Tooltip Implementation
.tooltip {
position: relative;
cursor: pointer;
text-decoration: none;
border-bottom: 1px dashed rgba(0, 0, 0, 0.6);
}
.tooltip::before {
content: attr(data-tooltip);
position: absolute;
background-color: rgba(255, 255, 255, 0.9);
color: #333;
padding: 6px 12px;
border-radius: 8px;
white-space: normal;
opacity: 0;
visibility: hidden;
transform: translateY(-100%);
transition: opacity 0.3s ease, visibility 0.3s ease, transform 0.3s ease;
font-family: ‘Arial’, sans-serif;
font-size: 14px;
box-shadow: 0px 4px 8px rgba(0, 0, 0, 0.1);
z-index: 10;
}
.tooltip:hover::before {
opacity: 1;
visibility: visible;
transform: translateY(-100%);
left: 1%;
transform: translateX(-1%) translateY(-100%);
}
document.addEventListener(‘DOMContentLoaded’, function () {
const wordsToTooltip = {
“General Inspection”: “Badanie ogólne”,
“Sensory examination”: “Badanie czucia”,
“Muscle wasting”: “Zanik mięśni”,
“Skin changes”: “Zmiany skórne”,
“Postural abnormalities”: “Nieprawidłowości postawy”,
“Chronic neurological impairment”: “Przewlekłe uszkodzenie neurologiczne”,
“Patient movements”: “Ruchy pacjenta”,
“Gait”: “Chód”,
“Involuntary movements”: “Ruchy mimowolne”,
“Tremors”: “Drżenia”,
“Dystonia”: “Dystonia”,
“Reduced dexterity”: “Zmniejszona zręczność”,
“Facial expressions”: “Wyraz twarzy”,
“Sensory deficits”: “Deficyty czuciowe”,
“Motor deficits”: “Deficyty ruchowe”,
“Coordination”: “Koordynacja”,
“Proprioception”: “Propriocepcja”,
“Neuropathic pain”: “Ból neuropatyczny”,
“Facial grimacing”: “Grymas twarzy”,
“Protective posturing”: “Postawa ochronna”,
“Light Touch Sensation”: “Czucie dotyku lekkiego”,
“Cotton wool”: “Wata bawełniana”,
“Peripheral neuropathy”: “Neuropatia obwodowa”,
“Spinal cord lesions”: “Uszkodzenia rdzenia kręgowego”,
“Cortical sensory deficits”: “Deficyty czuciowe korowe”,
“Hyperpathia”: “Hiperalgezja”,
“Pain Sensation”: “Czucie bólu”,
“Sharp/Dull Discrimination”: “Rozróżnianie ostrego/tępego bodźca”,
“Neurotip”: “Końcówka neurochirurgiczna”,
“Sterile safety pin”: “Sterylna agrafka”,
“Dermatomes”: “Dermatomy”,
“Radiculopathy”: “Radikulopatia”,
“Hyperalgesia”: “Hiperalegezja”,
“Central sensitization”: “Centralna sensytyzacja”,
“Complex regional pain syndrome (CRPS)”: “Złożony zespół bólu regionalnego (CRPS)”,
“Temperature Sensation”: “Czucie temperatury”,
“Spinothalamic tract”: “Droga rdzeniowo-wzgórzowa”,
“Central cord syndrome”: “Zespół środkowego rdzenia kręgowego”,
“Syringomyelia”: “Jamistość rdzenia”,
“Vibration Sensation”: “Czucie wibracji”,
“128-Hz tuning fork”: “Kamerton o częstotliwości 128 Hz”,
“Metacarpophalangeal joint”: “Staw śródręczno-paliczkowy”,
“Malleolus”: “Kostka boczna”,
“Tibial tuberosity”: “Guzowatość kości piszczelowej”,
“Vitamin B12 deficiency”: “Niedobór witaminy B12”,
“Posterior column lesions”: “Uszkodzenia sznurów tylnych rdzenia”,
“Proprioception”: “Propriocepcja”,
“Joint Position Sense”: “Czucie pozycji stawów”,
“Posterior columns”: “Sznury tylne rdzenia”,
“Balance”: “Równowaga”,
“Coordination”: “Koordynacja”,
“Diagnostic imaging”: “Obrazowanie diagnostyczne”,
“Two-Point Discrimination”: “Rozróżnianie dwupunktowe”,
“Calipers”: “Suwmiarki”,
“Cortical sensory function”: “Korowa funkcja czuciowa”,
“Parietal lobe”: “Płat ciemieniowy”,
“Graphesthesia”: “Grafestezja”,
“Blunt object”: “Tępy przedmiot”,
“Space-occupying lesion”: “Zmiana zajmująca przestrzeń”,
“Stereognosis”: “Stereognozja”,
“Tactile perception”: “Percepcja dotykowa”,
“Contralateral parietal lobe”: “Przeciwny płat ciemieniowy”,
“Sensory Ataxia”: “Ataksja czuciowa”,
“Romberg Test”: “Próba Romberga”,
“Positive Romberg sign”: “Dodatni objaw Romberga”,
“Vestibular dysfunction”: “Dysfunkcja przedsionkowa”,
“Allodynia”: “Allodynia”,
“Fibromyalgia”: “Fibromialgia”,
“Hyperesthesia”: “Hiperestezja”,
“Nerve regeneration”: “Regeneracja nerwów”,
“Glove and Stocking Pattern”: “Wzorzec rękawiczkowo-skarpetkowy”,
“Diabetic neuropathy”: “Neuropatia cukrzycowa”,
“Alcohol abuse”: “Nadużywanie alkoholu”,
“Sensory Integration”: “Integracja sensoryczna”,
“Higher Sensory Processing”: “Wyższe przetwarzanie czuciowe”,
“Deep Tendon Reflexes”: “Głębokie odruchy ścięgniste”,
“Achilles reflex”: “Odruch Achillesa”,
“Patellar reflex”: “Odruch kolanowy”,
“Hyperreflexia”: “Hiperrefleksja”,
“Upper motor neuron”: “Górny neuron ruchowy”,
“Lower motor neuron”: “Dolny neuron ruchowy”,
“Superficial Reflexes”: “Odruchy powierzchowne”,
“Abdominal reflex”: “Odruch brzuszny”,
“Cremasteric reflex”: “Odruch dźwigacza jądra”,
“Spinal injury”: “Uraz rdzenia kręgowego”
};
// Normalize keys in the dictionary
const normalizedWordsToTooltip = {};
for (const [key, value] of Object.entries(wordsToTooltip)) {
const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses
normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value;
}
function processNode(node) {
if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) {
let content = node.nodeValue;
// Regex to match only the main words (ignores parentheses)
const regex = new RegExp(
`b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})b`,
‘gi’
);
if (regex.test(content)) {
const wrapper = document.createElement(‘span’);
wrapper.innerHTML = content.replace(regex, (match) => {
const tooltip = normalizedWordsToTooltip[match.toLowerCase().trim()];
return `
${match}`;
});
node.replaceWith(wrapper);
}
} else if (node.nodeType === Node.ELEMENT_NODE) {
Array.from(node.childNodes).forEach(processNode);
}
}
document.querySelectorAll(‘body *:not(script):not(style)’).forEach((element) => {
Array.from(element.childNodes).forEach(processNode);
});
});
General Inspection
Begin the sensory examination by inspecting the patient for any obvious abnormalities such as muscle wasting, skin changes, or postural abnormalities, which may indicate chronic neurological impairment.
Observe the patient’s movements, gait, and any involuntary movements such as tremors or dystonia. Also note any asymmetries in movement, reduced dexterity, or alterations in facial expressions, as these may indicate underlying sensory or motor deficits affecting coordination and proprioception. Be attentive to any spontaneous pain behavior, such as facial grimacing or protective posturing, which may indicate ongoing neuropathic pain.
Light Touch Sensation
Use a piece of cotton wool or a light brush to assess light touch sensation. Instruct the patient to close their eyes, and lightly touch various areas of the skin, including the face, torso, arms, and legs. Ask the patient to report each touch by saying “yes” when they feel it. Ensure testing is performed symmetrically to compare corresponding areas on each side of the body.
- Distribution and Documentation: Assess and document any areas where the patient cannot perceive light touch, noting whether there is a specific dermatomal distribution or if the deficit follows a peripheral nerve pattern. Reduced or absent sensation may indicate peripheral neuropathy, spinal cord lesions, or cortical sensory deficits. Be sure to also note areas where sensation is hypersensitive or uncomfortable, as this can indicate hyperpathia, an increased response to sensory stimuli often seen in chronic pain conditions.
Pain Sensation (Sharp/Dull Discrimination)
To test pain sensation, use a neurotip or a sterile safety pin. Gently apply either the sharp or dull side of the instrument to the skin and ask the patient to identify whether they feel a sharp or dull sensation. Ensure that the testing is done symmetrically and in multiple dermatomes to determine the extent of sensory deficit and to compare the affected areas to normal reference points.
- Interpreting Results: Decreased or absent pain sensation may indicate a lesion involving the peripheral nerves, the dorsal root ganglia, or the spinal cord. Sharp-dull discrimination is particularly useful in identifying radiculopathy or peripheral neuropathy due to diabetes, trauma, or other systemic conditions. When assessing pain sensation, consider if there are any regions with hyperalgesia (an exaggerated response to painful stimuli), which can help determine the presence of central sensitization or conditions like complex regional pain syndrome (CRPS).
Temperature Sensation
Temperature sensation is tested using two test tubes—one filled with warm water and the other with cold water. Apply the test tubes randomly to different parts of the skin, asking the patient to identify whether the sensation is hot or cold. Ensure that each limb is tested to detect differences in temperature perception across dermatomes.
- Findings: A deficit in temperature sensation typically parallels pain sensation because both modalities travel through the spinothalamic tract. Abnormal temperature sensation may indicate spinal cord pathology or peripheral neuropathy. Loss of temperature perception can also help identify lesions that specifically affect the spinothalamic tracts, such as central cord syndrome or syringomyelia.
Vibration Sensation
Use a 128-Hz tuning fork to assess vibration sensation. Strike the tuning fork to start the vibration and place it over a bony prominence, such as the metacarpophalangeal joint, the malleolus, or the tibial tuberosity. Ask the patient to report when they can no longer feel the vibration. If vibration sensation is diminished distally, continue testing more proximally to determine the extent of impairment.
- Interpretation: Loss of vibration sense can be an early indicator of peripheral neuropathy, particularly in conditions like diabetes or vitamin B12 deficiency. Test vibration in multiple locations to determine if the deficit is length-dependent (as seen in peripheral neuropathy) or segmental, indicating a possible spinal cord lesion. Ensure that findings are documented bilaterally to help identify asymmetries that could indicate focal pathology such as radiculopathy.
Proprioception (Joint Position Sense)
Proprioception is assessed by holding the sides of a distal joint, such as a finger or toe, and gently moving it up or down. Instruct the patient to close their eyes and determine the direction of movement. Move the joint in small increments to assess whether the patient can accurately detect the change.
- Documenting Findings: Proprioceptive deficits can indicate lesions affecting the posterior columns of the spinal cord or peripheral nerves. Loss of proprioception may lead to difficulties with balance and coordination, especially in the dark or when the patient’s eyes are closed. Document specific joints where proprioception is impaired, as this can help localize lesions and guide further diagnostic imaging or laboratory tests.
Two-Point Discrimination
Use calipers or a bent paperclip to test two-point discrimination. Apply two points simultaneously to the skin, gradually decreasing the distance between them until the patient can no longer distinguish two separate points. Record the minimal distance at which the patient can accurately differentiate two points. Perform this assessment on different areas, including the fingertips, palms, and dorsum of the feet.
- Interpreting Results: This test helps assess cortical sensory function. Impaired two-point discrimination may indicate parietal lobe involvement, which suggests a central nervous system lesion affecting sensory processing. Compare the ability to discriminate two points between different dermatomes and sides of the body to determine if a focal cortical or spinal cord lesion may be present.
Graphesthesia and Stereognosis
- Graphesthesia: Ask the patient to close their eyes and use a blunt object, such as the end of a pen, to trace numbers or letters on their palm. Ask the patient to identify what was traced. Graphesthesia tests higher cortical sensory processing and is useful in detecting parietal lobe dysfunction, such as from a stroke or a space-occupying lesion.
- Stereognosis: Place a familiar object (e.g., a key, coin, or pen) in the patient’s hand while their eyes are closed and ask them to identify the object. Stereognosis is an important aspect of tactile perception and can help localize sensory deficits to cortical areas if impaired. Failure to correctly identify objects may indicate a lesion in the contralateral parietal lobe, and should prompt further evaluation, including imaging studies.
Testing for Sensory Ataxia
- Romberg Test: Ask the patient to stand with their feet together, first with their eyes open and then with their eyes closed. If the patient becomes unstable or begins to sway with their eyes closed, this suggests a deficit in proprioception and is referred to as a positive Romberg sign. Sensory ataxia can result from issues affecting the posterior columns of the spinal cord or peripheral neuropathy. Observe the patient for the degree of sway and whether they are able to maintain balance with corrective movements.
Examination for Allodynia and Hyperesthesia
- Allodynia: Allodynia refers to pain from a stimulus that does not normally provoke pain. Lightly brush the skin with a soft object, such as a cotton swab, and ask if it produces an uncomfortable sensation. This may be seen in patients with neuropathic pain syndromes, fibromyalgia, or complex regional pain syndrome. Note the distribution of allodynia, as this can provide clues about the extent and type of sensory impairment.
- Hyperesthesia: Hyperesthesia is an increased sensitivity to sensory stimuli. Use a feather or soft touch to assess whether the patient experiences heightened or exaggerated sensations. Hyperesthesia may indicate hyperactivity of the peripheral nerves or central sensitization. This heightened sensitivity is often a sign of nerve regeneration or hyperactivity in chronic pain conditions.
Patterns of Sensory Loss
- Dermatomal Distribution: Sensory loss following a dermatomal pattern often indicates a lesion at the level of the spinal nerve root. For instance, a patient presenting with pain or numbness in a specific dermatomal area could have a herniated disk impinging on that spinal nerve root. Documenting the specific dermatome helps localize the lesion to the level of the spinal cord or nerve root.
- Glove and Stocking Pattern: This pattern of sensory loss, which affects the hands and feet, is typically seen in peripheral neuropathies such as diabetic neuropathy. It is usually length-dependent, meaning that symptoms begin distally and gradually move proximally as the disease progresses. Conditions such as vitamin deficiencies, alcohol abuse, and certain toxins can also result in a glove and stocking distribution of sensory loss. Determining the specific pattern helps differentiate between systemic and focal causes of sensory impairment.
Sensory Integration and Higher Sensory Function
- Higher Sensory Processing: The sensory nervous system examination focuses on assessing cortical sensory integration through tests like graphesthesia, stereognosis, and two-point discrimination. Impairments in these areas point to issues beyond peripheral nerve dysfunction and are more indicative of cortical dysfunction or stroke affecting the sensory cortex. Evaluate sensory integration to determine if there is any difficulty processing multiple types of sensory input, which may be observed in conditions such as sensory processing disorder or stroke.
Integration with Reflex Testing
- Deep Tendon Reflexes: Sensory information plays a critical role in reflex arcs, particularly in deep tendon reflexes. For example, testing the Achilles or patellar reflexes can give additional information about the sensory input from specific nerve roots, helping to differentiate between upper motor neuron and lower motor neuron pathologies. Reflex asymmetries or hyperreflexia can also suggest a central lesion, whereas absent reflexes may indicate peripheral nerve dysfunction.
- Superficial Reflexes: Assess superficial reflexes, such as the abdominal reflex or the cremasteric reflex in males, which can provide insights into the integrity of sensory and motor pathways within the spinal cord. Reduced or absent superficial reflexes can indicate abnormalities in both sensory and motor function, often correlating with levels of spinal injury or disease.