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The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicin

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Title: The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicin


1
The Neurologic Exam for the Emergency Physician
Andy Jagoda, MD, FACEPMount Sinai School of
MedicineDepartment of Emergency MedicineNew
York, New York
2
Overview
  • Neuroanatomy
  • History
  • Physical
  • Clinical Scenarios

3
Introduction
  • Facilitates Communication
  • Provides Baseline
  • Directs Testing
  • Identifies Need For Life-Saving Therapies
  • Risk Management

4
Risk Management Case 1
  • A 46 year female with a long history of
    migraine headaches presented c/o a severe
    occipital HA that was different form her past
    headaches in location and intensity. Neuro exam
    WNL. Patient was treated with Compazine, 10 MG
    IV, with Resolution of Headache and discharged
    home to Follow-Up With PMD.
  • 18 Hours later, patient was brought in by EMS
    comatose.

5
Risk Management Case 2
  • A 64 year old male presented with lower back pain
    which had become progressively worse over the
    past 2 weeks. The pain was primarily in the lower
    back without radiation, with nonspecific numbness
    in the legs. PMH presently being treated for
    prostatitis. Exam Mild Paralumbar Tenderness,
    SLR -, Motor / Sensory Intact, Knee DTR 2.
    patient was prescribed Morton and told to
    follow-up with his PMD.
  • Patient developed irreversible renal damage.

6
Neuroanatomy
  • Central versus peripheral
  • symmetrical vs asymmetrical
  • If central, what is the level
  • Cerebrum
  • Brain Stem
  • Spinal cord
  • If peripheral, is it
  • Nerve
  • Muscle
  • NMJ

7
Neuroanatomy
8
Central Lesions
  • Lesions in the cerebral cortex result in
    contralateral deficits of the face and body
  • Lesions at the midbrain result in contralateral
    hemiplegia and ipsilateral peripheral paralysis
    of III and IV
  • Lesions at the pons result in contralateral
    hemiplegia and ipsilateral deficits of V, VI,
    VII, VIII
  • Lesions at the medulla result in contraleral
    hemiplegia and ipsilateral deficits of IX, X,
    XI, XIII

9
Anatomy of the Spinal Cord
  • Corticospinal Tracts motor from cerebral
    cortex cross in the lower medulla
  • Spinothalamic Tracts pain and temperature
    cross 1 or 2 levels above entry
  • Posterior Column proprioception and vibration

10
Spinal Cord Vascular Supply
  • Single Anterior
  • Paired posterior from vertebral arteries (Except
    in cervical cord)
  • Radicular Arteries from aorta
  • Varying degrees of contribution
  • Great radicular artery of Adamkiewicz T-10 to L-2
    (Major source of blood flow to 50 of anterior
    cord in 50 of patients)
  • Anterior perfuses anterior and central cord

11
UMN vs LMN
  • UMN increased DTR (after SS)
    LMN decreased DTR
  • UMN muscle tone increased
  • LMN tone decreased, atrophy
  • UMN no fasciculations
    LMN fasciculations

12
UMN vs LMN Weakness
  • Mylopathy Spinal Cord Process UMN findings
    (spasticity, weakness, atrophy, sensory findings,
    bowel and bladder complaints)
  • Radiculopathy Nerve Root Process LMN findings
    (Paresthesias, Fasciculations, Weakness,
    decreased DTR)
  • Patient may have a radiculopathy with mylopathy
    below the lesion

13
The Neuro Exam History
  • Neuro complaints may be primary or secondary to
    other system disease
  • Infection
  • Overdose
  • Metabolic Disorder
  • History often provides the key since the neuro
    exam may be normal
  • Subarachnoid Hemorrhage
  • Carbon Monoxide Poisoning
  • Subdural Hematoma
  • Nonconvulsive Seizures

14
The Neuro Exam History
  • Time of Onset
  • Type of Onset
  • Progression
  • Trauma
  • Associated Symptoms
  • Factors that make it better/worse
  • Past Symptoms / Events
  • Past Medical History
  • Occupational / Environ Exposures

15
The Neuro Exam Physical
  • Vital Signs
  • Head Evidence of Trauma
  • Neck Bruits, Rigidity
  • Heart Murmurs
  • Abdomen Masses / Distention
  • Skin / Scalp Lesions / Tenderness

16
The Neuro Exam Physical
  • Mental Status
  • Cranial Nerves
  • Motor
  • Sensory
  • Coordination
  • Reflexes

17
The Neuro Exam Initial Approach
  • Posture
  • Decorticate
  • Decerebrate
  • Facial or body asymmetry
  • Hemiparesis results in external rotation of the
    foot to the affected side

18
Mental Status Exam
  • AVPU
  • GCS
  • Orientation
  • Speech (dysarthria vs aphasia)
  • Comprehension
  • Confusion assessment method (CAM)
  • Acute onset / fluctuating course
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Mini-mental status exam
  • Score affected by education and age

19
Acute Altered Mental Status
  • Intracranial lesion
  • Metabolic disorder
  • Toxin
  • Infection
  • Ictal state
  • Postictal state
  • Psychogenic

20
Cranial Nerve Exam
  • Focus exam on II - VIII
  • Symmetrical vs symmetrical

21
Evaluation of II, III, IV, VI
  • Visual acuity
  • Visual fields
  • Examine the cornea, pupil, fundi
  • Check afferent function
  • Extraocular movements
  • Accentuated when looking in the direction of the
    paralyzed muscle
  • Differentiation can be facilitated by placing a
    colored glass over one eye

22
Cranial Nerve II
  • Visual acuity
  • Visual fields
  • Fundoscopy
  • Swinging flashlight test

23
III Nerve
  • Emerges from brainstem next to posterior cerebral
    artery
  • May be compressed by herniation
  • Runs in the lateral wall of the cavernous sinus

24
III Cranial Nerve
  • Parasympathetics
  • Levator Palpebrae
  • Inferior Obliques, Medial, Inferior, and Superior
    Rectus Muscles

IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
25
III Cranial Nerve Paralysis
  • Ptosis
  • Dilated Pupil
  • Paralyzed eye is deviated out and down SO and LR
    control eye

IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
26
III Cranial Nerve Lesions
  • Progressive lesions after passage through the
    dura usually usually causes a ptosis and pupil
    dilatation first
  • Lesions in the nucleus cause motor deficits first
  • Intact pupil indicates a peripheral ischemic
    lesion

27
IV Cranial Nerve
  • Superior oblique
  • Causes eye to turn in and down
  • When paralyzed, eye can not turn down when it is
    rotated in

IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
28
VI Cranial Nerve
  • Lateral rectus
  • Long course goes through the CS, not within the
    wall
  • Paralysis impairs abduction

IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
29
Conjugate Gaze
  • Controlled by supranuclear connections
  • Medial longitudinal fasciculus is responsible for
    coordinating the oculomotor nerves lesions
    result in impairment of LR and MR moving in sync,
    ie, contralateral eye does not pass the midline
  • Multiple sclerosis

30
Causes of III, VI, VI CN paralysis
  • Isolated cases usually due to vascular causes
    HTN, DM, Atherosclerosis
  • Tumors
  • Increased intracranial pressure
  • Colloid cyst of the III ventricle
  • Wernicke-korsakoff syndrome
  • Myasthenia, Botulism
  • Toxic drug reactions

31
Cranial Nerve V
  • Sensory corneal reflexes
  • Motor jaw strength and muscle bulk
  • Corneal reflex may be abnormal in
    cerebellopontine angle lesions test in patients
    with hearing deficits or vertigo

32
Cranial Nerve VII
  • Motor
  • smile
  • bury eyelashes
  • nasolabial fold
  • forehead has bihemispheric innervation centrally
  • Taste anterior 2/3

33
Cranial Nerves VIII - XII
  • VIII - vestibular function / hearing
  • IX - taste / sensation posterior pharynx
  • X - SCM chin to the opposite side
  • XII - tongue

34
Motor Exam
  • Strength
  • primary concern can patient breathe
  • key test drift of extremity
  • Tone
  • hypertonia subacute or chronic corticospinal
    lesion
  • hypotonia LMN lesion or acute UMN
  • rigidity basal ganglia disease
  • Bulk
  • wasting correlates with LMN
  • Fasciculation
  • anterior horn cell lesion
  • Tenderness
  • metabolic / inflammatory muscle disease

35
Motor Exam
  • 0 no movement
  • 1 flicker but no movement
  • 2 movement but can not resist gravity
  • 3 movement against gravity but can not resist
    examiner
  • 4 resists examiner but weak
  • 5 normal

36
Sensory Exam
  • Pain / Temp - cross at entrance, ascend in spinal
    thalamic tract
  • Light touch - ascend in posterior column, cross
    in the brain stem
  • Vibration - posterior column, cross in the brain
    stem

37
Sensory Exam
  • Dermatomal deficit accompanied with pain suggests
    peripheral lesion
  • Central deficits are not dermatomal and usually
    result in loss of sensation not pain
  • Thalamic pain syndrome

38
Sensory Exam
  • Distribution
  • right vs left vs bilateral
  • dermatomal
  • distal versus proximal
  • stocking glove
  • cape like
  • Pinprick versus light touch

39
Sensory Exam
  • Double simultaneous testing
  • Establish sharp / dull
  • Check cheek, dorsum of hands, dorsum of feet
  • Test both sides simultaneously with pin
  • lateralizes pain, significant sensory deficit
  • initially no lateralization but on repeat 15 sec
    later, lateralization suggests subtle deficit

40
Coordination
  • Requires integration of cerebellar, motor, and
    sensory functions
  • Balance requires (2 of 3)
  • vision
  • vestibular sense
  • proprioception
  • Falling with eyes open or closed cerebellar
  • Falling only with eyes closed posterior column
    or vestibular

41
Reflexes
  • Symmetry / upper vs lower
  • 0 absent
  • 1 hyporeflexia
  • 2 normal
  • 3 hyperreflexia
  • 4 clonus (usually indicates organic disease)
  • Superficial reflexes (corneal, pharyngeal,
    pharyngeal, abdominal, anal, cremasteric,
    bulbocavernosus)
  • Pathologic reflexes babinski

42
Hysteria (conversion vs malingering)
  • Blindness opticokinetic test
  • Hand drop on face test for coma or UE weakness
  • Hemianesthesia if real, patient cannot perform
    finger-to nose with eyes closed vibration
    remains intact (if bony skeleton intact)
  • Weakness elbow extension or flexor test wrist
    extensor test
  • Unilateral LE weakness thigh abduction test,
    hoover test

43
Pitfalls In The Neurologic Exam
  • Not getting a complete history utilizing family
    or observers
  • Not performing a systematic exam
  • Jumping to conclusions before gathering all the
    data
  • Misinterpreting old lesions for new
  • Misinterpreting limitations from pain as
    neurologic deficits

44
Pearls
  • Lesions of the cerebral cortex result in sensory
    and motor defects confined to the contralateral
    side of the body
  • Brain stem and spinal cord lesions result in
    ipsilateral as well as contralateral defects due
    to varying patterns of crossover
  • Unilateral pain syndromes without motor deficits
    suggest possible thalamic pathology
  • A careful exam of CN II, III, IV, and IV is
    indicated in patients with headache or suspected
    processes that cause increased ICP
  • Testing for pronator drift is the best screen for
    muscle weakness of central origin

45
The Neurologic Exam Case Scenarios
46
Case Scenario 1
  • A 46 yo female with a long history of migraine
    headaches presented c/o a severe occipital HA
    that was different from her past headaches in
    location and intensity. If an aneurysm is
    suspected to be causing the patients symptoms,
    which cranial nerve should your exam focus on?
  • A. III B. VI C. VII D.
    IV II

47
III NERVE
  • EMERGES FROM BRAINSTEM NEXT TO POSTERIOR CEREBRAL
    ARTERY
  • RUNS IN THE LATERAL WALL OF THE CAVERNOUS SINUS
  • MAY BE COMPRESSED
  • HERNIATION
  • ANEURYSM
  • POSTERIOR COMMUNICATING ARTERY
  • ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES
    ALSO INVOLVED)

48
Case Scenario 2
  • A 64 yo male presented C/0 low back pain
    which has become progressively worse over the
    past 2 weeks. The pain was primarily in the low
    back without radiation C/O nonspecific
    numbness in the legs. Which nerve root is
    responsible for plantar flexion and the ankle
    jerk?
  • A. L3 B. L4 C. L5
    D. S1 E. S2

49
Lower Extremity Innervation
  • L 3 / L 4 Patellar reflex
  • L 5 Big toe extension
  • S 1 Achilles reflex

50
Case Scenario 3
  • A 30 yo female is in an MVA hitting her head
    on the dash. The next day she developed a sudden
    onset severe right frontal HA, that persisted.
    One day later she developed left sided arm
    weakness that lasted 2 hours. In the ED she had
    an OD ptosis and OD miosis. Her motor / sensory
    exam was WNL. What is your initial impression?
  • A. Hysteria B. Subarachnoid bleed C.
    Epidural hematoma
  • D. Carotid artery dissection E. Entrapment
    syndrome

51
PUPIL CONSTRICTION
  • DISRUPTION OF THE SYMPATHETICS
  • HORNERS
  • CAROTID ARTERY DISSECTION
  • PONTINE HEMORRHAGE
  • TOXINS
  • NARCOTICS
  • CHOLINERGICS

52
Case Scenario 4
  • A 50 yo female c/o a diffuse headache for two
    months that is constant. There is no past HA
    history. She claims that intermittently her
    vision seems blurred but otherwise denies
    symtoms. On exam VSS VA 20/40. CN diplopia
    on far lateral gaze bilaterally. Which of the
    following is the most likely diagnosis.
  • A. Occipital Lobe Stroke B. Pituitary
    Adenoma
  • C. Multiple Sclerosis D. Myasthenia Gravis
  • E. Intracranial Hypertension

53
IDIOPATHIC INTRACRANIAL HYPERTENSION
(BENIGN INTRACRANIAL
HYPERTENSION, PSEUDOTUMOR CEREBRI)
  • SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH
    ICP WITHOUT APPARENT INTRACRANIAL MASS
  • 50 HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY
  • ALTERED ABSORPTION OF CSF AT THE ARACHNOID VILLUS
  • ALTERATION DUE TO EITHER
  • ELEVATED PRESSURE WITHIN THE SAGITTAL SINUS
  • INCREASED RESISTANCE TO DRAINAGE OF CSF WITHIN
    THE VILLUS

54
PHYSICAL FINDINGS
  • PAPILLEDEMA
  • VISUAL DISTURBANCE 50 - 80
  • BLINDNESS IN 10
  • DECREASED VISUAL ACUITY 30
  • TRANSIENT VISUAL OBSCURATION 68
  • ENLARGED BLIND SPOT
  • SCOTOMAS
  • VI NERVE PALSY (FALSE LOCALIZING) 38

55
Case Scenario 5
  • A 20 yo college student flips his car,
    hitting head on the dash. He arrives in the ED
    in full spinal immobilization. On exam he has
    2/5 strength in his wrists, 3/5 strength in his
    deltoids, 5/5 strength in his LE. He complains
    of numbness in his arms but is able to
    distinguish sharp from dull. DTRs intact. What
    is your leading diagnosis?
  • A. Central Cord Syndrome B. Anterior Cord
    Syndrome
  • C. Spinal Epidural Hemorrhage D. Subdural
    Hemorrhage
  • E. Brown - Sequard Syndrome

56
CENTRAL CORD SYNDROME
  • HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA
  • M U D
  • PARESIS OR PLEGIA OF ARMS LEGS
  • POSTERIOR COLUMN SPARED
  • SENSATION UELE SACRAL SPARING
  • PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT
    GREATEST RISK FOR VASCULAR INSULT
  • GOOD PROGNOSIS

57
Case Scenario 6
  • A 23 yo female presents complaining of
    feeling generally weak with the sensation that
    she is dragging her feet when she walks. On exam
    her sensation is intact motor strength is 5/5 in
    all major muscle groups deep tendon reflexes
    are 2/2 in the UE, 2/2 at the knees, and and 0/2
    at the ankles. What is your major concern?
  • A. Spinal Stenosis B. Conus Medularis
    C. Guillian Barre
  • D. Polymyalgia Rheumatica E. Myasthenia
    Gravis

58
GUILLAIN-BARRE
  • ACUTE POLYNEUROPATHY
  • SYMMETRIC ASCENDING WEAKNESS
  • ARRFLEXIA (LMN)
  • NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC
    ILLNESS
  • CSF INCREASED PROTEIN WITHOUT PLEOCYTOSIS

59
Case Scenario 7
  • A 30 yo male with AIDS complains of diffuse
    weakness that is progressive in the LE
    associated with paresthesias there is no back
    pain. On exam he has 4/5 upper extremity
    strength, 2/5 lower extremity strength DTRs are
    2/2 in the UE and 4/2 in the LE. His plantar
    reflexes are upgoing upgoing bilaterally.
  • Which of the following is the most likely
    diagnosis?
  • A. Myelopathy B. Neuropathy C. Myopathy
  • D. Neuromuscular Junction Disease E.
    Radiculopathy

60
HTLV-1 ASSOCIATED MYELOPATHY
  • PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE
    THAN LEGS)
  • SPASTICITY
  • PARESTHESIAS ARE COMMON SENSORY DEFICITS ARE
    RARE
  • SYMMETRIC UPPER MOTOR NEURON PARAPARESIS
  • SPHINCTER DISTURBANCES
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