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Part I: Neurological Exam Part II: Coma. Connie Chen Neurology Consultants of Dallas. Part I Neurological Exam. Neurological Exam: Some Basics. Purpose of exam: differential diagnosis The mantra: History comes first! Exam is next best option. “Pan-scanning” is a poor substitute for exam.

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part i neurological exam part ii coma

Part I: Neurological ExamPart II: Coma

Connie Chen

Neurology Consultants of Dallas

neurological exam some basics
Neurological Exam:Some Basics
  • Purpose of exam: differential diagnosis
  • The mantra:
    • History comes first!
    • Exam is next best option.
    • “Pan-scanning” is a poor substitute for exam.
    • “Pan-scanning” results in “missing the boat”.
neurological exam more basics
Neurological Exam:More Basics
  • Lecture goal:
    • Moving past medical school --see the forests, not the trees.
    • Tailor your exam to meet your needs.
    • Full neurological exams will waste your time?
case example
Case example
  • 65 yo with low back pain.
  • Pain radiates down right leg.
  • He notes new acute weakness in right leg.
  • Differential?
  • How can the exam support/aid in diagnosis?
exam purpose
Exam Purpose
  • Identify the part of the “neuro-axis” involved:
    • link EXAM with FUNCTION
  • Neuro-axis:
    • Cortex
    • Subcortex
    • Brain stem
    • Spinal cord
    • Nerve root
    • Peripheral nerve
    • Neuromuscular junction
    • Muscle.
the exam itself
The Exam Itself
  • Components:
    • Mental status
    • CN
    • Motor (tone, bulk, strength)
    • Sensation (soft touch/temp/pinprick vs vib/proprio)
    • Reflexes
    • Coordination
    • Gait (stressed gaits, base, arm swing, turn)
matching exam to location
Mental status

CN

Motor

Sensation

Reflexes

Coordination

Gait

Cortex

Subcortex

Brain stem

Spinal cord

Nerve root

Peripheral nerve

Neuromuscular junction

Muscle

Matching Exam to Location
slide9
Mental status

Level of alertness

Orientation

Language (naming, fluency, repetition, comprehension, reading)

Calculations

Memory

Judgement/insight

Executive function/Abstract thought

Visualspacial ability

Cortex (Frontal, parietal, temporal, occipital)

Subcortex (white matter, thalamus)

Exam
slide10
Cranial Nerves

III/IV

IV-VIII

V, IX-XII

Brainstem

midbrain

pons

medulla

Exam
motor exam
PATTERNS:

Corticospinal tract: strength “stroke pattern”

tone and bulk change later

spinal cord: spinal shock

Anterior horn: weakness at level, fasciculation

Root: weakness in all muscles involving root

Nerve: weakness in all muscles involving nerve

Muscle: proximal > distal weakness

Motor Exam

0= no movement, 1= f licker, 2= gravity removed,

3= against gravity, 4-/4/4+ = grades of resistance, 5= full

sensation exam
Sensation Exam
  • Notoriously painful for all involved.
  • Patterns: Central, cord, peripheral
  • Main pointers:
    • Dorsal columns: late cross, vib/proprio
    • Spinal thalamic tract: early cross, ST/temp/PP
reflexes
Reflexes
  • 0: absent
  • 1: present with distraction
  • 2: present without distraction
  • 3: spreads across more than one joint
  • 4: Clonus- sustained and non-sustained.

PATTERNS:

  • Up: Cortical, spinal (before anterior horn)
  • Down: Root, (nerve, muscle)
coordination cerebellum
Coordination=Cerebellum
  • Rapid alternating movements (dysdiadokinesia)
  • Past pointing
  • Dysmetria: finger nose/heel to shin
  • ??romberg-- not really
  • Wide based stance
  • (nystagmus at primary gaze)
  • ***Pre-existing weakness can fool you
slide15
Gait
  • The best part of exam
  • Evaluates strength, coordination, sensation
  • look at arm swing, base of stance, steps, turn,
  • stressed gaits will bring out subtleties.
case revisited
Case Revisited
  • 65 yo with low back pain.
  • Pain radiates down right leg.
  • He notes new acute weakness in right leg.
  • Differential?
  • Exam expectations?
case series
Case Series
  • 67 yo fell off of a horse and has developed bilateral LE weakness over the course of days.
  • Differential?
  • Exam findings?
  • What other pertinent HPI questions would have helped?
case series18
Case series
  • 25 yo notes water feels “funny” on right hand, and then his right leg felt strange.
  • Differential?
  • Exam findings?
case series19
Case Series
  • 40 yo notes left face and arm feels funny since last night and notes left arm and leg weakness.
  • Differential?
  • Exam findings?
case series20
Case Series
  • 78yo fell and couldn’t get up. “I knew I was going to get stuck [on the floor] for weeks now.” Why is he weak?
  • Differential?
  • Exam findings?
case series21
Case Series
  • 26 yo notes stumbling when walking and an inability to make his jump shots with basketball over the course of 2 days. His toes tingle.
  • Differential?
  • Exam findings?
case series22
Case series
  • 74 yo wm notes left face and arm weakness that lasts only 30 minutes. Later that day she develops vertigo, slurred speech, and diplopia. She can’t walk because she feels “like I’m drunk.” She has right carotid stenosis.
  • Differential?
  • Exam findings?
  • Right carotid stenosis relevance?
coma definition
Coma Definition
  • State of sustained unconsciousness
  • Ascertained by exam
how coma happens
How Coma Happens
  • Structural causes:
    • Bilateral supratentorial disruption
    • Disruption of the RAS of the brainstem
  • Practical thoughts (linking history, exam, and structure):
    • “metabolic”causes affect brain globally
    • “Vascular” causes are not equal: unilateral carotid artery vs. vertebral artery vs. basilar artery.
coma prognostication
Coma Prognostication
  • Gauging coma:
    • History
    • Exam
    • Ancillary studies
  • History cannot accurately predict outcome of coma.
coma prognostication27
Coma Prognostication
  • Ancillary studies cannot accurately ascertain coma emergence
  • Exception:
    • SSEP’s performed days 1-3 after coma.
    • Absence of cortical response shows poor prognosis.
coma prognosis
Coma Prognosis
  • Exam
    • Glascow coma score (eye opening, motor response, verbal response)

rather useless

    • Motor: Command>purposeful>flexor>extensor>flaccid
    • Cranial nerves: present>absent
    • Roving eye movements > no spontaneous
coma prognosis take home it s bad when
Coma Prognosis: Take Home(it’s bad when…)
  • First 24hr post circulatory arrest: myoclonus status epilepticus
  • Or by day 3:
    • no corneals, or
    • absent pupillary reaction, or
    • motor response is extensor or worse