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

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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 1 1 1 1."— Presentation transcript:

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

2 Overview Neuroanatomy History Physical Clinical Scenarios 3 3 3 3

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

4 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 4 4 4

5 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. 5 5

6 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 5 5

7 Neuroanatomy

8 Michelangelo

9 Michelangelo

10 Neuroanatomy Central versus peripheral If central, what is the level:
symmetrical vs asymmetrical If central, what is the level: Cerebrum Midbrain Spinal cord If peripheral, is it Nerve Muscle NMJ 7 5 6 6


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 7 5 6 6

13 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 7 5 6 6

15 UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR
UMN muscle tone increased LMN tone decreased, atrophy UMN no fasciculations LMN fasciculations 7 5 6 6

16 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 7 5 6 6

17 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 16 10 14 14


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 16 10 14 14

20 The Neuro Exam: Physical
Vital Signs Head: Evidence of Trauma Neck: Bruits, Rigidity Heart: Murmurs Abdomen: Masses / Distention Skin / Scalp: Lesions / Tenderness 17 11 15 15



23 The Neuro Exam: Physical
Mental Status Cranial Nerves Motor Sensory Coordination Reflexes 18 12 16 16

24 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 18 12 16 16

25 Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs assymetrical
18 12 16 16

26 Cranial Nerve II Visual acuity Visual fields Fundoscopy
Swinging flashlight test 18 12 16 16







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 18 12 16 16

34 Cranial Nerve VII Motor Taste anterior 2/3 Smile Bury eyelashes
Nasolabial fold Forehead has bihemispheric innervation centrally Taste anterior 2/3 18 12 16 16



37 Cranial Nerve VIII – XII
VIII – vestibular function / hearing IX – taste / sensation posterior pharynx X – SCM; chin to the opposite side XII - tongue 18 12 16 16

38 Motor Exam Strength Tone Bulk Fasciculation Tenderness
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 18 12 16 16



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 18 12 16 16

42 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 18 12 16 16

43 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 18 12 16 16


45 Sensory Exam Distribution Pinprick versus light touch
Right vs left vs bilateral Dermatomal Distal versus proximal Stocking glove Cape like Pinprick versus light touch 18 12 16 16

46 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. 18 12 16 16

47 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 18 12 16 16

48 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 18 12 16 16

49 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 18 12 16 16

50 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 18 12 16 16

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