reduced vision acuity or visual loss, behavior or personality change, seizure

o- altered consciousness, confusion, papilledema, cranial nerve impairment, aphasia, vision loss, gait distrubances, ataxia

intracranial hypertensino that mimics brain tumors

s- severe daily headache, throbbing, may awaken patient, pain behind eye, vomiting, short episodes of blurred vision, double vision, whooshing sounds in ears

o- papilledema, inferior nasal vision deficet

decreased visual acuity, alert, unimpaired consciousness, absense of focal neurological signs

CT/MRI

interupption of blood supply to brain

s- sudden numbness or weakness on one side of the body, sudden confusion or trouble speaking or understanding, seeing, walking, dizziness, or loss of balance, severe headache sudden

o-elevated blood pressure, altered level of consciousness, difficulty managing secretions, weakness or paralysis, apahsia, articulation impairment, impaired horizontal gaze

Myasthenia Gravis

PNS
autoimmune disorder of neuromuscular junction involved with muscle activation

s- drooping eyelids, double vision, difficulty swallowing or speaking, fluctuating fatigue or weakness, inability to work with arms above head, difficulty walking, worse later in the day improve with rest

o- ptosis that develops within two minutes of upward gaze, facial weekness when puffing cheeks, hypophonia, respiratory compromise or failure, weakness of skeletal muscles without reflex

Guillian Barre

postinfectious disorder that causes an acute neuromuscular paralysis

s- history of recent illness and recovery, progressive weakness, more in legs than in arms, increased difficulty walking, paresethesia, pain in the shoulder back or posterior thigh, double vision

o- distal weakness, usually bilateral and asymmetric, and diminished reflexes in ascending pattern, ataxia, progressing to flaccid paralysis, facial nerve weakness (Bell palsy) diplopia, dysphagia, difficulty handling secretions, respiratory distress, lumbar puncture reveals increased protein in CSF

One or more branches of the V cranial nerve

s- sharp pain episode on one side of the face that lasts seconds to minutes; pain may rarely be bilateral, potential pain triggers are chewing, swallowing, talking, washing the face, brushing the teeth, exposure to cold, even a breeze across the face, episodes may occur several times throughout the day

o- normal neurologic findings, slight sensory impairment in the regions of pain, pain occurs in the distribution of one or more divisions of the facial nerve

temporary acute paralysis or weakness of one side of the face

s- rapidly progressive muscle weakness on one side of face ( over 2 to 3 days)

feeling of facial numbness

o- facial creases and nasolabial fold disappear on affected side

eyelid will not close on afffected side and lower lid sags; leads to eye irritation, food and saliva may pool in affected side of mouth, facial sensation intact

results in motor and sensory loss in the distribution of the one or more nerves, commonly caused by DM

s- gradual onset of numbness, tingling, burning, and cramping, most commonly in hands and feet

night pain in one or both feet

walking on cotton, floors feeling strange, or inability to distinguish between coins by feel, sensation of burning accompanied by hyperalgesia and allodynia

o- reduced sensation in the foot with monofilament; loss of pain or shar touch sensation to the mid-calf level, distal pulses may present diminished, diminisehd or absent ankle and knee reflexes, decreased or no vibratory sensation, distal muscle weakness, inability to stand on toes or heels, skin ulceration that pt does not feel

group of permanent disorders of movement and posture development associated with nonprogressive disturbaces that occured in developing fetal or infant brain

s- delays in gross motor development that become more obvious, activity limitation, stiff joints and positioning, hearing, speech, language disorders, feeding difficulties, poor sucking, and swallowing coordination, seizures

o- cognitive impairment or learning disabilities, spastic CP- hypertonicity, tremors, scissor gait, toe walking, persistent primitive reflexes, exaggerated deep tendon reflexes

Dyskinetic CP- involuntary slow writhing movements of the extremities; tremors, exaggerated posturing, inconsistent muscle tone that varies

ataxic- abnormalities of movement involving balance and position of trunk and extremities, intention tremors, past pointing, increased or decreased muscle tone, hypotonia, instability- wide based gait

congenital vertebral defect (lumbar or sacral) that allows spinal cord contents to protrude

s-loss of bowel control or constipation, loss of bladder control, mobility problems

o- exposed meningeal sac filled with fluid and nerves, sensory deficit and parlysis or weakness dependent on level of defect, rapidly increasing head circumference (hydrocephalus), hip or foot abnormalities, learning disabilities and perceptual motor skills

severe form of child abuse resulting from shaking younger than 1 yo- shaking causes stretching and tearing nerve tissue and blood vessels and causing brain damage and subdural hematoma- spinal cord damage as well

s- fever, irritability, lethargy, decreased foot intake, breathing difficulty, seizures, loss of consciousness

o- altered level of consciousness, seizures, bilateral retinal hemorrhages with retinal detachments, absence of visible trauma to head- fingerprint bruises, bruising, bite marks, or burns, CT subdural

neuropathy that can occur during late pregnancy and delivery

s-intermittent pain that radiates from the buttock into the leg during late pregnancy, pain subsides after delivery but foot drop may be present

o- pain radiates from buttocks of the affected extremity in a lumbar 5 distribution, unilateral foot drop that may take weeks to resolve

degenerative neurologic disorder in which deficiency of the dopamine neurotransmitter results in poor communication between parts of the brain that control movement and balance

s- tremors-pill rolling movement, slowing of voluntary and automatic movements, numbness, aching, tingling, muscle soreness

o- tremors, muscle rigidity, stopped posture, balance, and postural instability, short steps, shuffling, freezing gait, difficulty swallowing, drooling, voice softening, slow, slurred monotonous speech, impaired cognition, dementia

noncommunicating hydrocephalus (dilated ventricles with intracranial pressure within expected range)

s- gait impaired, unsteadiness, difficulty turning, gorgetfulness, cognitive impairment, urinary frequency- urgency and incontinence

o-gait impairment, wide-based stance, short small steps, reduced floor clearance, no tremor no sensory impairment, cognitive impairment, impaired memory recall for recent events

CT scan- enlarged ventricles

Postpolio syndrome

reappearance of neurologic signs 10 or more years after survival of poliomyelitis

s-history of paralytic or nonparylitic polio, new onset muscle weakness, muscle cramps, increased pain sensitivity, fatigue, cold intolerance, difficulty with swallowing or speaking, shortness of breath, difficulty sleeping

o- focal and asymmetric muscle weakness and atrophy, fasciculations, dysphagia,, dysarthria(slow slurred speech) , sleep apnea, hypoventilation