The Neurologic Examination in the Emergency Setting Tintinalli Chapter 226

1
The Neurologic Examination in the Emergency
SettingTintinalli Chapter 226

• Jason Glagola PGY2
• Dr Gary Richardson
• 11/8/2005

2
Key to evaluation is HISTORY

• Time of onset
• Symptom progression
• Associated symptoms
• Exacerbating factors

3

• 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

4
Traditional Exam is three tiered

• 1 Is there a lesion of the nervous system
• 2 Where is the lesion
• 3 What is the lesion

5
Eight elements of exam

• 1 Mental status testing
• 2 Higher Cerebral functions
• 3 Cranial Nerves
• 4 Sensory Examination
• 5 Motor System
• 6 Reflexes
• 7 Cerebellar Testing
• 8 Gait and Station

6
Mental Status Testing
7
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)

8
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

9
Mental Status Testing - Basic

• Memory
• A complex process broken down into short and 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

10
Mental Status Testing - Advanced

• Mini-Mental Status exam
• Quick Confusion Scale
• Both found in chapter 229

11
Mini-Mental Status Exam
12
Quick Confusion Scale
13
Higher Cerebral Functions
14
Higher Cerebral Functions

• Test neurologic functions that are thought to
  reside in the cerebral cortex

15
Higher Cerebral Functions

• Language defines the dominant hemisphere.
• Majority of population is right-handed (90), for
  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

16
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)

17
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!

18
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

19
Higher Cerebral Functions - BASIC

• Normal conversation and correct response is
  common screen for language disorder
• If abnormal, need further testing

20
Higher Cerebral Functions - BASIC

• Comprehension ability to follow simple
  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

21
Higher Cerebral Functions - BASIC

• Non-Dominant hemisphere may also show problems of
  sensory descrimination, or auditory or visual
  inattention

22
Higher Cerebral Functions - ADVANCED

• Show patient a picture and see if what is
  described is correct
• Repeat a phrase No, Ifs, ands, or buts.
• Wernickes Aphasia
• Paraphasic errors i.e. use the word spool
  instead of spoon
• A person who is aphasic in speaking will also be
  in writing

23
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

24
CRANIAL NERVES
25
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

26
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

27
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

28
Cranial Nerves - BASIC

• IX (Glossopharyngeal)
• Motor voluntary swallow, phonation
• Sensory sensation nasopharynx, gag
• reflex, taste (post 1/3)
• Parasympathetic carotid reflex, salivary
• secretion

29
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

30
Sensory Exam
31
Sensory Exam

• Light touch
• Pinprick
• Position
• Vibration
• Temperature

32
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

33
Dermatome Map
34
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

35
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)

36
Motor System

• 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

37
Muscle Innervation Chart
38
Muscle Innervation Chart
39
Reflexes

• Least important part of exam
• Scale 1 to 4
• 0 no reflex
• 1 decreased
• 2 normal
• 3 increased
• 4 clonus

40
Reflexes

• Babinski
• Normal toes go down
• Clonus Rhythmic oscillation of a body part
  elicited by brisk stretch sign of spasticity

41
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

42
Cerebellar Testing
43
Cerebellar Testing

• 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.
• Central cerebellar structure axial coordination
• Lateral cerebellar structure appendicular
  coordination (extremities)

44
Cerebellar Testing Basic

• Rapidly alternating movements (rapid pronation
  and supination of hands). Should be equal and
  symmetric

45
Cerebellar Testing - Advanced

• Finger to nose, must be done rapidly
• Nystagmus

46
Gait and Station
47
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

48
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

49
Quick Review
50
Terminology of Mental Status Exam list is in
handout.Definitions of different aphasias etc..
51
References

• Tintinalli chapter 226
• Mosbys Guide to physical exam 4th edition
  chapter 20.
• Up to Date The Detailed Neurologic Exam in
  Adults

52
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?

53
Questions

• 4) Matching
• 4a) Dysphasia
• 4b) Dysarthria
• Answers
• 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!
• 2 - Problem of language resulting from
  cortical or subcortical damage. This portion of
  brain is concerned with comprehension,
  processing, or producing language

54
Questions

• 5) Matching
• 5a) Expressive Aphasia (non-fluent)
• 5b) Fluent Aphasia (receptive)
• Answers
• 1 - speed of language and the ability to
  find 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

55
Questions

• 6) What would the motor score (1 5) be if a
  person
• complete ROM against gravity, but not with any
  additional resistance?

56
Answers

• 1) True
• 2) Attention
• 3) True
• 4a) 2
• 4b) 1
• 5a) 1
• 5b) 2
• 6) 3