PHYSICAL EXAMINATION:

* Neurologic Examination
> MSE
> Cranial Nerve Exam
> Motor System Assessment
> Reflex Activity Assessment
•Neuro Check:
 GCS
 Pupillary Signs
 Eye movement
 Motor Response
 Vital Signs
 SENSORY EXAMINATION
It is largely subjective and requires the cooperation of the
patient.
During the sensory assessment, the patient’s eyes are closed.
Simple directions and reassurance that the examiner will not
hurt or startle the patient encourage the cooperation of the
patient
Tactile sensation is assessed by lightly touching a cotton wisp
to corresponding areas on each side of the body.
The sensitivity of proximal parts of the extremities is compared
with that of the distal parts.
Pain and temperature sensations are transmitted together in the
lateral part of the spinal cord
 SENSORY EXAMINATION

Determining the patient’s sensitivity to a sharp object can

assess superficial pain perception.

The patient is asked to differentiate between the sharp and

dull ends of a broken wooden swab or tongue blade.

Using a safety pin is inadvisable because it breaks the

integrity of the skin.

Both the sharp and dull sides of the objects are applied with
equal intensity at all times and are both compared.
 MOTOR EXAMINATION
Reflects the integrity of the corticospinal tracts, the
extrapyramidal system and cerebellar function

Five-point scale to rate muscle strength:

5 = indicates full power of contraction against gravity and
resistance or normal
4 = indicates a fair but not full strength against gravity and moderate
amount of resistance or slight weakness.

3 = indicates just sufficient strength to overcome the force of gravity or

moderate weakness.
2 = indicates the ability to move but not to overcome the force of
gravity or severe weakness

1 = indicates minimal contractile power. Weak muscle contraction can

be palpated but no movement is noted. Very severe weakness.
 COORDINATION MOVEMENT
The smoothness, accuracy and strength that characterized the
muscular movements of a normal person are attributed to the
influence of the cerebellum and the basal ganglia

Cerebellum: responsible for coordination and timing of all

muscular movements that originate in the motor centers of the
cerebral cortex.

Basal ganglia: play an important role in planning and coordinating

motor movements and posture
 REFLEX EXAMINATION

GRADE DESCRIPTION
4+ markedly hyperactive with sustained clonus
3+ indicates a hyperactive reflex

2+ indicates a normal or physiologic reflex

0 absent
 Biceps reflex Triceps reflex Patellar reflex

Achilles reflex Babinski reflex

Others:
Pupillary Signs
Respiratory Pattern
Eye Movement
Vital Signs
DIAGNOSTIC ASSESSMENT:
CT-Scan
MRI
EEG
Radiologic Exams
Eye Test
Hearing Test
Common Health Problems of the:
Neonate and Infant
Child and Adolescent
Middle Aged Adult
Across the Life Span
 COMMON HEALTH PROBLEMS OF THE
NEONATE AND INFANT:
Cranial Abnormalities:
Hydrocephalus
Encephalocele
Spinal Cord Abnormality:
Myelomeningocele
 HYDROCEPHALUS
Pathophysiology:
blockage of the opening in the fourth ventricle or
the cerebral aqueduct that result to accumulation
of CSF in the ventricles
The accumulation of fluid inside the brain
ventricles causes increased pressure that dilates
the ventricles and compresses the brain

Treatment: placing a drainage tube(shunt) from the

ventricles to the abdominal cavity to eliminate the
high internal pressure.
 ENCEPHALOCELE
Pathophysiology:
There is a mesodermal defect resulting in a defect in the
calvarium and dura associated with herniation of CSF,
brain tissue and meninges.
The root cause is the failure of surface ectoderm to
separate from the neuroectoderm early in embryonic
development.
It may be occipital (75%), frontoethmoidal (13-
14%),parietal (10-12%) or sphenoidal.
Frontoethmoidal encephaloceles are common in Asia
 ENCEPHALOCEL
Mortality/Morbidity:
The prognosis depends on the associated malformations
and the size and contents of the defect.
21% are born live but only one half survive.
Approximately 75% of survivors have mental deficit.
3% recurs after surgical repair.
The absence of brain tissue with in the herniated sac is the
single most favorable prognostic feature for survival.
 MYELOMENINGOCELE
Definition:
is a congenital disorder(birth defect) where the backbone and
spinal canal do not close before birth. This can result in the
spinal cord & its covering membranes protruding from the
infant’s back.
Most common birth defects of the CNS.
Affects 1 out of 800 infants.
Cause is unknown.
Folic acid deficiency is thought to play a part in neural tube
defects.
A viral cause may trigger.
Environmental factor: radiation
 MYELOMENINGOCELE
Symptoms:
Partial or complete paralysis of the legs
Partial or complete lack of sensation may include loss of
bladder or bowel control
Visible sac-like protrusion on the mid to lower back of a
newborn.
Weakness of the hips, legs or feet of a newborn
For Spina bifida:
a tuft of hair at the sacral area(back part of the pelvis)
dimpling of the sacrum
COMMON HEALTH PROBLEMS OF THE
CHILD AND ADOLESCENT:

Cerebral Palsy
Reye’s Syndrome
 CEREBRAL PALSY
Cause is unknown
Most have congenital malformation of the brain
that existed at birth and was not a caused by factors
occurring during the birthing process.
Not all of these malformations can be seen by the
physician, even with today’s sophisticated scans,
but when CP is recognized in a newborn, a
congenital malformations is suspected.
 REYE’S SYNDROME
Reported in 1929
Cause is still not well understood
Predominantly affect children 4-16 years old and is more
frequent when viral diseases are epidemic such as the
winter months or following an outbreak of chickenpox
The use of salicylates like aspirin during viral disease
appears to be linked to reye’s syndrome
No diagnostic test to detect is currently available.
 REYE SYNDROME
Signs and Symptoms:
Almost always preceded by a viral illness.
Usually appear 3-5 days after the onset of the chicken pox rash.
Incubation ranges:1-14 days
Nausea, vomiting, lethargy & indifference
Exhibit irrational behavior or delirium and rapid breathing.-
comatose
Liver maybe enlarged but there is usually no jaundice or fever.
 REYE SYNDROME
Is rare; approximately 0.1 case per 100,000 population.
It is, however, often thought of when a child has contnual
vomiting or change of mental status-particularly after a recent
viral illness.
Prevention
Aspirin and other salicylate drugs should never be used in the
treatment of chickenpox, influenza and other viral diseases

Aspirin is not recommended in any illness contracted by children

younger than 12.

In general, aspirin should not be used for children or teenagers

except on advice of a doctor for certain conditions.
COMMON HEALTH PROBLEMS OF
THE ADULT:

MUTIPLE SCLEROSIS
MYASTHENIA GRAVIS
 MULTIPLE SCLEROSIS

Is the most common of the CNS demyelinating disorder,

characterized by a loss of myelin & preservation of axons

Onset of symptoms is between 15-50 years of age

History may reveal unexplained symptom of paresthesia,

blurred vision, dizziness, urinary retention, motor
abnormalities (paralysis, loss of balance)
 MULTIPLE SCLEROSIS

Physical examination:
optic nerve involvement
cerebellar pathway involvement (ataxia, dysmetria,
dysarthria & nystagmus)
hyperactive deep tendon reflex
sensory findings
MULTIPLE SCLEROSIS
 MYASTHENIA GRAVIS

An autoimmune disorder of the myoneural junction.

Antibodies to the acetycholine receptor block nerve impulse
transmission at the neural junction and destroy the
receptors.

Prevalence: 1:20000 with women >men

 MYASTHENIA GRAVIS

Clinical evaluation:
fluctuating muscle weakness with out sensory
changes or pain occurring at any age.
common: eye involvement ( intermittent diplopia or
ptosis )
MYASTHENIA GRAVIS
COMMON HEALTH PROBLEMS OF
THE MIDDLE AGED ADULT:

TRIGEMINAL NEURALGIA
( Tic doulourex )
 TRIGEMINAL NEURALGIA
( Tic doulourex )

Is a condition involving the 5th cranial nerve.

It is said to be the most painful condition known
It consist of episodes of intense, stabbing pain that people
describe like an electrical shock.
It involves the lips, eyes, side of the nose, forehead & jaw.
It usually affects only one side of the face.
Usually lasts a short time
 TRIGEMINAL NEURALGIA
( Tic doulourex )

Triggered by something such as brushing the teeth, shaving

or even the slightest touch.
Etiology is unknown
pressure from an artery onto the Trigeminal nerve is
a suggested cause.
Occurs more often in females.
COMMON HEALTH PROBLEMS OF
THE MIDDLE AGED ADULT:

CEREBROVASCULAR ACCIDENT
CEREBROVASCULAR ACCIDENT

Intracerebral Hemorrhage
Subarachnoid hemorrhage
Cerebral Thrombosis
Cerebral Embolism
Transient Ischemic Attack
Stroke in Evolution
Stroke in the Young
COMMON HEALTH PROBLEMS THAT
OCCUR ACROSS THE LIFE SPAN:

HEAD INJURY
BRAIN TUMOR
INCREASE INTACRANIAL PRESSURE
Common Health Problems of the:
Neonate and Child
Adult
Across the Life Span
COMMON HEALTH PROBLEMS OF
THE NEONATE AND CHILD:

CONGENITAL CATARACT
STRABISMUS
RETINOBLASTOMA
CONGENITAL CATARACTS

Any opacity of the lens

Discrete dots or small white plaque like opacities of
the lens capsule
Rubella are more frequent cause of congenital cataract
than syphilis
CONGENITAL CATARACT
 STRABISMUS
SQUINT, CAST, TROPIA, PHORIA, CROSS-EYE,
WALL-EYE
Deviation of the visual axis
Paralytic strabismus: due to weakness or paralysis of 1 or
more of the extraocular muscles.
Nonparalytic strabismus: more common & are due to
underlying ocular or visual defects such as may occur in
cataracts, lesions of the optic nerve or macula, high
refractive errors or asymmetric refractive errors
Incidence increases with low birth weight
Maternal cigarette smoking of two packs/day during
pregnancy increases the risk about twofold
STRABISMUS
 RETINOBLASTOMA

Occurs either as a nonheritable sporadic mutation

involving the retinal cells or as a heritable germinal
mutation transmitted as a dominant characteristics
Most unilateral retinoblastomas are the result of somatic
mutation.
All patients with bilateral retinoblastoma have either a
new or inherited germinal mutation.
 RETINOBLASTOMA

Malignant tumor
Ages: 5yr or most commonly in the early years.
Most frequent sign: leukocoria=white or “cat’s eye”reflex
in the pupil.
RETINOBLASTOMA
COMMON HEALTH PROBLEMS OF
ADULT:

GLAUCOMA
CATARACTS
 GLAUCOMA
Is a group of diseases that can lead to damage to the
eye’s optic nerve and result in blindness.
Increases with advancing age.
Family history
Open-angle glaucoma is the most common form.
Increased pressure in the eye
GLAUCOMA
CATARACT
COMMON HEALTH PROBLEMS THAT
OCCUR ACROSS THE LIFE SPAN:

ERROR OF REFRACTION
TRAUMATIC INJURY TO THE EYE
INFECTIONS AND INFLAMMATION OF THE
EYE
RETINAL DETACHMENT
 ERROR OF REFRACTION

Refraction: check for visual acuity

Myopia: (short sightedness): near vision is usually clear
Hypermetropia: (long sightedness):
Astimagtism: both distance & near vision may be distorted
ERROR OF REFRACTION
 RETINAL DETACHMENT

Can cause a total loss of sight

Causes:
Trauma to the eye, high myopia, tumors and certain
diseases that produce fibrous bands of scar tissue pull the
retina away from its attachment to the back of the eye
RETINAL DETACHMENT
Common Health Problems of the:
Neonate
Infants and Child
Young Adult
Across the Life Span
Outer M Inner
COMMON HEALTH PROBLEMS OF
THE NEONATES:

CONGENITAL ANOMALIES
COMMON HEALTH PROBLEMS OF
THE INFANTS AND CHILD:
OTITIS MEDIA
MASTODITIS
FOREIGN BODY
ARTICULATION DISORDERS
 OTITIS MEDIA

Inflammation of the middle ear characterized by

fluid in the middle ear with signs and symptoms
of:

Ear pain, drainage, decreased hearing, fever,

irritability, tinnitus

About one third have symptoms lasting 2 weeks or

less
 EAR DRUM

NORMAL INFLAMMED
SECRETORY OTITIS
MEDIA

more commonly
known as “glue ear”.
caused by blockage
of the eustachian
tube as a result of
allergies, swollen
adenoids or other
infections of the nose
& throat, that
dampens down the
conduction of sound
and reduces hearing
 ACUTE OTITIS
MEDIA

also known as
“ bacterial otitis media

acute infection of the

middle ear usually
started by an infection
in the URT
is the most frequent
diagnosis of children
in clinical practice
 CHRONIC OTITIS
MEDIA

is the result of a prolong

middle ear infection with
perforation of the
eardrum.
affects 20-40% of all
children under the age 6
 MASTOIDITIS
Infection of the mastoid that typically follows
otitis media.

Appears initially to be otitis media, then swelling,

erythema & tenderness develop over the mastoid

Pinna of the ear may be displaced down and away from

the head.
MASTODITIS
FOREING BODY OF THE EAR
 ARTICULATION DISORDER
DISORDER OF RHYTHM SLUTTERING
VOICE QUALITY EDUCATION
Clinical speech-language pathologist conducts comprehensive
evaluations .
A language disorder is the inability to use words and their
meanings properly
Children may exhibit inappropriate grammatical patterns, poor
treading comprehension, poor decoding skills, difficulty with word
retrieval or difficulty with the knowledge of the sound system
A speech disorder is characterized by difficulty producing sounds
(articulation), dysfluent speech and voice difficulties.
ARTICULATION DISORDER
ARTICULATION DISORDER
COMMON HEALTH PROBLEMS OF
YOUNG ADULTS:

OTOSCLEROSIS
MENIERE’S DISEASE
LARYNGITIS
 OTOSCLEROSIS

is a condition of the middle ear which mainly affects the

tiny stapes bone.
it causes gradual hearing loss.
cause is not known
hereditary factors: family history of otosclerosis
virus may trigger the disease.
 OTOSCLEROSIS
affects 1-2 in 100 people in the UK
ages 15-35, but sometimes develops in younger children
women are affected twice as men
Treatment:
hearing aids
surgery (replacement of the stapes with artificial plastic
bone)
Flouride tablet in drinking water
 56 year old male who has
been deaf from 1947-1975.
He is currently hearing noise
in his left ear when he
stamps his feet, runs down
stairs, grunts or counts aloud.
The patient describes the
sensation as astrong
vibration that ends in a
fraction of a second.

Red arrows demonstrate

lucencies in the otic capsule
surrounding the structures of
the inner ear.

OTOSCLEROSIS
 LARYNGITIS
Is an inflammation or swelling of the vocal cords in response
to an infection, irritation or damage (trauma).
Vocal cords become thicker and stiffer & do not vibrate
well.
Most people have experienced acute laryngitis at some point
in their lives, usually in association with common cold or
prolonged shouting
It can occur at any age from childhood to old age.
 Treatment:
The voice should be rested as much as
possible.
The body should be well hydrated by
drinking an increased amount of water.
Drinks containing caffeine such as
coffee, tea & cola & irritants such as
smoke should be avoided.
Throat lozenges can help sooth and
relax the throat.
Simple over the counter painkillers help
with discomfort.
NORMAL LARYNX
LARYNGITIS
COMMON HEALTH PROBLEMS
ACROSS THE LIFE SPAN:

OTITIS MEDIA
HEARING IMPAIRMENT
 OTITIS MEDIA

Characterized by a severe earache and drainage,

decreased hearing, fever, irritability, vertigo, tinnitus &
fluid in the ear.
 EAR DRUM

NORMAL INFLAMMED
Common Health Problems of the:
Neonate and Infant
Child and Adolescent
Young Adult
Adult
Across the Life Span
COMMON HEALTH PROBLEMS OF
THE NEONATES AND INFANTS:

CONGENITAL HIP DISPLACEMENT

CLUB FOOT
TORTICOLIS
CONGENITAL HIP DISPLACEMENT
 CLUBFOOT

Talipes equinovarus
Occurs 1/1000 births
Characterized by: talar plantar flexion, hindfoot
varus, forefoot adduction & soft tissue curvatures
resulting in cavus foot deformity

It is thought to be secondary to intrauterine position

in a genetically predisposed fetus but is also
associated with congenital hip dislocation,
nyelomeningocele
CLUB FOOT
CLUB FOOT
 TORTICOLIS

Is a form of dystonia(prolonged muscle contraction in

which the neck muscle contract involuntarily causing
the head to turn.
May occur without known cause (idiopathic, genetic) or
be acquired secondary to damage to the NS or muscles.
Newborns often have positional deformities that reflect
their cramped intrauterine environment
 TORTICOLLIS

Infant with torticollis has spent a number of weeks with

one side of the head pushing on the ipsilateral shoulder.
As a result muscle may have become fibrotic, shortened
or injured
The trapezius and small strap muscles in the neck may
also be involve
COMMON HEALTH PROBLEMS OF
CHILD:

JUVENILE RHEUMATOID ARTHRITIS

LEG-CALVE-PERTHES DISEASE
RICKETS
JUVENILE RHEUMATOID ARTHRITIS

Causes are unknown

Thought to be associated with an autoimmune problem.
Not regarded as hereditary.
Most commo symptom: persistent joint swelling, pain &
stiffness that are typically worse in the morning or after a nap.
Difference with the adult RA: children with JRA outgrow the
illness while adults have lifelong symptoms.
JUVENILE ARTHRITIS
 LEGG-CALVE-PERTHES DISEASE
( LCPD )

Is avascular necrosis of the femoral head in otherwise clinically

normal children.
Presents between 4 & 8 years of age with the boy/ratio of 5:1
Children with LCPD are often small for age, thin & hyperactive
with bone age that is delayed by 1-2 years
LEGG-CALVE-PERTHES DISEASE
 RICKETS

A disease of children in which the bones fail to calcify.

Bones soften & a definite bowing of the weight-bearing
bones of the legs occurs.
Due to lack of calcium in the diet or lack of vitamin D
COMMON HEALTH PROBLEMS OF OF
THE ADOLESCENT

SCOLIOSIS
 SCOLIOSIS
Lateral or sideways curve in the spine that is apparent
when viewing the spine from behind.
Occurs in thoracic or thoraco-lumbar regions.
2 types:
* Structural: the mechanics of the curve are such that rotation of the
vertebrae occurs in combination with lateral curvature that usually
produces a protruberance of one side of the rib cage.
*Functional: fixed rotation does not occur & the curvature is usually
non-progresive.
Unknown or idiopathic.
COMMON HEALTH PROBLEMS OF
YOUNG ADULT
OSTEOGENIC SARCOMA
 OSTEOGENIC SARCOMA

Most common of the malignant neoplasm derived from bone cells

that in the jaws exhibit radiographic widening of periodontal
membrane of teeth and histologically exhibit a wide expectrum of
findings all of which contain atypical osteoblast & abnormal bone
or osteoid formation.

Ages between 30-40

Usually affects the mandible
Firm,rapidly growing swelling, pain & mobility of teeth, loss of
sensation.
OSTEOGENIC SARCOMA
COMMON HEALTH PROBLEMS OF
THE ADULT

ADULT RHEUMATOID ARTHRITIS

GOUT
CARPAL TUNNEL SYNDROME
OSTEOMALACIA
OSTEOPOROSIS

DEGENERATIVE JOINT DISEASE (osteoarthritis)

 ADULT RHEUMATOID ARTHRITIS

Chronic inflammatory disorder.

Occurs between the ages 40-50, but may occur at any age.
It affects as many women than men.
Joints: fingers, ankles, wrists & feet ( symmetrical).
 GOUT
Is a disease in which uric acid (a normal waste product of
nucleic acid metabolism) accumulates in the blood and
maybe deposited as needle-shaped crystals in the soft tissues
of joints
Small joint at the base of the big toe is the most common site
Others: ankles, knees, wrists, fingers, elbows
Most common in males & rarely appears before the age 30
Genetic factors: families
 CARPAL TUNNEL SYNDROME

Is a painful disorder of the wrist & hand.

Carpal tunnel is a narrow tunnel formed by the bones & other
tissues of the wrist. It protects the median nerve
Median nerve gives you the feeling in your thumb, index middle
& ring fingers.
But when other tissues in the carpal tunnel such as the ligaments
& tendons are swollen or inflamed, they press against the
median nerve.
 CARPAL TUNNEL SYNDROME

What leads to carpal tunnel syndrome:

doing the same hand movements over & over again.
people at risks: computers,carpenters, grocery checkers,
meat packers, violinists & mechanics.
 OSTEOMALACIA

Means “soft bones

Insufficient mineral or osteoblast dysfunction, the
osteoid does not mineralize properly
OSTEOMALACIA
 OSTEOPOROSIS

Loss in bone mass leading to thin, fragile bones, especially in

the spine & the neck of the femur
Common in aging in women
Estrogen helps to mainatain the health & normal density of a
woman’s skeleton.
Others: diet poor in calcium & protein, lack of vitamin D,
smoking & insufficient weigh bearin exercise
COMMON HEALTH PROBLEMS
ACROSS THE LIFE SPAN:

FRACTURES
INJURY TO SOFT TISSUE
“ The essence of science, is not the
learning of facts; not memorizing but
wondering; Not being told, but trying to
find out”.

E. Wood