Transcript The Neurologic Examination in the Emergency Setting

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