Examination for signs of cognitive and motor disturbances

2021-02-05 12:00 AM

Muscle tone is a regular state of muscle contraction under the domination and regulation of reflex arcs, pyramids, extrapyramidal systems, cerebellum, vestibule.

State of consciousness

Common sense

The patient judges and answers the questions clearly and accurately. Usually, we record in the medical record as alert, which means common sense.

Consciousness disturbances

Disorder in the amount of consciousness

From mild to severe as follows:

Dark sense: The patient is able to orient and answer the questions correctly but slowly, with poor intentions.

Drowsiness: The patient snores, drowsily but also responds to strong stimuli, while a protective response such as calling out loud, opening his eyes to follow, also being able to comply with the physician's orders such as holding hands, sticking out tongue ... When the stimulus stops, the patient goes back to sleep even though the physician is sitting beside.

Pre-coma: The physician cannot contact the patient such as calling, asking, and not answering; Pain stimulation does not return to consciousness but also reacts properly.

Coma: Loss of contact with the world and plant life more or less disturbed. Painful irritations that respond incorrectly or no longer respond.

Consciousness disorders are found in brain damage, metabolic disorders, poisoning ...

Substance disorder of consciousness

Delirium: The patient cannot recognize and answer the questions correctly, panic, babble, even run, smash. Having delusions (which are false perceptions of external real things) and hallucinations (which are false perceptions of external things) are commonly seen as visions and hallucinations. After the delusion is over, the patient remembers the delusions and hallucinations that have passed. Delirium is common in malignant malaria, pre-coma, high fever in children ...

Dementia: Always say nonsense, unrelated words, and sentences. Not being oriented to space (where), time (when), and even myself (name, age, profession ...) also have illusions, hallucinations but less than delusion. When the patient regained consciousness, there is no longer remember the hallucinogenic delusions that passed. Met in stage III nerve syphilis, severe brain degeneration, encephalopathy caused by hypertension ...

Movement characteristics

Mechanical examination

Muscle power depends on the nervous system, musculoskeletal system, psychological factors ... There are 3 ways to examine the muscles in sequence as follows:

How to examine

Do normal movements: Instruct the patient to perform two-sided movements such as raising arms or legs, folding or stretching arms or 2 legs ... if not, then severe paralysis after removal except hysteric, musculoskeletal disease.

Anti-movement: Tells us the muscles of each muscle group. If the patient does a certain movement, the physician fights like the patient shrink his arm, the physician tries to pull it out or vice versa ... and must make the two sides symmetrical. After examining which muscle group is weak if, in doubt, they must use the methods to evaluate. 

Legal test: There are two methods, only used when mild paralysis also does not require severe paralysis.

Barré maneuvers:

Upper limb: The patient lies on his back, hands out straight in front of the bed at an angle of 60 (and palms up. the hand was crumpled up and down slowly falling or brought up and down (seesaw).

Upper limb Barré test combined with Mingazini method according to Strumpel (Paralysis of left limbs)

Figure: Upper limb Barré test combined with Mingazini method according to Strumpel (Paralysis of left limbs).

On the upper limb, you can also use the plier's test to evaluate the force of your thumb and index finger. The patient presses the thumb and index finger together to form a pincer, then the examiner uses the index finger to break the pincer. Side pincers are easier to open.

Lower limbs: The patient lies on his stomach with his two legs not touching each other to create the bed surface at an angle of 45. When the paralysis is mild, the side leg is paralyzed, not falling, if the paralysis is severe, it will fall quickly but must eliminate factors mentality. When psychological factors are suspected, it is necessary to use the modified Barré test to distinguish by letting the patient lie on his stomach, with his maximum two legs folded into the buttocks. If the paralysis is true, the leg will stretch, while pretending it will remain as the roots.

Test of the lower limb Barré (Left leg paralysis)

Photo: Test of the lower limb Barré (Left leg paralysis).

Modified Barré test (Left leg paralysis)

Photo: Modified Barré test (Left leg paralysis).

Mingazini test: Only give the lower limb to the patient lying on his back, classic is to raise the legs, thighs perpendicular to the bed surface and lower legs are perpendicular to the thighs. These days are of little use but instead create an obtuse angle between shins and thighs, thighs and torso around 1300 (see figure 1). If any side is paralyzed, that side falls to the bed surface.

Exam Results:

Mechanical examination to know the degree of preliminary paralysis is as follows, severe paralysis is unable to do normal movements, mild paralysis is able to do normal movements but is slow and weak. concentration. A more detailed evaluation of muscle force by scoring (0 = complete paralysis; 1 = moving only some muscle groups; 2 = muscle contraction weaker than countervailing force; 3 = muscle contraction stronger than opposing force; 4 = good force; 5 = normal force). In addition, the mechanical examination also shows the position of paralysis. However, the mechanical examination does not know whether the paralysis is due to damage to the central or peripheral motor neuron. Through the test of muscle tone partly answers the above problem.

Muscle tone examination

Muscle tone is a regular state of muscle contraction under the domination and regulation of reflex arcs, pyramids, extrapyramidal systems, cerebellum, vestibule. Examination in a completely relaxed patient condition is also called a passive motor exam. There are also 3 methods of examination and after completing all 3 exams, assess muscle tone.

How to examine

Evaluate muscle strength: By touching the muscles in a fully stretched, symmetrical position on both sides, see if the muscles are tight or bouncy. Normally, there is a certain level of strength on both sides.

Evaluation of tickling: The patient lies on his back with two legs stretched out, his forearms are standing perpendicular to the bed surface. The physician grabbed his wrists and shook them steadily, then took both his ankles and shook them, see if they were waving evenly or not. Normally, the ticks regularly.

Evaluation of elasticity: By testing the arm around the neck, put the fingers on the shoulder blade at the same side. Normally the finger touches the base of the scapula. The upper limb elasticity decreases when not touched, if the elasticity increases, it is too touch.

Also, in the lower limb by the heel touches the buttock by lying on his stomach twice the lower legs are usually the heel about 5cm from the butt. If the elasticity decreases the heel to reach the buttock from 7-10cm or more, the increase is the heel reaching to the buttock. It is necessary to exclude musculoskeletal pain or joint laxity that changes elasticity.

Exam results

Reduced tone: Decreased firmness, increased tickling strength, increased elasticity. Muscle hypotonia due to paralysis occurs in peripheral nerve damage or when central motor neuron injury stage soft paralysis (with the brain, spinal shock) is also not due to paralysis as in sensory lesions, posterior roots, posterior spinal horn, cerebellum, new striatum.

Increased tonicity: Tensile strength increases, ticks decrease, elasticity decreases. Includes paralysis of myotonia (damage to the spastic central motor neuron) and non-paralysis (Parkinson's disease, meningitis, tetanus).

Table: Distinguishing hypertonia due to paralysis and Parkinson's disease.

No

Characteristics

Spastic paralysis

Parkinson disease

1

Selective

Upper limbs fold, lower limbs stretched

Not selective

2

Elastic

(+)

(-): crimp/lead tube

3

Signal

Open a knife tweezers

Serrated wheel

4

Tendon reflex

Increase

Normal

5

Scopolamine injection

No changes in tonicity

Reduced tonicity

Balance disorder and movement coordination

The imbalance and coordination of movements are called staggering, which occurs when damage to one of the three organs that is the deep feeling, the cerebellum or vestibule. Usually use the following 3 methods:

How to examine

Finger-pointing for the nose: The patient lies, sits, or stands with his hand straightened, then uses his index finger to point to the right tip of his nose when he opens his eyes 3 times and when he closes his eyes 3 times. As for the lower limb for the heel-knee maneuver, the patient lay on his back, but the heel on this side on the opposite knee and then slid along the tibia, also when he opened his eyes and closed his eyes 3 times. Normally just right, not trembling. If you go in the right direction but just too target (on the forehead or above the knee) is called too out of reach in the cerebellum. Direction disturbance in the first place causes movements with trembling hands/feet, the wrong direction, especially when the eyes are closed, is known as a disorder in the deep sense of consciousness, previously commonly seen in Tabès' disease. meridian).

 Fingertip test and heel knee test

Figure: Fingertip test and heel knee test.

Continuously flip the hands: Instruct the patient to repeatedly turn the hands upside down. Normally smooth and agile. If you make it difficult, embarrassing, slow, or confused, it is called loss of contact with the cerebellum. Note that this test is valid in the absence of paralysis or in the absence of musculoskeletal disease.

Test method of folding thigh-body combination: Being in a lying position with two legs stretched, the patient crossed his arms and sat up without leaning on the legs, no arms. Normally sit up and see 2 heels resting on the bed. If when performing that movement, the legs are lifted and it is difficult to sit up because of damage to the cerebellum, so it loses copper power.

The Romberg maneuver: Stand up with feet, eyes closed, hands out in front of hands to tummy. Romberg (+) when there are two conditions that are staggering and falling. Römberg (-) when staggering or completely normal (no change of position). Romberg (+) encounters conscious deep sensory injury (falls in any direction) and also vestibular lesions (falls in a certain direction according to head position)

Result

Table: Disorders of balance and coordination.

Reel

A deep sense of consciousness

Cerebellum

Vestibule

Too close

0

+

0

Confusion

+

0

0

Loss of energy

0

+

0

Disconnected

0

+

0

Römberg(+)

+ (With eyes closed)

Wobble

(Fall in the position of the head)

Unusual movement

Observed at rest, sometimes stimulated. Note the location, the rhythm, the intensity ...

Run (tremor)

Rhythm and amplitude, mainly apical.

There are two main types of tremors that are tremors at rest, decrease/go away with an exercise called mood swings in Parkinson's disease; tremors during active movements and decreased or stopped at rest are called tremors in the cerebellum. There is also postural tremor which means trembling only when the limb is held in a certain position commonly encountered during emotion, in the elderly, hyperthyroidism ...

Convulsions

Has a rhythm but large amplitude, lower frequency of tremor encountered in major epilepsy, motor local epilepsy, eclampsia, high fever convulsions in children ...

Chorea (Chorea)

The jerk dance is an automatic movement without a rhythm, a sudden movement, a large amplitude, and chaos in space and time. There are two types of jerk dance depending on age - at the age of 7-12 years old, the Sydenham jerk dance in rheumatism, which is common in women. Also, Huntington jerking due to damage to the new striatum, met from 40 years of age, family nature, severe prognosis.

Athetosis

The play is automatic, slow, without a winding rhythm usually on the limbs. Increases with self-control and disappears during sleep. Common in encephalopathy after jaundice in children or myelin disorder.

Hemiballismus (hemiballismus)

Swing dance is an abnormal, strong, large-amplitude movement that can be repeated mainly in the base of the limb but also sometimes in the body due to damage to Luis.

Muscle twitching (myoclonia)

Unconscious muscle jerking in one or more muscle groups due to aliasing, nuclear red-serrated nucleus    

Tics

The movements are very fast, localized in a certain muscle, possibly due to psychological factors or physical damage in encephalitis, high blood urea ...

Fibrillations

Muscle fibers jerking due to damage to the anterior spinal horn in lateral sclerosis atrophy, chronic anterior spinal keratitis, spinal muscular atrophy ...

Fasciculations (fasciculations)

Muscle twitching is a contraction of each muscle group with a crawling or flicker-like appearance in the myokymia that becomes even more pronounced by a gentle flick of the muscle group. Muscle bundle twitching occurs in chronic damage to the anterior medullary horn, XII cord nucleus ... Also, can be encountered in a state of fatigue, but it is jerking physiological muscle bundles.

Dystonia (dystonia)

Dystonia (LTL) is a persistent muscle spasm syndrome that causes repetitive twisting movements that cause abnormal postures. LTL can be localized or globalized, genetically or secondary to trauma, stroke, strong sedation, infection, toxin, metabolism ...

Muscle dystonia in thumb and index finger

Figure: Muscle dystonia in thumb and index finger.

Gait

Fadeaway form

In paralysis, with legs stretched and stretched, when stepping to avoid the foot sweeping the ground, the side should form an arc while the arms fold at the elbows and stick closely to the body.

Horse-style gait

Paralysis of the outer hippocampus, when walking on the side, the paralyzed leg is raised, the footfalls down and when the foot is put down, the toe touches the ground before and after the heel. In addition, it can be seen in muscle damage such as Steinert muscular dystrophy, chiropractic disease ...

Heel pose

Deep sensory damage, always use eyes to check. When walking the patient leans his leg forward, thumping his heel to the ground increased when his eyes are closed. In the post marrow column injury due to Tabès disease, due to macrocytic anemia, posterior marrow compression ...

Drunken gait

When walking, we tilt one side when we lean to the other side, seen in bilateral cerebellar injury.

If one side cerebellum is damaged, the affected leg will be closed and excessively lifted when stepping; While standing, he swayed, but did not fall, and closed his eyes, the above symptoms worsened.

Posture Parkinson

She bowed slightly, walked slowly, took small steps, her hands were not waving.

Star-shaped gait

When the eyes are closed, going back and forth, they are deflected, creating a wing-like shape of the star encountered in vestibular lesions.

Waddling gait

Like a duck walking, his back arched too high, his stomach held out first, stepping on a step is very difficult. When squatting down and standing up, the patient has to put his hand on the thigh on one side and the other thigh, so it is also called the benchmark. Having severe progressive muscular dystrophy or quadriceps muscle weakness in hyperthyroidism ...

Small steps

When walking, his feet do not lift but only slip on the ground with the myeloid prosthetic syndrome and sphincter disorders seen in defect syndrome.

Dancing figure

When the legs are paralyzed at first, it is difficult to stretch the knees, the nose, and the outside of the feet sweep the ground.

Handshake poses

When the legs are completely paralyzed, the patient must use crutches to walk, so the legs are swaying.

Scissor pose

The paralysis of the legs is too stiff, so the foot is entwined in the form of a horse's foot, so when going against the inside of the soles of the feet and the big toe, making scissor; met in marrow compression, paralysis of a family nature.

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