Tuesday, November 26, 2013

Call me Mrs. Shepherd Day 2

Today was a very information loaded day.

We spend the whole morning reviewing and practicing a thorough neurological examination.

This included:
-the basic things non-neurologists have to at least complete if they see a patient (for instance in the emergency room)
-the cranial nerves and how each one is individually examined (see below for more information if you'd like to know more)
-examining muscle strength
-motor function
-muscle tone (muscle tension)
-muscle trophy (muscle mass)
-autonomic nerves system

I offered to be the genuine pig for the demonstration of the exams. This meant I was poked, hammered, touched, moved and asked to walk, stand, touch my nose with eyes closed and so much more for a good cause. :)

After many hours of all of that, we had a quick 20 minutes lunch break (just enough time to inhale a sandwich) and were off to the neurophysiology department to get an introduction into EMGs.

EMG= electro-myo-graphy
basically using electricity to record the muscle (myo) activity

For this examination, it is necessary to insert a needle probe into a muscle. As always, I was the guinea pig (I like being the guinea pig, it's like a free check up at the doctor).

Getting mentally prepared
Here comes the needle
The needle is in

Okay let's do this

Pressing against the docs hand
The electrical potentials in my muscle

It didn't really hurt having the needle inserted. It was a bit odd leaving it there for a bit.

We recorded the electrical potentials while relaxing and then while contracting the muscle. All is good with my deltoid muscles :)

After we discussed a few more possible pathological EMG findings, we were done for the day.

It was just around the time that some of my American friends tend to be in the hospital restaurant grabbing lunch so I stopped by to see if they were there. Indeed they were. I sat and chatted with them a bit. I try to use these opportunities to see people (these are the same friends that complained about seeing me too little).

After weeks of just opening letters and putting them to the side, I used my time at home to finally catch up on all of that, do laundry and clean my room.

Tomorrow is only a half day in the hospital and then I have to teach English.

Below I described how to do a rough exam of the cranial nerves. It's really only for those interested. It is kind of funny to test them all on a friend though, who knows what you'll find. Hopefully nothing pathological :)

See y'all tomorrow!



The cranial nerves:
We have 12 cranial nerves

I olfactory nerve
II optic nerve
III oculomotor nerve
IV trochlear nerve
V trigeminal nerve
VI abducens nerve
VII facial nerve
VIII vestibulocochlear nerve
IX glossopharyngeal nerve
X vagus nerve
XI accessory nerve
XII hypoglossal nerve

So how do you roughly examine the function of each? Well here we go...

Olfactory Nerve: 
Function: smell
Test: Ask the patient if he still smells the same or if food still tastes good (a lot of our taste sensation comes from the smell)

Optic Nerve:
Function: sight
Test: A very basic test would be to use one of those boards with the letters or numbers that keep getting smaller and see how much the patient can read. Even more basic: "How many fingers am I holding up?"

Oculomotor, trochlear and abducens nerve:
Function: They all innervate the eye muscles.
Test: Have the patient look at your finger or pen and tell them not to move their head (or you can hold onto it). Now move the pen up, down, left, right, upper right, lower left, upper left, lower right (not necessarily in that order), make sure it is far enough that the whole scope of the eye movement is examined and see if the eyes move along nicely and symmetrically. It is okay for the eyes to show a nystagmus (a jerking back and forth) for about 2-4 times when on the far left or right if it stops after a few beats.

Trigeminal nerve:
Function: sensory innervation of the face and motor innervation of the chewing muscles. Also sensory innervation of the cornea of the eye
Test: The nerves exit the face at very specific points. You press those spots and ask if that hurts the patient (beyond the feeling of the pressure). Then you stroke the patient along the forehead, below the eyes and the chin and ask if they have the same sensation on both sides. The corneal reflex is performed by touching the cornea with a Q-tip and the patient should blink or shut his eyes (contact lens wearers usually can tolerate more since they overcome this reflex while putting their contacts in). The chewing muscles can be tested by asking the patient to clench his teeth and you touching the muscles to see if they contract.

Facial nerve:
Function: sensory innervation of the face and taste
Test: Ask the patient to show his teeth with a big smile and see if the mouth opens equally or if one side droops. Ask the patient to lift his forehead (again, looking for symmetry if they are healthy and asymmetry if something is wrong with the nerve). Ask the patient to scrunch his nose. Ask the patient to fill his cheeks with air like a hamster. Ask the patient to pretend to whistle (or really whistle I guess, unless you are my sister Fran who absolutely hates it when people whistle.) Again, this is a nerve to ask the patient about taste differences.

Vestibulocochlear nerve:
Function: innervate the balance center and the hearing center in the ear.
Test: Ask if the patient has experienced dizziness. Depending on the direction, the appearance and duration one can differentiate the origin. Rub your fingers together next to the patients ears and ask if they hear it at the same loudness on both sides. Hold the patients head in your hands, tell them to focus on your nose and quickly turn their head from side to side. They should be able to not lose focus of your nose the whole time you move their head.

Glossopharyngeal nerve:
Function: innervation of the uvula and muscles in the back of your throat.
Test: Look into the patients mouth and tell them to say "AHHHHH". The uvula should rise symmetrically. The other muscles in the back of the oral cavity as well.

Vagus nerve:
Function: This guy does a whole lot of things. For the purpose of a rough neurological examination, we will concentrate on his contribution to the vocal cord innervation.
Test: Ask the patient if he can still speak normally. Is he hoarse?

Accessory nerve:
Function: innervates the sternocleidomastoid and trapezius muscle.
Test: Place your hands on the patients shoulders and ask them to shrug their shoulders while you try to push down to see how strong they are (test for trapezius). Ask the patient to turn his head from side to side (test for sternocleidomastoid).

Hypoglossal nerve:
Function: motor innervation of the tongue.
Test: Ask the patient to stick his tongue out and then move it from left to right.

These are obviously not all the nerves' functions or all the tests available but if these are performed, you've done a good job for a rough neurological examination of the cranial nerves.

Have fun examining!

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