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

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

1 The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency 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 female with a long history of migraine headaches presented c/o a severe occipital HA that was different form 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 Morton and told to follow-up with his PMD. Patient developed irreversible renal damage.

6 Andy Jagoda, MD Neuroanatomy Central versus peripheral –symmetrical vs asymmetrical If central, what is the level: –Cerebrum –Brain Stem –Spinal cord If peripheral, is it –Nerve –Muscle –NMJ

7 Andy Jagoda, MD Neuroanatomy

8 Central Lesions Lesions in the cerebral cortex result in contralateral deficits of the face and body Lesions at the midbrain result in contralateral hemiplegia and ipsilateral peripheral paralysis of III and IV Lesions at the pons result in contralateral hemiplegia and ipsilateral deficits of V, VI, VII, VIII Lesions at the medulla result in contraleral hemiplegia and ipsilateral deficits of IX, X, XI, XIII

9 Andy Jagoda, MD 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

10 Andy Jagoda, MD Spinal Cord : Vascular Supply Single Anterior Paired posterior from vertebral arteries (Except in cervical cord) Radicular Arteries from aorta: Varying degrees of contribution Great radicular artery of Adamkiewicz T-10 to L-2 (Major source of blood flow to 50% of anterior cord in 50% of patients) Anterior perfuses anterior and central cord

11 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

12 Andy Jagoda, MD UMN vs LMN Weakness Mylopathy = Spinal Cord Process = UMN findings (spasticity, weakness, atrophy, sensory findings, bowel and bladder complaints) Radiculopathy = Nerve Root Process = LMN findings (Paresthesias, Fasciculations, Weakness, decreased DTR) Patient may have a radiculopathy with mylopathy below the lesion

13 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

14 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

15 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

16 Andy Jagoda, MD The Neuro Exam: Physical Mental Status Cranial Nerves Motor Sensory Coordination Reflexes

17 Andy Jagoda, MD The Neuro Exam: Initial Approach Posture Decorticate Decerebrate Facial or body asymmetry Hemiparesis results in external rotation of the foot to the affected side

18 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

19 Andy Jagoda, MD Acute Altered Mental Status Intracranial lesion Metabolic disorder Toxin Infection Ictal state Postictal state Psychogenic

20 Andy Jagoda, MD Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs symmetrical

21 Andy Jagoda, MD Evaluation of II, III, IV, VI Visual acuity Visual fields Examine the cornea, pupil, fundi Check afferent function Extraocular movements Accentuated when looking in the direction of the paralyzed muscle Differentiation can be facilitated by placing a colored glass over one eye

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

23 Andy Jagoda, MD III Nerve Emerges from brainstem next to posterior cerebral artery May be compressed by herniation Runs in the lateral wall of the cavernous sinus

24 Andy Jagoda, MD III Cranial Nerve Parasympathetics Levator Palpebrae Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles LRMR LR IO IO SRSR IR SO SO IR

25 Andy Jagoda, MD III Cranial Nerve Paralysis Ptosis Dilated Pupil Paralyzed eye is deviated out and down; SO and LR control eye LRMR LR IO IO SRSR IR SO SO IR

26 Andy Jagoda, MD III Cranial Nerve Lesions Progressive lesions after passage through the dura usually usually causes a ptosis and pupil dilatation first Lesions in the nucleus cause motor deficits first Intact pupil indicates a peripheral ischemic lesion

27 Andy Jagoda, MD IV Cranial Nerve Superior oblique Causes eye to turn in and down When paralyzed, eye can not turn down when it is rotated in LRMR LR IO IO SRSR IR SO SO IR

28 Andy Jagoda, MD VI Cranial Nerve Lateral rectus Long course; goes through the CS, not within the wall Paralysis impairs abduction LRMR LR IO IO SRSR IR SO SO IR

29 Andy Jagoda, MD Conjugate Gaze Controlled by supranuclear connections Medial longitudinal fasciculus is responsible for coordinating the oculomotor nerves; lesions result in impairment of LR and MR moving in sync, ie, contralateral eye does not pass the midline Multiple sclerosis

30 Andy Jagoda, MD Causes of III, VI, VI CN paralysis Isolated cases usually due to vascular causes: HTN, DM, Atherosclerosis Tumors Increased intracranial pressure Colloid cyst of the III ventricle Wernicke-korsakoff syndrome Myasthenia, Botulism Toxic drug reactions

31 Andy Jagoda, MD 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

32 Andy Jagoda, MD Cranial Nerve VII Motor smile bury eyelashes nasolabial fold forehead has bihemispheric innervation centrally Taste anterior 2/3

33 Andy Jagoda, MD Cranial Nerves VIII - XII VIII - vestibular function / hearing IX - taste / sensation posterior pharynx X - SCM; chin to the opposite side XII - tongue

34 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

35 Andy Jagoda, MD Motor Exam 0 = no movement 1 = flicker but no movement 2 = movement but can not resist gravity 3 = movement against gravity but can not resist examiner 4 = resists examiner but weak 5 = normal

36 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

37 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 not pain Thalamic pain syndrome

38 Andy Jagoda, MD Sensory Exam Distribution –right vs left vs bilateral –dermatomal –distal versus proximal stocking glove cape like Pinprick versus light touch

39 Andy Jagoda, MD Sensory Exam Double simultaneous testing –Establish sharp / dull –Check cheek, dorsum of hands, dorsum of feet –Test both sides simultaneously with pin lateralizes pain, significant sensory deficit initially no lateralization but on repeat 15 sec later, lateralization suggests subtle deficit

40 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

41 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, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus) Pathologic reflexes: babinski:

42 Andy Jagoda, MD Hysteria (conversion vs malingering) Blindness: opticokinetic test Hand drop on face test for coma or UE weakness Hemianesthesia: if real, patient cannot perform finger-to nose with eyes closed; vibration remains intact (if bony skeleton intact) Weakness: elbow extension or flexor test; wrist extensor test Unilateral LE weakness: thigh abduction test, hoover test

43 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

44 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 IV 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

45 Andy Jagoda, MD The Neurologic Exam The Neurologic Exam Case Scenarios

46 Andy Jagoda, MD Case Scenario #1 A 46 yo 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. If an aneurysm is suspected to be causing the patient’s symptoms, which cranial nerve should your exam focus on? A. III B. VI C. VII D. IV II A. III B. VI C. VII D. IV II

47 Andy Jagoda, MD III NERVE EMERGES FROM BRAINSTEM NEXT TO POSTERIOR CEREBRAL ARTERY RUNS IN THE LATERAL WALL OF THE CAVERNOUS SINUS MAY BE COMPRESSED: HERNIATION ANEURYSM POSTERIOR COMMUNICATING ARTERYPOSTERIOR COMMUNICATING ARTERY ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ALSO INVOLVED)ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ALSO INVOLVED)

48 Andy Jagoda, MD Case Scenario #2 A 64 yo male presented C/0 low back pain which has become progressively worse over the past 2 weeks. The pain was primarily in the low back without radiation; C/O nonspecific numbness in the legs. Which nerve root is responsible for plantar flexion and the ankle jerk? A. L3 B. L4 C. L5 D. S1 E. S2 A. L3 B. L4 C. L5 D. S1 E. S2

49 Andy Jagoda, MD Lower Extremity Innervation L 3 / L 4 = Patellar reflex L 5 = Big toe extension S 1 = Achilles reflex

50 Andy Jagoda, MD Case Scenario #3 A 30 yo female is in an MVA hitting her head on the dash. The next day she developed a sudden onset severe right frontal HA, that persisted. One day later she developed left sided arm weakness that lasted 2 hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your initial impression? A. Hysteria B. Subarachnoid bleed C. Epidural hematoma D. Carotid artery dissection E. Entrapment syndrome

51 Andy Jagoda, MD PUPIL CONSTRICTION DISRUPTION OF THE SYMPATHETICSDISRUPTION OF THE SYMPATHETICS HORNER’SHORNER’S CAROTID ARTERY DISSECTIONCAROTID ARTERY DISSECTION PONTINE HEMORRHAGEPONTINE HEMORRHAGE TOXINSTOXINS NARCOTICSNARCOTICS CHOLINERGICSCHOLINERGICS

52 Andy Jagoda, MD Case Scenario #4 A 50 yo female c/o a diffuse headache for two months that is constant. There is no past HA history. She claims that intermittently her vision seems blurred but otherwise denies symtoms. On exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following is the most likely diagnosis. A. Occipital Lobe Stroke B. Pituitary Adenoma C. Multiple Sclerosis D. Myasthenia Gravis E. Intracranial Hypertension

53 Andy Jagoda, MD IDIOPATHIC INTRACRANIAL HYPERTENSION (BENIGN INTRACRANIAL HYPERTENSION, PSEUDOTUMOR CEREBRI) SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH ICP WITHOUT APPARENT INTRACRANIAL MASSSYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH ICP WITHOUT APPARENT INTRACRANIAL MASS 50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY ALTERED ABSORPTION OF CSF AT THE ARACHNOID VILLUSALTERED ABSORPTION OF CSF AT THE ARACHNOID VILLUS ALTERATION DUE TO EITHER:ALTERATION DUE TO EITHER: ELEVATED PRESSURE WITHIN THE SAGITTAL SINUSELEVATED PRESSURE WITHIN THE SAGITTAL SINUS INCREASED RESISTANCE TO DRAINAGE OF CSF WITHIN THE VILLUSINCREASED RESISTANCE TO DRAINAGE OF CSF WITHIN THE VILLUS

54 Andy Jagoda, MD PHYSICAL FINDINGS PAPILLEDEMAPAPILLEDEMA VISUAL DISTURBANCE %VISUAL DISTURBANCE % BLINDNESS IN 10%BLINDNESS IN 10% DECREASED VISUAL ACUITY30%DECREASED VISUAL ACUITY30% TRANSIENT VISUAL OBSCURATION68%TRANSIENT VISUAL OBSCURATION68% ENLARGED BLIND SPOTENLARGED BLIND SPOT SCOTOMASSCOTOMAS VI NERVE PALSY (FALSE LOCALIZING) 38%VI NERVE PALSY (FALSE LOCALIZING) 38%

55 Andy Jagoda, MD Case Scenario #5 A 20 yo college student flips his car, hitting head on the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is your leading diagnosis? A 20 yo college student flips his car, hitting head on the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is your leading diagnosis? A. Central Cord Syndrome B. Anterior Cord Syndrome C. Spinal Epidural Hemorrhage D. Subdural Hemorrhage E. Brown - Sequard Syndrome

56 Andy Jagoda, MD CENTRAL CORD SYNDROME HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIAHYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA M U DM U D PARESIS OR PLEGIA OF ARMS > LEGSPARESIS OR PLEGIA OF ARMS > LEGS POSTERIOR COLUMN SPAREDPOSTERIOR COLUMN SPARED SENSATION UE>LE; SACRAL SPARINGSENSATION UE>LE; SACRAL SPARING PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT GREATEST RISK FOR VASCULAR INSULTPERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT GREATEST RISK FOR VASCULAR INSULT GOOD PROGNOSISGOOD PROGNOSIS

57 Andy Jagoda, MD Case Scenario #6 A 23 yo female presents complaining of feeling generally weak with the sensation that she is dragging her feet when she walks. On exam her sensation is intact; motor strength is 5/5 in all major muscle groups; deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, and and 0/2 at the ankles. What is your major concern? A. Spinal Stenosis B. Conus Medularis C. Guillian Barre D. Polymyalgia Rheumatica E. Myasthenia Gravis

58 Andy Jagoda, MD GUILLAIN-BARRE ACUTE POLYNEUROPATHYACUTE POLYNEUROPATHY SYMMETRIC ASCENDING WEAKNESSSYMMETRIC ASCENDING WEAKNESS ARRFLEXIA (LMN)ARRFLEXIA (LMN) NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESSNO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESS CSF: INCREASED PROTEIN WITHOUT PLEOCYTOSISCSF: INCREASED PROTEIN WITHOUT PLEOCYTOSIS

59 Andy Jagoda, MD Case Scenario #7 A 30 yo male with AIDS complains of diffuse weakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally. A 30 yo male with AIDS complains of diffuse weakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally. Which of the following is the most likely diagnosis? A. Myelopathy B. Neuropathy C. Myopathy D. Neuromuscular Junction Disease E. Radiculopathy

60 Andy Jagoda, MD HTLV-1 ASSOCIATED MYELOPATHY PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE THAN LEGS)PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE THAN LEGS) SPASTICITYSPASTICITY PARESTHESIAS ARE COMMON; SENSORY DEFICITS ARE RAREPARESTHESIAS ARE COMMON; SENSORY DEFICITS ARE RARE SYMMETRIC UPPER MOTOR NEURON PARAPARESISSYMMETRIC UPPER MOTOR NEURON PARAPARESIS SPHINCTER DISTURBANCESSPHINCTER DISTURBANCES


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