The High-Yield Examination Approach Neurologic Examination Two - PDF document

3/15/2016 The High-Yield Examination Approach Neurologic Examination • 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 Senior Executive Vice Chairman, Department of Neurology Director, Neurohospitalist Program Medical Director, Inpatient Neurology University of California, San Francisco The speaker has no disclosures The “High-Yield” Neurologic Examination: Top Ten Examination Approach Suggestions for a Better Neurologic Examination • Organization 1. If the patient can give a completely 1. Mental Status coherent history, then the mental status 2. Cranial Nerves examination is probably normal 3. Motor 4. Reflexes 5. Sensory 6. Coordination 7. Gait 1

3/15/2016 Digits Forward Case 1: Mental Status • Outstanding test of attention to screen for delirium • A 73 year-old woman comes to the ER with 2 days of feeling fatigued • Given successively long strings of digits 1 second apart • General physical examination is normal and – 6-8-2-4 there is no weakness on neurological – 5-1-9-3-5 examination – 8-6-2-6-3-7 • Language testing is abnormal – 5-4-6-9-7-5-2 • Less than 5 is abnormal and indicates an attentional deficit The “High-Yield” Neurologic Examination: Top Ten Aphasia Testing Suggestions for a Better Neurologic Examination 1. If the patient can give a completely • Fluency: Use Naming and Conversation coherent history, then the mental status • Comprehension: More difficult commands examination is probably normal • Repetition: “Today is a sunny day…” 2. Speech does not equal language: test three elements of language in each patient 2

3/15/2016 Aphasia Chart Cranial Nerve Testing Name Fluency Comp Rep II: Pupils, Acuity, Visual Fields Broca’s Bad Good Bad III, IV, VI: Extraocular Movements Wernicke’s Good Bad Bad V: Facial Sensation Global Bad Bad Bad VII: Facial Strength Conduction Good Good Bad VIII: Hearing Transcort Motor Bad Good Good IX, X: Palatal Elevation and Gag Transcort Sens. Good Bad Good XI: SCM and Trapezius Power Transcort Mixed Bad Bad Good XII: Tongue Power The “High-Yield” Neurologic Examination: Top Ten Screening for Visual Suggestions for a Better Neurologic Examination Field Deficits • Cooperative patient: Move examiner finger in the 1. If the patient can give a completely center of each quadrant with patient gaze fixed coherent history, then the mental status – Test each eye by covering the opposite eye, present examination is probably normal stimulus in all 4 quadrants 2. Speech does not equal language: test three • Uncooperative patient: Use a single digit to elements of language in each patient suddenly approach each half of the visual fields; normally elicits a blink 3. Visual field testing is highly informative – Avoid using entire hand: elicits corneal reflex and underutilized by the non-neurologist – Report as “Does/Does not blink to threat” 3

3/15/2016 Central vs. Peripheral: Coma Vertigo Exam Findings • Always central, always needs imaging • Definition: – 1. Any Cranial Nerve Lesion – Not Awake – 2. Any Asymmetric Cerebellar Finding – Not Arousable – 3. Complete Absence of Peripheral Signs – Not Aware The “High-Yield” Neurologic Examination: Top Ten Two Localizations of Coma Suggestions for a Better Neurologic Examination 4. After establishing new-onset coma, the pupillary • 1. Brainstem examination is the most important initial • 2. Bilateral Hemispheres neurologic examination test • Step 1: CN exam to localize to brainstem or hemispheres • Step 2: Pupils uneven: Structural not metabolic etiology 4

3/15/2016 Case 2: Cranial Nerves “Fixed” Pupils and Coma • A 54 year-old man with no PMH presents after being hit in the right temple with a baseball while • Dilated (7-9mm): Early Herniation playing with his son. • Mid-Position (3-5mm): Late Herniation • General physical exam is normal. On neurologic • Caveats examination the patient is lethargic. The right pupil is 7mm and minimally reactive while the left – ? Adequacy of light stimulus reacts briskly 3 to 2mm. The rest of the neurologic – ? Drug Effect examination is normal. Case 2: Cranial Nerves Cranial Nerve Testing: Coma • Over the next hour, the patient becomes II: Pupils, Visual Fields unresponsive and develops extensor III, IV, VI: Oculocephalic Maneuver posturing on his left side V, VII: Corneal Reflex VIII: Cold Calorics IX, X: Gag, Cough, Spontaneous Respirations 5

3/15/2016 The “High-Yield” Neurologic Examination: Top Ten Case 3: Motor Suggestions for a Better Neurologic Examination 4. After establishing new-onset coma, the • A 75 yo male with HTN, DM and current pupillary examination is the most tobacco use comes to the ED with mild important initial neurologic examination problems walking and a complaint of “my test left arm is not working right.” 5. Use an appropriate screen for Upper Motor Neuron-type weakness Upper Motor Neurons of the Case 3: 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

3/15/2016 The “High-Yield” Neurologic Examination: Top Ten Quick Screen for Upper Motor Suggestions for a Better Neurologic Examination Neuron/Pyramidal Weakness 4. After establishing new-onset coma, the • Pronator Drift pupillary examination is the most • Fine Finger Movements/Toe Taps important initial neurologic examination • One muscle in each of four extremities test – Upper Extremities: 1 st DI or finger extensors 5. Use an appropriate screen for Upper – Lower Extremities: Extensor of big toe Motor Neuron-type weakness 6. Use the exam to localize the weakness in the nervous system • Common ED screen VERY insensitive! UMN LMN Motor Neuron Neuropathy NMJ Myopathy Disease Pattern of Weakness Pyramidal Variable Weakness Variable Distal Diffuse Proximal Pattern DTR Increased, Decreased or Normal or Normal or Function/Dexterity Slow alternate motion rate Impairment of function is normal and/or absent decreased decreased mostly due to weakness decreased Tone Increased Decreased Atrophy Yes Yes No No Fasciculations Yes Sometimes No No Tendon Reflex Increased Decreased, absent or normal Sensory No Yes No No Other signs Babinski sign, other CNS signs Atrophy (except with problem symptoms/ signs (e.g. aphasia, visual field cut) of neuromuscular junction) 7

3/15/2016 The “High-Yield” Neurologic Examination: Top Ten Sensory Testing Modalities Suggestions for a Better Neurologic Examination 4. After establishing new-onset coma, the pupillary • Vibration (128Hz Tuning Fork) examination is the most important initial • Joint Position Sense/Proprioception neurologic examination test 5. Use an appropriate screen for Upper Motor • Temperature Neuron-type weakness • Pinprick 6. Use the exam to localize the weakness in the • Light Touch (Not Useful) nervous system 7. Use the sensory examination sparingly and logically, testing each major pathway Sensory Testing Modalities Case 4: Sensory • Vibration (128Hz Tuning Fork) • A 45 yo man presents with 2 days of • Joint Position Sense/Proprioception progressive tingling and weakness of the • Temperature lower extremities. He now is having trouble walking and rising from a chair. • Pinprick 8

3/15/2016 The “High-Yield” Neurologic Examination: Top Ten Case 4: Sensory Suggestions for a Better Neurologic Examination 8. Symmetry of reflexes is important, rather • Exam than absolute value – MS, CN normal – Motor: normal tone throughout, normal power in upper ext., 4/5 throughout in the lower extremities – Sensory: decreased PP/Vib/temp patchy in lower extremities • A sensory level is found at T10 Reflex Tips Case 5: Coordination • Know the cord level of each reflex • A 54 year-old woman presents with vertigo – Biceps: C5-6 and gait difficulties – Triceps: C7-8 • On finger-nose-finger, she exhibits – Patella: L2-4 dysmetria with the right upper extremity, – Ankle: L5-S1 but not with the left • Symmetric positioning is key • Expose the muscle being tested • Strike with only moderate force 9