Slide1 l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 50

The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York PowerPoint PPT Presentation


  • 116 Views
  • Uploaded on
  • Presentation posted in: General

The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York. Overview. Neuroanatomy History Physical Clinical Scenarios. Introduction. Facilitates communication Provides baseline Directs testing

Download Presentation

The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Slide1 l.jpg

The Neurologic ExamAndy Jagoda, MDDepartment of Emergency MedicineMount Sinai School of MedicineNew York, New York


Overview l.jpg

Overview

  • Neuroanatomy

  • History

  • Physical

  • Clinical Scenarios


Introduction l.jpg

Introduction

  • Facilitates communication

  • Provides baseline

  • Directs testing

  • Identifies need for life-saving therapies

  • Risk management


Risk management case 1 l.jpg

Risk Management: Case #1

  • A 46-year-old 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. 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


Risk management case 2 l.jpg

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 Motrin and told to follow-up with his PMD.

  • Patient developed irreversible renal damage.


Cauda equina syndrom l.jpg

Cauda Equina Syndrom

  • Injury to lumbosacral roots

  • Variable sensorimotor deficits and bowel and bladder function

  • Conus medullaris: s3-5: saddle anesthesia, sphincter loss, intact LE motor/sensory


Neuroanatomy l.jpg

Neuroanatomy


Michelangelo l.jpg

Michelangelo


Michelangelo9 l.jpg

Michelangelo


Neuroanatomy10 l.jpg

Neuroanatomy

  • Central versus peripheral

    • symmetrical vs asymmetrical

  • If central, what is the level:

    • Cerebrum

    • Midbrain

    • Spinal cord

  • If peripheral, is it

    • Nerve

    • Muscle

    • NMJ


Anatomy of the spinal cord l.jpg

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


Cross section l.jpg

Cross-section


Brown sequard l.jpg

Brown-Sequard

  • Usually after penetrating trauma

  • Ipsilateral motor paralysis

  • Ipsilateral loss of light touch and proprioception (anesthesia) below the level of the lesion

  • Ipsilateral hyperaesthesia

  • Contralateral loss of pain and temperature (analgesia) found one or two segments below the lesion


Umn vs lmn l.jpg

UMN vs LMN

  • UMN increased DTR (after SS)

    LMN decreased DTR

  • UMN muscle tone increased

    LMN tone decreased, atrophy

  • UMN no fasciculations

    LMN fasciculations


The neuro exam history l.jpg

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


The neuro exam history17 l.jpg

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


The neuro exam initial approach l.jpg

The Neuro Exam: Initial Approach

  • Posture

    • Decorticate

    • Decerebrate

    • Facial or body assymetry

      • Hemiparesis results in external rotation of the foot to the affected sides


The neuro exam physical l.jpg

The Neuro Exam: Physical

  • Vital Signs

  • Head: Evidence of Trauma

  • Neck: Bruits, Rigidity

  • Heart: Murmurs

  • Abdomen: Masses / Distention

  • Skin / Scalp: Lesions / Tenderness


The neuro exam physical23 l.jpg

The Neuro Exam: Physical

  • Mental Status

  • Cranial Nerves

  • Motor

  • Sensory

  • Coordination

  • Reflexes


Mental status exam l.jpg

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

    • < 20 = cognitive impairment


Cranial nerve exam l.jpg

Cranial Nerve Exam

  • Focus exam on II - VIII

  • Symmetrical vs assymetrical


Cranial nerve ii l.jpg

Cranial Nerve II

  • Visual acuity

  • Visual fields

  • Fundoscopy

  • Swinging flashlight test


Cranial nerve v l.jpg

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


Cranial nerve vii l.jpg

Cranial Nerve VII

  • Motor

    • Smile

    • Bury eyelashes

    • Nasolabial fold

    • Forehead has bihemispheric innervation centrally

  • Taste anterior 2/3


Cranial nerve viii xii l.jpg

Cranial Nerve VIII – XII

  • VIII – vestibular function / hearing

  • IX – taste / sensation posterior pharynx

  • X – SCM; chin to the opposite side

  • XII - tongue


Motor exam l.jpg

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


Motor exam41 l.jpg

Motor Exam

  • 0 = no movement

  • 1 = flicker but no movement

  • 2 = movement but cannot resist gravity

  • 3 = movement against gravity but cannot resist examiner

  • 4 = resists examiner but weak

  • 5 = normal


Sensory exam l.jpg

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


Sensory exam43 l.jpg

Sensory Exam

  • Dermatomal deficit accompanied with pain suggests peripheral lesion

  • Central deficits are not dermatomal and usually result in loss of sensation and pain

  • Thalamic pain syndrome


Sensory exam45 l.jpg

Sensory Exam

  • Distribution

    • Right vs left vs bilateral

    • Dermatomal

    • Distal versus proximal

      • Stocking glove

      • Cape like

  • Pinprick versus light touch


Sensory exam46 l.jpg

Sensory Exam

  • Double simultaneous testing

    • Establish sharp / dull

    • Check cheek, dorsum of hands, dorsum of feet

    • Test both sides simultaneously with pain

      • Lateralized pain, significant sensory deficit

      • Initially no lateralization but on repeat 15 sec later, lateralization suggest subtle deficit.


Coordination l.jpg

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


Reflexes l.jpg

Reflexes

  • Symmetry / upper vs lower

    • 0 = absent

    • 1 = hyporeflexia

    • 2 = normal

    • 3 = hyperreflexia

    • 4 = clonus (usually indicates organic disease)

  • Superficial reflexes (corneal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)

  • Pathologic reflexes: babinski


Pitfalls in the neurologic exam l.jpg

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


Pearls l.jpg

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 V 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


  • Login