The Neurologic Examination for the Emergency Physician
                          Andy Jagoda, MD, FACEP

The ...
The Neurologic Examination for the Emergency Physician                          Page 2 of 13
Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP
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Andy Jagoda, MD, FACEP

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The Neurologic Examination for the Emergency Physician

  1. 1. The Neurologic Examination for the Emergency Physician Andy Jagoda, MD, FACEP Introduction The neurologic screening examination focuses primarily on identifying acute, potentially life- threatening processes, and secondarily on identifying disorders that require referral to, and management by, other specialists. In recent years there have been a number of advances in the management of neurologic disorders placing emphasis on the importance of the neurologic exam. For many of these processes, interventions can be time sensitive and can significantly reduce morbidity and mortality; examples include thrombolytics for stroke, anticonvulsants for nonconvulsive and subtle generalized status epilepticus, and plasmapheresis for Guillain-Barre. The neurologic evaluation can only be accomplished successfully if placed in the context of the patient’s overall medical history and physical. The six major components of the neurologic exam include: 1) mental status 2) cranial nerve exam 3) motor exam 4) reflexes 5) sensory exam 6) evaluation of coordination and balance. A comprehensive neurologic screening exam can be accomplished within minutes if performed in an organized and systematic fashion. Based on the patient’s chief complaint or findings on the screening exam, components of the evaluation are then elaborated upon. For example, a full mental status exam is not necessarily warranted in the patient who is awake, oriented, and conversant, while it must be fully investigated in patients with altered mental status or a history of a change in behavior. Likewise, in a patient with no sensory complaints, a determination of the ability to distinguish sharp from dull bilaterally is sufficient, while a patient complaining of vague sensory deficits might need to be tested for extinction on simultaneous sensory stimulation, or for astereognosis (inability to identify an object by palpation), or for a sensory level. This article does not provide a comprehensive review of the full neurologic examination. Instead, the intent is to review the basic components of a screening exam in order to provide a framework for clinicians to work from. Some concepts are introduced but not fully developed with the expectation that it will prompt further reading in an appropriate reference. Actual cases that we have been involved in either for medical-legal review, or in our clinical practices are presented to stimulate thought and emphasize central concepts.
  2. 2. The Neurologic Examination for the Emergency Physician Page 2 of 13 Andy Jagoda, MD, FACEP History The patient’s chief complaint often serves to direct the examination, however, caution must always be exercised in order to avoid introducing bias into the evaluation. The subarachnoid hemorrhage patients presenting complaining of a “migraine”, or the patient with Guillain-Barre complaining of the “flu” are examples in the risk management literature. Consequently, a careful history is the key to successful management. The history often provides important clues to the etiology of the patient’s condition, and may direct diagnostic testing. For example, an alert patient with a headache associated with neck pain that started after a car accident might direct the examination and radiographic imaging to focus on carotid or vertebral artery dissection. The history begins with a definition of the patient’s complaint since many neurologic symptoms are nonspecific, e.g. it is important to distinguish vertigo from dizziness, blindness from decreased vision, or weakness from fatigue. Corroboration from family members or bystanders can be critical since they are often able to place the patient’s complaint in perspective with other events. Key components of the history include: Time of onset, mode of onset, progression, associated factors which improve or exacerbate the symptoms, and a prior history of similar problems. The acute onset of a neurologic complaint suggests a vascular event and requires immediate attention. The patient’s past medical history, occupation, medications, or illicit drug use must also be investigated in that they may help in making the diagnosis or have bearing on therapeutic interventions. Case #1: A 46 year old woman presented to the emergency department (ED) complaining of a severe migraine. She had a past history of monthly migraines without aura that she described as being unilateral and throbbing, associated with nausea and vomiting. She had taken 500 mg of naproxen without relief and presented 12 hours into the event. She visited the ED 3 or 4 times a year for refractory migraines. She claimed that the present migraine was similar in intensity to past events but different in location in that it was bilateral and radiated into her occiput. A neurologic examination was deferred because the patient was uncomfortable and the diagnosis appeared evident to the treating physician. Prochloperazine, 10 mg IV, was given with resolution of the headache. The patient was discharged home with instructions to follow-up with her private physician. Eighteen hours later she was found unresponsive by her family and brought to the ED by EMS. A diagnosis of subarachnoid bleed was made by noncontrast head CT; the patient had a complicated hospital course and died eight days later. Commentary This case emphasizes two fundamental concepts: 1) A change in clinical presentation of an existing condition requires an evaluation as if the patient had a new complaint. In this case, the patient clearly stated that her headache was different from past headaches and therefore she needed to be approached with an open differential diagnosis. The decision to treat with prochlorperazine was appropriate for managing a migraine, however, prochlorperazine being a serotonin receptor modulator will attenuate headache pain regardless of the underlying pathology. 2) Patients with a neurologic complaint require a neurologic examination. In cases of headache, the exam focuses on CN II, III, IV, and VI (see section on CNs). There is the
  3. 3. The Neurologic Examination for the Emergency Physician Page 3 of 13 Andy Jagoda, MD, FACEP possibility that in this patient’s case, the exam would have revealed a dilated pupil since the most common cause for subarachnoid hemorrhages is a ruptured cerebral aneurysm and a common site is at the posterior communicating artery which is located next to CN III; compression of CN III results in parasympathetic dysfunction hence the dilated pupil. Physical Exam Mental Status The neurologic examination begins by assessing the patient’s mental status. Often times, subtle changes in mental status are not overtly obvious and careful consideration must be given to concerns expressed by family. The mental status evaluation begins with a basic determination using the “A,V,P,U” method: A, alert; V, responsive to verbal stimuli or commands; P, responsive to painful stimuli only; U, unresponsive. The Glasgow Coma Scale (GCS) score was developed as a prognostic tool for traumatic brain injured patients. The score is a calculated value from the best eye opening response (1-4), verbal response (1-5), and motor response (1-6) with a score of 3 consistent with coma and a score of 15 consistent with minor or no trauma related dysfunction. The GCS is not useful in patients with metabolic or toxic conditions. Having a systematic approach to the mental status is helpful in diagnosing acute processes in patients with chronic disease, such as the demented patient with delirium. The confusion assessment method or “CAM” score was developed to assist in diagnosing delirium. This method assesses four components: presence of acute onset, fluctuating course, inattention, and disorganized thinking or an altered level of consciousness. The ‘Mini-mental status’ method is reserved for patients with suspected cognitive dysfunction. A full discussion is beyond the scope of this article, however, in essence, the mini-mental status method evaluates five areas: orientation, registration, attention, recall, and language. Case #2 A 78 year old man was brought to the ED by his family who claimed that he was not acting himself. The patient had a history of hypertension but otherwise in excellent health until two days prior when he began “just not being himself” and expressing paranoid ideations. According to the family, during the episode on the day of admission, the patient had tried to leave the apartment claiming that someone was trying to hurt him. Medications included procardia and one baby aspirin a day. There was no past psychiatric history. On exam, the blood pressure was 148/92, pulse 82, respirations 16, skin warm and dry, and finger stick glucose was 110. The patient appeared comfortable and cooperated with all questions. He was alert, oriented to person, place, and time but his answers were slow and he appeared distracted (which according to the family was very unlike him). The physical and neurologic exam were reported as normal and the patient was admitted to the psychiatry service with a diagnosis of “psychosis”. Three days after being on the psychiatry service the patient experienced a brief tonic-clonic seizure afterwhich he returned to the baseline established at admission. A neurology consultation was obtained during which it was noted that the patient had subtle intermittent tics on the left side of his mouth. A bedside EEG was obtained and a diagnosis of nonconvulsive status epilepticus was
  4. 4. The Neurologic Examination for the Emergency Physician Page 4 of 13 Andy Jagoda, MD, FACEP made. The patient was given lorazepam, 2 mg IV, with normalization of the EEG and complete resolution of his abnormal behavior. Commentary This case demonstrates the importance of carefully considering concerns expressed by family, evaluating patients with altered behavior for medical causes before prematurely diagnosing a psychiatric disorder, and including nonconvulsive status epilepticus in cases of altered mental status. Nonconvulsive status epilepticus (NCS), like convulsive status epilepticus, results from either a primary generalized process (absence status), or a secondary generalized process (complex partial status). The hallmark of NCS is altered mental status and therefore, unless it is suspected, the diagnosis can be easily missed. Patients in NCS can appear totally functional and perform complex tasks such as driving a car. Other changes can include speech arrest, cognitive deficits, delusions, paranoia, hallucinations, or psychosis. Disturbances in speech patterns are frequently seen ranging from verbal perseveration to aphasia. Motor activity, including automatisms, is rarely the predominant clinical finding in NCS, though when present may be helpful towards making the diagnosis. The literature has many reports of patients presenting with altered mental status who were initially labeled as having a psychiatric problem, and only at a later time in their evaluation was the correct diagnosis identified, either by EEG or by the onset of a convulsive component. There appears to be a distinct subgroup of patients who develop NCS in later life either due to metabolic abnormalities, drug withdrawal, or idiopathically. When presented with a patient who is thought to be in NCS, EEG confirmation is recommended before instituting pharmacologic interventions. NCS is reportedly highly responsive to the benzodiazepines, either diazepam or lorazepam. Cranial Nerve (CN) Exam In general, CN II - VIII are of the most value in the neurologic screening exam; testing the other cranial nerves is complaint based. CN II: Testing the optic nerve involves visual acuity (central vision), gross visual fields (peripheral vision), and the ophthalmoscopic exam. Visual acuity must be checked individually in each eye. Changes in visual acuity are due to either refractive error or optic nerve dysfunction; the former will correct with a pinhole test while the later does not. Optic nerve function is tested using the swinging flashlight test (discussed below under CN III). Peripheral vision is checked by a visual field exam, testing each eye individually using the confrontation method. Blindness in one eye suggests a lesion in front of the chiasm; bitemporal hemianopsia suggests a lesion at the optic chiasm; a quadrant deficit suggests a lesion in the optic tracts; bilateral blindness suggests cortical disease. The ophthalmoscopic exam evaluates the optic disc, retinal arteries, and retinal veins. Pearls in diagnosing papilledema include blurring of the lateral margin of the optic disc, loss of blood vessels as they cross the edematous disc, distended veins, and loss of venous pulsations.
  5. 5. The Neurologic Examination for the Emergency Physician Page 5 of 13 Andy Jagoda, MD, FACEP CN III, IV, VI: CN III, innervates the extraocular muscles effecting primarily adduction and vertical gaze. CN III function is tested in conjunction with CN IV, which aids in internal depression via the superior oblique, and CN VI, which controls abduction via the lateral rectus. Extraocular muscle function is tested by holding a pen vertically in front of the patient. Instructing the patient to follow while the pen is moved horizontally, the patient is asked how many pens he sees (split images suggests diplopia). This is repeated in the horizontal plane. Diplopia requires binocular vision and thus will resolve when one eye is occluded (dislocated lens or retinal detachment can cause distorted images but not split images). While checking the extraocular movements, the presence of nystagmus is noted. Slight nystagmus on extreme lateral gaze may be normal. Marked nystagmus on lateral gaze or any nystagmus on vertical gaze is abnormal, suggesting a peripheral or central nervous system lesion. Vertical nystagmus is seen in brainstem lesions or intoxication with phencyclidine. Pendular nystagmus (equal to and fro movements) is generally a congenital condition. The pupillary light reflex is mediated via the parasympathetic nerve fibers which run on the outside of CN III. The pupillary response is tested by shining a light individually into each eye. In the swinging flashlight test a light in shined from one eye to the other; when the light is shined directly into a normal eye, both eyes constrict via the direct light response and the consensual light response. A Marcus-Gunn pupil is a pupil that constricts to the consensual response but dilates when light is shined directly into it indicating an afferent nerve defect; this is seen in optic nerve disease, e.g. multiple sclerosis. Pupillary size must be observed and documented. Asymmetric pupils of <1mm are of no pathologic significance. A larger difference in pupil size suggests a CN III compression; this can result from compression of the nerve by aneurysms, or, in patients with an altered mental status, by cerebral herniation. Bilateral pupillary dilation is seen with prolonged anoxia or due to drugs (anticholinergic, sympathomimetic agents). Unilateral pupillary constriction in seen in sympathetic chain dysfunction, e.g. Horner’s syndrome or carotid artery dissection. Bilateral pupillary constriction is seen with pontine hemorrhage or as the result of drugs (e.g. opiates, organophosphates, clonidine). CN V: The trigeminal nerve has both sensory and motor function. A central nervous system lesion affecting CN V usually involves all three branches, making individual testing unnecessary. Sensory function is most reliably tested using double simultaneous stimulation, see below in the section on sensory testing. CN V also supplies the muscles of mastication which are tested by palpating the masseter muscles while the teeth are clenched. CN VII: The facial nerve innervates the motor function to the anterior scalp and face, and sensory to the anterior two-thirds of the tongue, to the ear canal and behind the ear. Weakness is often apparent as a facial droop or flattening of the nasolabial fold. In more subtle cases, weakness becomes apparent by asking the patient to show his teeth or whistle. Central lesions cause contra-lateral weakness of the face below the eyes but with forehead sparing due to the crossing of central fibers; thus with central lesions the eyebrows can be elevated and the eyes tightly closed. Patients with peripheral VIIth nerve lesions, including Bell’s Palsy, may have a complete facial weakness that includes the forehead. Of note, an isolated central VIIth lesion is
  6. 6. The Neurologic Examination for the Emergency Physician Page 6 of 13 Andy Jagoda, MD, FACEP rare, therefore absence of brow and forehead involvement does not necessarily indicate a central lesion, especially if the patient is otherwise neurologically intact. CN VIII: The acoustic nerve has a vestibular and a cochlear component. The vestibular nerve supplies the semi-circular canals, the cochlear nerve supplies the Organ of Corti (hearing). Decreased hearing is due to either a conductive defect (e.g. wax in the ear canal) or a sensorineural defect. An easy screening test for hearing defects is accomplished by asking the patient to hum; in conductive defects, the affected ear hears the hum louder. In sensorineural defects it is the normal ear which hears the louder hum. When vestibular nerve defects are suspected, patients are assessed for nystagmus and a Nylen- Barany maneuver is performed by rapidly taking the patient from a sitting to supine position where the head lies 45 degrees below the horizontal. The test is repeated with the patient’s head turned 30-45 degrees to the right and then to the left. The test is considered positive with either the onset of nystagmus, reproduction of vertigo, or both, and suggests a peripheral cause of vertigo. The nystagmus of peripheral vertigo has a brief period of latency prior to onset, is suppressible by visual fixation, is fatigable, and worsens with changes in position. Central vertigo has nystagmus of immediate onset and is not suppressible, fatigable, or positional. Case #3 A 38 year old man presented to the ED complaining of double vision when looking to the left. The patient complained of a dull, persistent frontal headache that had been present for two months. He denied fevers, nausea or vomiting, weakness, or fatigue. He had no past medical history and was on no medications. On physical exam he appeared comfortable and had stable vital signs. Pupils were equal and reactive to light; the fundi were not visualized. There was no ptosis, CN III and IV were intact; on left lateral gaze the left eye did not move past the midline. A noncontrast head CT was obtained and was normal. A neuro-ophthalmology consultation was obtained to evaluate the patient’s sixth cranial nerve palsy. The eyes were dilated and the findings shown in Figure 4. A lumbar puncture was performed with an opening pressure of 260 mm of water and otherwise a normal CSF analysis. The diagnosis of idiopathic intracranial hypertension (IIH) was made. Commentary This case emphasizes the importance of the CN assessment in patients complaining of headache or disturbances with vision; ophthalmoscopy is an important component of the assessment. In this case, the finding of papilledema in a patient with a normal CT lead to the correct diagnosis. IIH, once termed pseudotumor cerebri, is a diagnosis made by documenting elevated intracranial pressure, normal neurologic findings except for papilledema and an occasional CN VI palsy, absence of space-occupying lesion or ventricular enlargement on CT, and normal CSF composition. The differential of diplopia includes processes affecting the muscles (e.g. thyroid disease or other myopathies), the neuromuscular junction (e.g. myasthenia gravis, botulism), or cranial nerve function. The cranial nerve may be affected by extrinsic compression (i.e. mass lesions) or by
  7. 7. The Neurologic Examination for the Emergency Physician Page 7 of 13 Andy Jagoda, MD, FACEP intrinsic pathologies (e.g. ischemia). An isolated CN VI palsy is often caused by head trauma since this is the longest intracranial CN; it is rarely caused by those processes affecting the neuromuscular junction or the muscles since these generally have more diffuse involvement. Interestingly, approximately 30% of patients with IIH have a CN IV palsy in which case it is thus labeled “a false lateralizing sign”. Motor exam The motor screening exam focuses on detecting asymmetric strength deficits since this may be an indication of an acute CNS lesion. Testing motor strength is difficult or impossible in the uncooperative patient, and results may be significantly affected by pain. In general, it is not necessary to test every muscle group individually but instead to test for the presence of a "drift". The patient, with eyes closed, holds his arm out horizontally, palms up, for 30 seconds. If weakness is present, the hand and arm on the affected side will slowly drift or pronate. Lower extremity drift can be checked by having the patient lie prone with knees bent 90 degrees and legs pointing vertically up. A weak leg will tend to drift downwards within 30 seconds. Other motor tests for extremity weakness include hand grasp, and foot plantar and dorsiflexion. Hand grasp testing of the ulnar aspect of the hand is more reliable than the radial aspect. In the case of possible peripheral nerve or muscle injury, or in the case of abnormal results with motor testing as described above, more formal testing of the extremity is in order. Case #4 A 34 year old male with AIDS and a CD4 count of 10 presented to the ED complaining of diffuse weakness. The patient claimed that he has been weak for months but over the past week he has had increased weakness in his lower extremities and has had new onset of difficulty standing and walking without assistance. He denied fevers, cough, bowel or bladder dysfunction, or back pain. Past history included two episodes of pneumonia and oral thrush. He was noncompliant with antiviral and antifungal medications. On exam the patient appeared cachectic but in no distress. Vital signs were stable; HEENT, heart, lungs, abdomen were normal. On rectal exam there was good tone, stool was guaiac negative. The cranial nerves were intact; on motor testing there was no upper extremity drift, lower extremity testing revealed spasticity and there was bilateral drift after 5 seconds; lower extremity strength was assessed to be 3/5 in all the muscle groups; on sensory testing the patient could distinguish sharp from dull in upper and lower extremities, vibratory sense was absent in the lower extremities; deep tendon reflexes were 2/2 at the biceps, and patella reflexes were 4/2 bilaterally; extensor plantar reflexes were present bilaterally. The patient had magnetic resonance imaging (MRI) of the spinal cord to assess for the presence of a mass lesion; the MRI was normal and a CSF analysis was performed . Tests for syphilis, mycobacterium, cryptococcus, herpes, and cytomegalovirus were negative. A final diagnosis of HIV-related myelopathy was made. Commentary This case demonstrates the potential difficulty in assessing a patient with chronic disease who has an acute complaint; it also demonstrates the utility of the motor, sensory, and reflex exam in
  8. 8. The Neurologic Examination for the Emergency Physician Page 8 of 13 Andy Jagoda, MD, FACEP differentiating central from peripheral lesions. This patient had clear findings of upper motor neuron dysfunction including spasticity, hyperreflexia, and positive Babinski reflexes. HIV myelopathy is seen in up to 90% of patients with end-stage disease. Clinically patients present with leg weakness, unsteadiness, gait impairment, and variable sensory impairment. Bowel and bladder dysfunction can occur. On exam patients have spasticity, weakness, hyperreflexia, extensor planter responses. Reflexes may be decreased since these patients often have associated peripheral neuropathies. Sensory deficits involve primarily vibratory and position sense. Management focuses on eliminating reversible etiologies of myelopathy. Reflexes Reflex testing in the screening exam includes the major deep tendon reflexes and the planter reflex (Babinski’s Sign). The major deep tendon reflexes are the patellar reflex (L3,4), Achilles reflex (S1,2), the biceps reflex (C5,6), and the triceps reflex (C7,8). The response is graded from O (no reflex) to 4+ (hyperreflexia). Symmetrical hyporeflexia may be normal, or indicative of metabolic derangements or of a peripheral neuropathy. Symmetrical hyperreflexia may also be systemic in origin, frequently resulting from hypocalcemia or hyperthyroidism. Unilateral hyperreflexia suggests an upper motor neuron process. Asymmetrical reflexes are generally pathologic. There are several reflexes which indicate upper motor neuron disease, the most commonly elicited is the planter flexion/extension reflex (Babinski reflex). A normal response to stroking the planter surface of the foot is plantar flexion of the toes; a positive Babinski reflex is characterized by dorsiflexion of the big toe with fanning out of the smaller toes. Case #5 A 23 year old woman presented to the ED complaining of weakness and of her legs feeling “heavy” and “tingly”. For the preceding three days she complained of having had a “cold” with low grade fevers, myalgias, and sinus congestion. She had no significant past medical history; medications included birth control pills and over-the-counter cold remedies. The ED record documented that she was afebrile and “HEENT - normal”. A neurologic exam was not documented on the chart. The patient was discharged with a diagnosis of “viral syndrome”. Over the next 12 hours, the “heaviness” in the patient’s legs increased and she returned to the ED requiring assistance for ambulation. On exam her vital signs were stable. There were no CN deficits; on sensory testing she could distinguish sharp from dull on all four extremities; on upper extremity motor testing she had 5/5 strength; on lower extremity motor testing ankle flexion/extension was 2/5, knee flexion/extension was 3/5, hip flexion was 4/5; deep tendon reflexes were 2/2 in the upper extremities, 0/2 bilaterally at the patella and gastrocnemius. Acute inflammatory demyelinating polyneuropathy (Guillain-Barre Syndrome) was suspected and confirmed with CSF analysis which revealed a protein of 140. The patient was admitted to the ICU.
  9. 9. The Neurologic Examination for the Emergency Physician Page 9 of 13 Andy Jagoda, MD, FACEP Commentary This case demonstrates the importance of performing a neurologic exam in all patients with a neurologic complaint. Guillain-Barre can be rapidly progressive and discharging this patient from the hospital placed her at risk for a negative outcome. Guillain-Barre Syndrome is a polyneuropathy resulting from immune-mediated inflammation of the myelin. Clinically, patients typically present with distal paresthesias followed by symmetrical ascending paresis. Bulbar weakness, respiratory muscle involvement, and autonomic instability can occur. Since this is a lower motor neuron process, deep tendon reflexes are decreased. Despite sensory complaints, sensory testing usually reveals minimal or no deficits. Patients may have a positive straight leg raising test due to nerve root irritation. CSF analysis demonstrates an elevated protein, normal glucose, and usually less than 10 mononuclear cells. It may take up to 72 hours for abnormalities in the CSF to develop making a repeat spinal tap necessary when an initial tap is normal yet the diagnosis is suspected. Patients with Guillain-Barre are at risk of respiratory compromise and arrhythmias and therefore all but the mildest, stable cases need to be admitted to a monitored setting. The disease may progress over 4 to 6 weeks before resolving; approximately 5% of patients are left with residual symptoms. Plasmapheresis has been shown to reduce duration and severity of the disease. Steroids are not recommended, while gamma globulin might decrease duration of the disease. Sensory exam The screening sensory exam consists of testing pain and light touch; the spinothalamic tract in the anterior cord carries temperature and both pain and light touch fibers, while the posterior column carries fibers for light touch thus explaining preservation of light touch in patients with anterior cord syndromes. Testing for proprioception, stereognosis and vibration is generally reserved for patients with suspected neuropathies or further evaluation of sensory complaints. Dermatomal testing is performed in patients with suspected radiculopathies since central lesions do not present with dermatomal deficits. Evaluating sensation in patients with vague complaints is best done by testing for extinction on double simultaneous stimulation. In this test, the patient closes his eyes and two sharp objects are simultaneously applied. If the patient reports sharpness on one side only, a sensory deficit on the other side is present. If both sides are initially reported as sharp, repeated testing is performed looking for extinction of response on the affected side. Case #6 A 64 year old woman with hypertension and diabetes presented complaining of numbness in her left upper extremity for 48 hours. She denied headache, weakness, difficulty with speech, vision, or gait. She had no past history of strokes. Medications included enalapril and metformin. On exam she was alert, oriented to person, place, and time, and had fluent speech. Blood pressure was 150/90, respirations 16, pulse 76; fingerstick glucose was 130 mg/dl. On exam the cranial nerves were intact including no facial asymmetry and normal CN V testing; motor testing revealed no drift; deep tendon reflexes were 2/2 and symmetrical; toes were downgoing. On
  10. 10. The Neurologic Examination for the Emergency Physician Page 10 of 13 Andy Jagoda, MD, FACEP sensory testing the patient distinguished sharp from dull on the left upper extremity but demonstrated extinction on simultaneous testing; on further testing she demonstrated astereognosis when asked to identify a quarter placed in her left palm. A noncontrast head CT was obtained and demonstrated a right parietal cortex infarct. Commentary This case demonstrates the importance of pursing the clinical evaluation in a patient with a neurologic complaint. The patient had a sensory complaint that was not evident on the initial exam; a more indepth evaluation uncovered the sensory deficit. Making the final diagnosis of a cortical stroke was key to the proper management of this patient. Patients who have had one stroke are at increased risk for another event and thus reversible causes of thromboembolism must be searched for. These patients require a careful evaluation that includes an electrocardiogram, echocardiogram, carotid artery imaging, and a complete hematologic assessment. Coordination and Balance Coordination is a function of the cerebellum combined with input from vision, proprioception, and vestibular sense. Cerebellar function can be easily evaluated by asking the patient to close his eyes and rapidly alternate touching the finger from one hand between a finger on the other hand and his nose. A variation of this test involves the patient rapidly alternating touching his finger from his nose to the examiner’s finger though in this case the patient must open his eyes and therefore visual problems may interfere with performance. Heel-to-shin testing is another frequently used test of cerebellar function. Difficulty in performing rapid alternating movements may also demonstrate cerebellar pathology. Balance requires an integration of cerebellar, visual, vestibular, and proprioception input. It is evaluated by the Romberg test and tandem gait (heel-to-toe). In the Romberg test, the patient is asked to stand with his feet together (proprioceceptive input), without support; first with eyes open (visual input) and then with eyes closed. Closing the eyes eliminates vision, but with proprioception and vestibular sense intact, the patient will not sway. If there is a proprioceptive deficit, the patient will keep his balance with the eyes open and lose his balance when the eyes are closed. When this occurs, the Romberg test is positive. If the patient sways with the eyes open or closed, this is suggestive of a cerebellar lesion which is not compensated by sensory input from the other systems. Case #7 A 64 year old man was brought to the ED by ambulance with a chief complaint of vertigo. According to the patient, he had several similar episodes over the past year which his physician had diagnosed as benign positional vertigo and treated with meclizine. On this presentation, the patient claimed that the room spinning had started approximately 6 hours prior to presentation while he was watching television. It was associated with severe nausea and vomiting. He had taken 25 mg of meclizine without improvement. Past medical history was positive for hypertension; medications included atenolol and hydochlorothiazide. Based on the past history of
  11. 11. The Neurologic Examination for the Emergency Physician Page 11 of 13 Andy Jagoda, MD, FACEP benign positional vertigo, the patient was symptomatically treated with phenergan, 25 mg IV. Three hours later, his symptoms persisted and a physical exam was performed. On physical exam, the patient’s blood pressure was 190/100 mm Hg; heart rate, 64 beats per minute; respiratory rate, 18 breaths per minute. The patient was lying still on the stretcher with his eyes closed complaining that the room was spinning. He was alert, orientated to person, place, and time. He was cooperative and able to articulate clear answers to all questions. Cranial nerves II, III, IV and VI were intact though it was noted that he had pronounced vertical nystagmus that was not suppressed with fixation. There was no facial asymmetry, hearing was decreased on the left, speech was clear, and he was able to handle secretions and swallow normally. There was no extremity weakness though limb ataxia was noted on the left. On finger-to-nose testing, gross dysmetria (missing the target with pass pointing) was also present on the left. A magnetic resonance image of the brain revealed a left ventral cerebellar infarct. Commentary Correctly diagnosing this case was delayed as a result of initiating management based on the “label” given by another care provider prior to performing a neurologic exam. Findings on the exam clearly pointed towards a central cause of the patient’s vertigo instead of a peripheral cause. Vertical nystagmus is strongly suggestive of central pathology and supported in this case by the findings of decreased hearing, ataxia, and dysmetria. Peripheral vertigo results from lesions of the semicircular canals, utricle, or the saccule. When peripheral vertigo is induced by cupulotithiasis it is referred to as “benign positional vertigo” in which case the vertigo is usually not present at rest but induced by movement (in vestibular neuronitis and acute labyrinthitis vertigo can be present at rest). In benign positional vertigo, onset of nystagmus is delayed after change in position, it fatigues with repeat provocation, and can be suppressed with fixation. It is not associated with cerebellar or cranial nerve deficits. The vertigo associated with central lesions is often present at rest, though may be worsened by changes in position. It tends to be less severe but more persistent than peripherally induced vertigo, it does not fatigue, and it is usually associated with cerebellar or brainstem deficits. In this patient’s case, the work-up ultimately included an arteriogram which demonstrated stenosis of the left vertebral artery. The prior episodes of vertigo were most likely due to transient ischemic attacks from thromboemboli in the posterior circulation. Conclusions 1. The neurologic screening examination when performed in a systematic manner provides the clinician with the necessary data to make management decisions. It focuses on differentiating central from peripheral nervous system pathology; upper from lower motor neuron involvement. 2. Family and friends can often provide the historical key to the evaluation. Subtle, but significant, changes in mental status may not be initially evident to the clinician. 3. Cranial nerves II, III, IV, and IV are critical components of the screening exam and must be carefully assessed in all patients with neurologic complaints.
  12. 12. The Neurologic Examination for the Emergency Physician Page 12 of 13 Andy Jagoda, MD, FACEP 4. Motor testing for facial asymmetry and extremity “drift” provides an excellent screen for a central nervous system motor lesion. 5. Central lesions (upper motor neuron) result in hyperreflexia, increased muscle tone, but no atrophy or fasciculations; peripheral lesions (lower motor neuron) result in hyporeflexia, decreased muscle tone, atrophy, and fasciculations. 6. Simultaneous sensory extinction testing is used to uncover subtle central nervous system sensory deficits. 7. Balance requires the integration of cerebellar, visual, vestibular, and proprioceptive functions; each must be considered individually in patients suspected of having a balance or coordination problem.
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