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The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
The Neurologic Examination in the Emergency Setting
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The Neurologic Examination in the Emergency Setting

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  • 1. The Neurologic Examination in the Emergency Setting Tintinalli Chapter 226 Jason Glagola PGY2 Dr Gary Richardson 11/8/2005
  • 2. Key to evaluation is HISTORY: <ul><li>Time of onset </li></ul><ul><li>Symptom progression </li></ul><ul><li>Associated symptoms </li></ul><ul><li>Exacerbating factors </li></ul>
  • 3. <ul><li>“Complete” exam is not required or appropriate </li></ul><ul><li>However organized framework to exam is key </li></ul><ul><li>In children, indirect observation is key. Such as how a child plays with a toy </li></ul>
  • 4. Traditional Exam is three tiered <ul><li>1 – Is there a lesion of the nervous system </li></ul><ul><li>2 – Where is the lesion </li></ul><ul><li>3 – What is the lesion </li></ul>
  • 5. Eight elements of exam: <ul><li>1 – Mental status testing </li></ul><ul><li>2 – Higher Cerebral functions </li></ul><ul><li>3 – Cranial Nerves </li></ul><ul><li>4 – Sensory Examination </li></ul><ul><li>5 – Motor System </li></ul><ul><li>6 – Reflexes </li></ul><ul><li>7 – Cerebellar Testing </li></ul><ul><li>8 – Gait and Station </li></ul>
  • 6. Mental Status Testing
  • 7. Mental Status Testing - Basic <ul><li>“ awake, alert, and conservant “ </li></ul><ul><li>Assess emotional and intellectual function </li></ul><ul><li>Thought disorders or abnormal thought content such as hallucinations, mood, insight, and sensorium (appropriate awareness and perception of consciousness) </li></ul>
  • 8. Mental Status Testing - Basic <ul><li>Attention and Memory </li></ul><ul><li>Attention testing best performed with digit repetition. </li></ul><ul><li>Average adult should be able to repeat six digits forward and four or five backwards. </li></ul><ul><li>Failure to do so may suggest confusion, delerium or problem with language perception </li></ul>
  • 9. Mental Status Testing - Basic <ul><li>Memory </li></ul><ul><li>A complex process broken down into short and long term memory </li></ul><ul><li>Long term = months or years ago </li></ul><ul><li>Short term = events of day, or three object five minute recall </li></ul><ul><li>If unable to repeat three objects immediately, it is a problem with attention not memory </li></ul>
  • 10. Mental Status Testing - Advanced <ul><li>Mini-Mental Status exam </li></ul><ul><li>Quick Confusion Scale </li></ul><ul><li>Both found in chapter 229 </li></ul>
  • 11. Mini-Mental Status Exam
  • 12. Quick Confusion Scale
  • 13. Higher Cerebral Functions
  • 14. Higher Cerebral Functions <ul><li>Test neurologic functions that are thought to reside in the cerebral cortex </li></ul>
  • 15. Higher Cerebral Functions <ul><li>Language defines the dominant hemisphere. </li></ul><ul><li>Majority of population is right-handed (90%), for these patients left hemisphere is dominant and that is where language resides. (left hemisphere dominant) </li></ul><ul><li>Even most left handed people are left hemisphere dominant for speech </li></ul><ul><li>Large cortical stroke in dominant hemisphere will affect language </li></ul>
  • 16. Higher Cerebral Functions <ul><li>Nondominant hemisphere is concerned with spatial relationships. </li></ul><ul><li>I.E. Visual inattention to care provider approaching from one side (usually the left, since most patients are left hemisphere dominant) </li></ul>
  • 17. Higher Cerebral Functions <ul><li>Dysarthria – mechanical disorder of speech resulting from difficulty in the production of sound from weakness or incoordination of facial or oral musculature. This may be motor (cortical, subcortical, brainstem, cranial nerve, or cerebellar) NOT higher cerebral dysfunction! </li></ul>
  • 18. Higher Cerebral Functions <ul><li>Dysphasia – Problem of language resulting from cortical or subcortical damage. This portion of brain is concerned with comprehension, processing, or producing language </li></ul>
  • 19. Higher Cerebral Functions - BASIC <ul><li>Normal conversation and correct response is common screen for language disorder </li></ul><ul><li>If abnormal, need further testing </li></ul>
  • 20. Higher Cerebral Functions - BASIC <ul><li>Comprehension – ability to follow simple commands, and name common objects </li></ul><ul><li>Apraxia – Inability to show how a common object may be used (pencil) </li></ul><ul><li>Nonfluent aphasia (expressive aphasia) – speed of language and the ability to find the correct word – eponymous portion of dominant cortex </li></ul><ul><li>Fluent aphasia (receptive aphasia) – quantity of word production is normal or increased. Normal rhythm and intonation, but incorrect words </li></ul>
  • 21. Higher Cerebral Functions - BASIC <ul><li>Non-Dominant hemisphere may also show problems of sensory descrimination, or auditory or visual inattention </li></ul>
  • 22. Higher Cerebral Functions - ADVANCED <ul><li>Show patient a picture and see if what is described is correct </li></ul><ul><li>Repeat a phrase: “No, Ifs, ands, or buts.” </li></ul><ul><li>Wernicke’s Aphasia </li></ul><ul><li>Paraphasic errors – i.e. use the word spool instead of spoon </li></ul><ul><li>A person who is aphasic in speaking will also be in writing </li></ul>
  • 23. Higher Cerebral Functions <ul><li>Have patient draw circle and make a clock. </li></ul><ul><li>Sensory perception – place an object in hand and have identify </li></ul><ul><li>Must also make sure patient is not intoxicated or has severe psych illness </li></ul>
  • 24. CRANIAL NERVES
  • 25. Cranial Nerves - BASIC <ul><li>I (olfactory) – smell </li></ul><ul><li>II (Optic) – Visual acuity, visual fields </li></ul><ul><li>III (Oculomotor) – </li></ul><ul><li>Motor – raise eyelids, extraocular muscle </li></ul><ul><li>Parasympathetic – pupillary constriction </li></ul><ul><li>IV (Trochlear) – Downward/inward gaze </li></ul>
  • 26. Cranial Nerves - BASIC <ul><li>V (Trigeminal) – </li></ul><ul><li>Motor – jaw open, clench teeth, chew </li></ul><ul><li>Sensory – sensation cornea, iris, lacrimal </li></ul><ul><li>glands, conjunctiva, eyelids, forehead, </li></ul><ul><li>nose, teeth, tongue, ear </li></ul><ul><li>VI (Abducens) – lateral eye movement </li></ul>
  • 27. Cranial Nerves - BASIC <ul><li>VII (Facial) </li></ul><ul><li>Motor – facial expression except jaw, </li></ul><ul><li>close eyes . . </li></ul><ul><li>Sensory – taste, ant 2/3 tongue, </li></ul><ul><li>sensation to pharynx </li></ul><ul><li>VIII (Acoustic) – hearing and equilibrium </li></ul>
  • 28. Cranial Nerves - BASIC <ul><li>IX (Glossopharyngeal) </li></ul><ul><li>Motor – voluntary swallow, phonation </li></ul><ul><li>Sensory – sensation nasopharynx, gag </li></ul><ul><li>reflex, taste (post 1/3) </li></ul><ul><li>Parasympathetic – carotid reflex, salivary </li></ul><ul><li>secretion </li></ul>
  • 29. Cranial Nerves - <ul><li>X (Vagus) </li></ul><ul><li>Motor – voluntary phonation, swallow </li></ul><ul><li>Sensory – behind ear, external canal </li></ul><ul><li> Parasymp – peristalsis, carotid reflex, heart, lung, digestion </li></ul><ul><li>XI (Spinal Accessory) – Turn head, shrug shoulders </li></ul><ul><li>XII (Hypoglossal) – Tongue articulation (l, t, n) and swallow </li></ul>
  • 30. Sensory Exam
  • 31. Sensory Exam <ul><li>Light touch </li></ul><ul><li>Pinprick </li></ul><ul><li>Position </li></ul><ul><li>Vibration </li></ul><ul><li>Temperature </li></ul>
  • 32. Sensory Exam <ul><li>Usually start with touch and pinprick in extremity, if intact stop unless . . . . </li></ul><ul><li>Suspect peripheral nerve or spinal cord injury </li></ul><ul><li>Position testing – best for peripheral neuropathy or posterior spinal cord injury </li></ul>
  • 33. Dermatome Map
  • 34. Sensory Exam <ul><li>Cervical Injury = thoracic dermatomes and upper extremity </li></ul><ul><li>The demonstration of a preserved island of sensation around the perineum may be the only sign of an incomplete spinal cord injury, which has a different prognosis than complete spinal cord injury </li></ul>
  • 35. Motor System <ul><li>Tone – normal, decreased, increased </li></ul><ul><li>Increased – ask patient to relax, and not resist. Test Passively. I.E. cogwheeling </li></ul><ul><li>Arms out palms up, observe for inward rotation or downward drift (pronator drift) </li></ul>
  • 36. Motor System <ul><li>Compare muscle mass and bulk </li></ul><ul><li>Look for atrophy, fasciculations </li></ul><ul><li>A rating for strength 0 to 5 </li></ul><ul><li>5 = normal </li></ul><ul><li>4 = weakness w/ ability for some resistance </li></ul><ul><li>3 = complete ROM against gravity </li></ul><ul><li>2 = movement w/ gravity eliminated </li></ul><ul><li>1 = minimal flicker of contraction </li></ul><ul><li>0 = no movement </li></ul>
  • 37. Muscle Innervation Chart
  • 38. Muscle Innervation Chart
  • 39. Reflexes <ul><li>Least important part of exam </li></ul><ul><li>Scale 1 to 4 </li></ul><ul><li>0 = no reflex </li></ul><ul><li>1 = decreased </li></ul><ul><li>2 = normal </li></ul><ul><li>3 = increased </li></ul><ul><li>4 = clonus </li></ul>
  • 40. Reflexes <ul><li>Babinski </li></ul><ul><li>Normal = toes go down </li></ul><ul><li>Clonus = Rhythmic oscillation of a body part elicited by brisk stretch = sign of spasticity </li></ul>
  • 41. Reflexes <ul><li>Hyperactive, babinski, clonus = upper motor neurons (cortical and spinal cord injuries) </li></ul><ul><li>Hypoactiive = Lower motor neurons, peripheral nerve roots </li></ul><ul><li>But NOT reliable and may take time to develop </li></ul>
  • 42. Cerebellar Testing
  • 43. Cerebellar Testing <ul><li>The cerebellum is concerned with involuntary activities of the central nervous system and may be simply thought of as a structure that helps with smoothing muscle movements and aiding with movement coordination. </li></ul><ul><li>Central cerebellar structure = axial coordination </li></ul><ul><li>Lateral cerebellar structure = appendicular coordination (extremities) </li></ul>
  • 44. Cerebellar Testing – Basic <ul><li>Rapidly alternating movements (rapid pronation and supination of hands). Should be equal and symmetric </li></ul>
  • 45. Cerebellar Testing - Advanced <ul><li>Finger to nose, must be done rapidly </li></ul><ul><li>Nystagmus </li></ul>
  • 46. Gait and Station
  • 47. Gait and Station <ul><li>It has been said that if only one neurologic test could be formed, walking would be most important. </li></ul><ul><li>See Chapter 230 for ataxia and gait disturbance </li></ul>
  • 48. Gait and Station <ul><li>Cerebellar infarct or hemorrhage is a true emergency because it can compress on the brain stem causing apnea and death. </li></ul><ul><li>Cerebellar hemorrhage may cause sudden nausea, vomiting, and diaphoresis </li></ul><ul><li>Cerebellar infarct may also cause sudden inability to walk </li></ul>
  • 49. Quick Review
  • 50. Terminology of Mental Status Exam list is in handout. Definitions of different aphasias etc..
  • 51. References: <ul><li>Tintinalli chapter 226 </li></ul><ul><li>Mosby’s Guide to physical exam 4 th edition chapter 20. </li></ul><ul><li>Up to Date “The Detailed Neurologic Exam in Adults” </li></ul>
  • 52. Questions: <ul><li>1) The average adult should be able to repeat 6 digits forward and 4 to 5 backwards? T/F? </li></ul><ul><li>2) IF unable to repeat 3 objects immediately after being told them, is this a problem with memory or attention? </li></ul><ul><li>3) A cortical stroke in the dominant hemisphere will affect language? T/F? </li></ul>
  • 53. Questions: <ul><li>4) Matching: </li></ul><ul><li>4a) Dysphasia </li></ul><ul><li>4b) Dysarthria </li></ul><ul><li>Answers </li></ul><ul><li>1- mechanical disorder of speech resulting from difficulty in the production of sound from weakness or incoordination of facial or oral musculature. This may be motor (cortical, subcortical, brainstem, cranial nerve, or cerebellar) NOT higher cerebral dysfunction! </li></ul><ul><li>2 - Problem of language resulting from cortical or subcortical damage. This portion of brain is concerned with comprehension, processing, or producing language </li></ul>
  • 54. Questions: <ul><li>5) Matching </li></ul><ul><li>5a) Expressive Aphasia (non-fluent) </li></ul><ul><li>5b) Fluent Aphasia (receptive) </li></ul><ul><li>Answers </li></ul><ul><li>1 - speed of language and the ability to find the correct word – eponymous portion of dominant cortex </li></ul><ul><li>2 - quantity of word production is normal or increased. Normal rhythm and intonation, but incorrect words. Comprehension is impaired </li></ul>
  • 55. Questions <ul><li>6) What would the motor score (1 – 5) be if a person: </li></ul><ul><li>complete ROM against gravity, but not with any additional resistance? </li></ul>
  • 56. Answers <ul><li>1) True </li></ul><ul><li>2) Attention </li></ul><ul><li>3) True </li></ul><ul><li>4a) 2 </li></ul><ul><li>4b) 1 </li></ul><ul><li>5a) 1 </li></ul><ul><li>5b) 2 </li></ul><ul><li>6) 3 </li></ul>

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