1. Pearls in the Neurologic Exam: Don’t miss findings Andy Jagoda, MD, FACEP Professor and Chair of Emergency Medicine Mount Sinai School of Medicine Department of Emergency Medicine New York, New York 1 1 1 1

2. Why the Neurologic Exam in Emergency Medicine
Facilitates communication
Provides baseline
Directs testing
Identifies need for life-saving therapies
Risk management 3 3 3 3

3. Pearls Sudden severe headache or back pain = vascular emergency
Spinal cord lesions cause hyperreflexia; peripheral nerve lesions cause hyporeflexia
Low back pain = exam motor, sensory, bowel, and bladder
CN II, III, IV, and IV in patients with headache or suspected ICP
Optic nerve disease causes an afferent defect
Unilateral ptosis = 3ird nerve or sympathetic chain deficit
Patients with dizziness / vertigo must have careful assessment of the posterior circulation including cerebellar testing and gait 73 42 44 44

4. Risk Management 18 medical legal case reviews: 4 missed cauda equina
4 missed subarachnoid
5 missed vertebral or carotid artery dissections
3 cerebellar strokes
Other

5. Risk Management: Case #1
A 46 you 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 prochlorperazine, 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

6. 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 ibuprofen and told to follow-up with his PMD.
Patient developed irreversible renal damage. 5 5

7. Neuroanatomy Central versus peripheral If central, what is the level:
symmetrical vs asymmetrical
If central, what is the level:
Cerebrum
Brain Stem
Spinal cord
If peripheral, is it
Nerve, muscle, NMJ 7 5 6 6

8. 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 9 9

10. UMN increased DTR (after SS) LMN decreased DTR
UMN vs LMN
UMN increased DTR (after SS) LMN decreased DTR
UMN muscle tone increased LMN tone decreased, atrophy
UMN no fasciculations LMN fasciculations 11 11

11. The Neuro Exam: History
History often provides the key since the neuro exam may be normal
Subarachnoid Hemorrhage
Carbon Monoxide Poisoning
Subdural Hematoma
Nonconvulsive Seizures 15 9 13 13

12. 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

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

15. Mental Status Exam AVPU GCS Orientation Mini-mental status exam
Confusion assessment method (CAM) 19 14 18 18

16. Symmetrical vs symmetrical
Cranial Nerve Exam
Focus exam on II - VIII
Symmetrical vs symmetrical 23 17 20 20

17. Evaluation of II, III, IV, VI
Visual acuity
Visual fields
Examine the cornea, pupil, fundi
Check afferent function
Extraocular movements 24 18 21 21

18. Swinging flashlight test
Cranial Nerve II
Visual acuity
Visual fields
Fundoscopy
Swinging flashlight test 25 19 22 22

19. III Cranial Nerve Parasympathetics Levator Palpebrae
Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles SR
IO IO SR LR
MR MR LR
IR SO SO IR 28 21 24 24

20. III Cranial Nerve Paralysis
Ptosis
Dilated Pupil
Paralyzed eye is deviated out and down; SO and LR control eye SR
IO IO SR LR
MR MR LR
IR SO SO IR 29 22 25 25

21. IV Cranial Nerve Superior oblique Causes eye to turn in and down
When paralyzed, eye can not turn down when it is rotated in SR
IO IO SR LR
MR MR LR
IR SO SO IR 31 24 27 27

22. VI Cranial Nerve Lateral rectus
Long course; goes through the CS, not within the wall
Paralysis impairs abduction SR
IO IO SR LR
MR MR LR
IR SO SO IR 32 25 28 28

23. Forehead has bihemispheric innervation centrally
Cranial Nerve VII
Motor
Forehead has bihemispheric innervation centrally
Taste anterior 2/3 36 29 32 32

24. 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 39 31 34 34

25. 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 40 32 35 35

26. 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

27. 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 38 40 40

28. 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: 49 39 41 41

29. 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 72 41 43 43

30. Pearls Sudden severe headache or back pain = vascular emergency
Spinal cord lesions cause hyperreflexia; peripheral nerve lesions cause hyporeflexia
Low back pain = exam motor, sensory, bowel, and bladder
CN II, III, IV, and IV in patients with headache or suspected ICP
Optic nerve disease causes an afferent defect
Unilateral ptosis = 3ird nerve or sympathetic chain deficit
Patients with dizziness / vertigo must have careful assessment of the posterior circulation including cerebellar testing and gait 73 42 44 44