Examination Approach High Yield Techniques Two types of neurologic - PDF document

5/30/2013 The Neurological Exam In the ICU: Examination Approach High Yield Techniques • Two types of neurologic examinations – 1. Screening Examination – 2. Testing Hypotheses • Select high-yield tests and techniques S. Andrew Josephson MD Carmen Castro-Franceschi and Gladyne K. Mitchell Neurohospitalist Distinguished Professor Vice Chairman, Parnassus Programs Director, Neurohospitalist Program Medical Director, Inpatient Neurology University of California, San Francisco The speaker has no disclosures Examination Approach Case 1: Mental Status • Organization • A 73 year-old woman comes to the ER with 1. Mental Status 2 days of feeling fatigued 2. Cranial Nerves • General physical examination is normal and 3. Motor there is no weakness on neurological 4. Reflexes examination 5. Sensory • Language testing is abnormal 6. Coordination 7. Gait 1

5/30/2013 Aphasia Anatomy Aphasia Testing • Fluency: Use Naming and Conversation • Comprehension: More difficult commands • Repetition: “Today is a sunny day…” Blumenfeld H. Neuroanatomy Through Clinical Cases . 2002. Aphasia Chart Evaluating Patients for Delirium • Multiple screening tools have been Name Fluency Comp Rep Broca’s Bad Good Bad examined for delirium, each with its own Wernicke’s caveats Good Bad Bad – Compared with DSM-IV criteria: likely Global Bad Bad Bad insensitive Conduction Good Good Bad • Would like to design a tool that is short and Transcort Motor Bad Good Good easy to use by nurses as well as physicians Transcort Sens. Good Bad Good • ABCDE bundle Transcort Mixed Bad Bad Good 2

5/30/2013 Confusion Assessment Method Deficits of Attention (CAM-ICU) • Sensitivity and specificity > 90% • Neuropsychologic hallmark of delirium • Four elements (need 1 and 2 and 3 or 4) • Diffuse localization used to define delirium at the bedside • Diagnose during the history 1. Acute Onset and Fluctuating Course – Tangential speech, fragmented ideas 2. Inattention • Test at bedside with digits forward task 3. Disorganized Thinking – Four digits or less signifies lack of attention 4. Altered Level of Consciousness (RASS) • MMSE often not helpful icudelirium.org Cranial Nerve Testing Coma • Definition: II: Pupils, Acuity, Visual Fields III, IV, VI: Extraocular Movements – Not Awake V: Facial Sensation – Not Arousable – Not Aware VII: Facial Strength VIII: Hearing • Test with cerebral motor response to pain IX, X: Palatal Elevation and Gag centrally and in all four extremities XI: SCM and Trapezius Power (supraorbital and nail-bed pressure) XII: Tongue Power 3

5/30/2013 Structures involved in coma Two Localizations of Coma • 1. Brainstem • 2. Bilateral Hemispheres • Use the CN exam to localize to brainstem or hemispheres Blumenfeld H. Neuroanatomy Through Clinical Cases . 2002. Cranial Nerve Nuclei in the Brainstem Pupillary Reaction • Midbrain: CN III – Parasympathetics mediate • Caveats – Make sure light stimulus is adequate – Assure no drug effects • In many cases of brain death, the pupils are not “blown” and are midposition 4

5/30/2013 Corneal Reflex Oculocephalic Reflex • Pons: CN V and VII • Pons: CN III, VI, and VIII • Test with a Q-tip or drops of saline • Vestibulo-ocular reflex (VOR) which we • Caveat: Make sure you are touching the use on a moment-by-moment basis to foveate cornea not the sclera • Testing procedure • Doll’s don’t do this anymore Cold Calorics Cough and Gag • Pons: CN III, VI, and VIII • Medulla: CN IX and X • Stronger stimulus than oculocephalic • Best to do both by suctioning through ET • 30cc of ice saline in each ear (1-3 min tube and touching each side of the palate with a tongue depressor between); wait 1 minute for the response • Asymmetry is more interesting for us… • Correct response very misunderstood and – Remember 10-30 percent have no gag normally poorly taught 5

5/30/2013 Respiratory Drive Case 2: Motor • Lowest Part of the Medulla • A 75 yo male with HTN, DM and current • Technique tobacco use comes from the ED with mild problems walking and a complaint of “my – Are they overbreathing? left arm is not working right.” – Consider apnea test in specific situations such as brain death determination Upper Motor Neurons of the Case 2: Motor Pyramidal Tract • The ED physician tells you that he knows the patient has no weakness in his extremities as his own exam shows equal hand grasps, moving all fours, and “stepping on the gas” in the lower extremities. Predictable Pattern of Weakness Distal Extensors of the UEs and Distal (Dorsi)Flexors of the LEs 6

5/30/2013 UMN LMN Quick Screen for Upper Motor Neuron/Pyramidal Weakness Pattern of Weakness Pyramidal Variable • Pronator Drift Function/Dexterity Slow alternate motion rate Impairment of function is mostly due to weakness • Fine Finger Movements/Toe Taps • One muscle in each of four extremities Increased Decreased Tone – Upper Extremities: 1 st DI or finger extensors Tendon Reflex Increased Decreased, absent or normal – Lower Extremities: Extensor of big toe Other signs Babinski sign, other CNS signs Atrophy (except with problem • Common ED screen VERY insensitive! (e.g. aphasia, visual field cut) of neuromuscular junction) Motor Neuron Neuropathy NMJ Myopathy Disease Case 3: Sensory Weakness Variable Distal Diffuse Proximal Pattern DTR Increased, Decreased or Normal or Normal or • A 45 yo man presents with 2 days of normal and/or absent decreased decreased decreased progressive tingling and weakness of the Atrophy Yes Yes No No lower extremities. He now is having trouble walking and rising from a chair. Fasciculations Yes Sometimes No No Sensory No Yes No No symptoms/ signs 7

5/30/2013 Case 4: Coordination Case 3: Sensory • A 54 year-old woman presents with vertigo • Exam and gait difficulties – MS, CN normal • On finger-nose-finger, she exhibits – Motor: normal tone throughout, normal power dysmetria with the right upper extremity, in upper ext., 4/5 throughout in the lower but not with the left extremities – Sensory: decreased PP/Vib/temp patchy in lower extremities • A sensory level is found at T10 Key Cerebellar Exam Tips • Bilateral dysfunction is often benign and drug/medication related • Unilateral dysfunction is a cerebellar lesion until proven otherwise – CT insensitive in this region • Cerebellar tracts run through the brainstem – Cerebellar signs with cranial nerve deficits is a brainstem lesion until proven otherwise 8