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The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York.

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Presentation on theme: "The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York."— Presentation transcript:

1 The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York

2 Andy Jagoda, MD Overview Neuroanatomy History Physical Clinical Scenarios

3 Andy Jagoda, MD Introduction Facilitates communication Provides baseline Directs testing Identifies need for life-saving therapies Risk management

4 Andy Jagoda, MD Risk Management: Case #1 A 46-year-old female with a long history of migraine headaches presented c/o a severe occipital HA that was different from her past headaches in location and intensity. Neuro exam “WNL”. Patient was treated with Compazine, 10 mg IV, with “resolution of headache” and discharged home to “follow-up With PMD”. 18 hours later, patient was brought in by EMS comatose

5 Andy Jagoda, MD Risk Management: Case #2 A 64-year-old male presented with lower back pain which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “mild paralumbar tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. Patient was prescribed Motrin and told to follow-up with his PMD. Patient developed irreversible renal damage.

6 Andy Jagoda, MD Cauda Equina Syndrom Injury to lumbosacral roots Variable sensorimotor deficits and bowel and bladder function Conus medullaris: s3-5: saddle anesthesia, sphincter loss, intact LE motor/sensory

7 Andy Jagoda, MD Neuroanatomy

8 Michelangelo

9 Michelangelo

10 Neuroanatomy Central versus peripheral –symmetrical vs asymmetrical If central, what is the level: –Cerebrum –Midbrain –Spinal cord If peripheral, is it –Nerve –Muscle –NMJ

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12 Anatomy of the Spinal Cord Corticospinal Tracts: motor from cerebral cortex: cross in the lower medulla Spinothalamic Tracts: pain and temperature cross 1 or 2 levels above entry Posterior Column: proprioception and vibration

13 Andy Jagoda, MD Cross-section

14 Brown-Sequard Usually after penetrating trauma Ipsilateral motor paralysis Ipsilateral loss of light touch and proprioception (anesthesia) below the level of the lesion Ipsilateral hyperaesthesia Contralateral loss of pain and temperature (analgesia) found one or two segments below the lesion

15 Andy Jagoda, MD UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR UMN muscle tone increased LMN tone decreased, atrophy UMN no fasciculations LMN fasciculations

16 Andy Jagoda, MD The Neuro Exam: History Neuro complaints may be primary or secondary to other system disease –Infection –Overdose –Metabolic disorder History often provides the key since the neuro exam may be normal –Subarachnoid hemorrhage –Carbon monoxide poisoning –Subdural hematoma –Nonconvulsive seizures

17 Andy Jagoda, MD The Neuro Exam: History Time of Onset Type of Onset Progression Trauma Associated Symptoms Factors that make it better/worse Past Symptoms / Events Past Medical History Occupational / Environ Exposures

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19 The Neuro Exam: Initial Approach Posture –Decorticate –Decerebrate –Facial or body assymetry Hemiparesis results in external rotation of the foot to the affected sides

20 Andy Jagoda, MD The Neuro Exam: Physical Vital Signs Head: Evidence of Trauma Neck: Bruits, Rigidity Heart: Murmurs Abdomen: Masses / Distention Skin / Scalp: Lesions / Tenderness

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23 The Neuro Exam: Physical Mental Status Cranial Nerves Motor Sensory Coordination Reflexes

24 Andy Jagoda, MD Mental Status Exam AVPU GCS Orientation –Speech (dysarthria vs aphasia) –Comprehension Confusion assessment method (CAM) –Acute onset / fluctuating course –Inattention –Disorganized thinking –Altered level of consciousness Mini-mental status exam –Score affected by education and age –< 20 = cognitive impairment

25 Andy Jagoda, MD Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs assymetrical

26 Andy Jagoda, MD Cranial Nerve II Visual acuity Visual fields Fundoscopy Swinging flashlight test

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33 Cranial Nerve V Sensory: corneal reflexes Motor: jaw strength and muscle bulk Corneal reflex may be abnormal in cerebellopontine angle lesions: test in patients with hearing deficits or vertigo

34 Andy Jagoda, MD Cranial Nerve VII Motor –Smile –Bury eyelashes –Nasolabial fold –Forehead has bihemispheric innervation centrally Taste anterior 2/3

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37 Cranial Nerve VIII – XII VIII – vestibular function / hearing IX – taste / sensation posterior pharynx X – SCM; chin to the opposite side XII - tongue

38 Andy Jagoda, MD Motor Exam Strength –Primary concern: can patient breathe –Key test: drift of extremity Tone –Hypertonia: subacute or chronic corticospinal lesion –Hypotonia: LMN lesion or acute UMN –Rigidity: basal ganglia disease Bulk –Wasting correlates with LMN Fasciculation –Anterior horn cell lesion Tenderness –Metabolic/inflammatory muscle disease

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41 Motor Exam 0 = no movement 1 = flicker but no movement 2 = movement but cannot resist gravity 3 = movement against gravity but cannot resist examiner 4 = resists examiner but weak 5 = normal

42 Andy Jagoda, MD Sensory Exam Pain/Temp – cross at entrance, ascend in spinal thalamic tract Light touch – ascend in posterior column, cross in the brain stem Vibration – posterior column, cross in the brain stem

43 Andy Jagoda, MD Sensory Exam Dermatomal deficit accompanied with pain suggests peripheral lesion Central deficits are not dermatomal and usually result in loss of sensation and pain Thalamic pain syndrome

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45 Sensory Exam Distribution –Right vs left vs bilateral –Dermatomal –Distal versus proximal Stocking glove Cape like Pinprick versus light touch

46 Andy Jagoda, MD Sensory Exam Double simultaneous testing –Establish sharp / dull –Check cheek, dorsum of hands, dorsum of feet –Test both sides simultaneously with pain Lateralized pain, significant sensory deficit Initially no lateralization but on repeat 15 sec later, lateralization suggest subtle deficit.

47 Andy Jagoda, MD Coordination Requires integration of cerebellar, motor, and sensory functions Balance requires (2 of 3) –Vision –Vestibular sense –Proprioception Falling with eyes open or closed = cerebellar Falling only with eyes closed = posterior column or vestibular

48 Andy Jagoda, MD Reflexes Symmetry / upper vs lower –0 = absent –1 = hyporeflexia –2 = normal –3 = hyperreflexia –4 = clonus (usually indicates organic disease) Superficial reflexes (corneal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus) Pathologic reflexes: babinski

49 Andy Jagoda, MD Pitfalls in the Neurologic Exam Not getting a complete history utilizing family or observers Not performing a systematic exam Jumping to conclusions before gathering all the data Misinterpreting old lesions for new Misinterpreting limitations from pain as neurologic deficits

50 Andy Jagoda, MD Pearls Lesions of the cerebral cortex result in sensory and motor defects confined to the contralateral side of the body Brain stem and spinal cord lesions result in ipsilateral as well as contralateral defects due to varying patterns of crossover Unilateral pain syndromes without motor deficits suggest possible thalamic pathology A careful exam of CN II, III, IV and V is indicated in patients with headache or suspected processes that cause increased ICP Testing for pronator drift is the best screen for muscle weakness of central origin

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