The ER Neurological Exam

1. The ER Neurological Exam Dr. Tallam Prepared by T. Gifford

2. Axiomatic points • Neurological examination does not exist in isolation from the physical examination • Rarely does the neurological examination delineate a problem not suggested by the history or general exam. • A “complete” neurological examination is neither required nor appropriate in the ER.

3. Mental status testing Higher cerebral functions Cranial nerves Sensory examination Motor system Reflexes Cerebellar testing Gait and station Approach

4. Mental Status Testing • Basic • Appearance • Awake, alert, etc • Thought disorders / abnormal thought • Hallucinations, mood, insight, sensorium • Attention • Assessed with 6 digit repetition • Memory • Long term • Short term

5. Mental Status Testing • Advanced • Mini mental status exam (MMSE) • Quick Confusion scale (QCS)

6. Higher Cerebral Functions • Tests functions of the cortex. • Dominant hemisphere = language (usually left) • Nondominant hemisphere = spatial relationship • Assessment of higher cerebral function is primarily done by language assessment

7. Higher Cerebral Functions • Speech assessment • Dysarthria • Mechanical disorder of speech • May be motor problem • Not cortex problem • Dysphagia • Problem with comprehension, processing, or producing language. • Is a cortex problem

8. Higher Cerebral Functions • Basic exam • Normal conversational monitoring • Comprehension – identify objects • Aphasia • Non fluent (motor or expressive) • Speed and ability to find correct words impaired • Broca aphasia – speech halting, slow with word fragments • Fluent (auditory or receptive) • Speed and grammar may be correct • Peculiar language – may lack content, substituted words. • Wernicke aphasia • Mixed

9. Higher Cerebral Functions • Advanced • Ask patient to describe a pictured scene • Assesses interpretation, content, sentence structure and word selection • Repeat a phrase • Delineates some types of fluent aphasias • Short words are more impaired than longer • No ifs, ands, or buts.

10. Higher Cerebral Functions • Special • Fluent aphasias may be confused for intoxication.

11. Basic exam Most information can be gained informally by conversation Formal CN exam Cranial Nerves

12. Cranial Nerves • Advanced • Anisocoria – baseline 20% • Peripheral CN VII lesion will cause complete facial paralysis on the same side as the lesion. • A CN VII cortical lesion results in weakness of the lower and midface sparing motor to the upper face “central seventh pattern”.(this is due to bilateral cortical upper motor innervation of the forehead)

13. Cranial Nerves • Special • Comatose with unilaterally dilated pupil = impingement of CN III at the tentorium (uncal herniation)

14. Sensory Exam • Basic • Establish presence of touch in all extremities – usually sufficient. • Position testing or vibratory sensation – useful in detecting peripheral neuropathy or posterior column disease

15. Advanced Dermatome levels – useful if alteration of sensation is present to localize defect. Sensory Exam

16. Sensory Exam • Special • Cervical spinal cord injury • Transverse sensory loss • Spinal cord injury • Preserved sensation around perineum is sign of incomplete spinal cord injury • Hemi body sensory alteration suggests cortical or subcortical lesions • Single limb sensory alteration suggests peripheral nerve

17. Motor Exam • Basic • Tone – assess by passive motion • Cogwheeling – muscle catches and releases • Strength scale • Pronator drift • Arm rolling • In comatose – hold arms up

18. Motor Exam • Advanced • Muscle twitch, fasciculations • Atrophy • Specific muscle innervation testing • Special • Bladder status - ? Neurogenic bladder and spinal cord compression.

19. Arguably the least important part of a neurological examination Reflexes

20. Reflexes • Basic • Scale 0 to 4 • Babinski – toe moves upward in response to mildly noxious stimulus to the lateral plantar surface. • Normal response in adult is for the toe to move downward. • Advanced • Clonus – rhythmic oscillation (typically ankle) elicited by brisk stretch. • May indicate metabolic or neurological problem.

21. Reflexes • Special • Interpretation • UMN / Cortical / Spinal cord injuries result in • Hyperactive reflexes • Babinski response (upward going toes) • Clonus • LMN and axons / peripheral nerve and roots / muscles • Hypoactive reflexes • In stroke or spinal cord injury it may take several hours to see changes.

22. Cerebellar Testing • Testing of involuntary activities of the CNS. • Central cerebellum: coordination of posture and truncal movements • Lateral cerebellum: movement of extremities • Basic • Rapidly alternating hand movements • Pronation / supination of forearm

23. Cerebellar Testing • Advanced • Eye movement • Tracking an object slowly should be smooth • Looking back and forth between objects • Finger to nose testing

24. Gait and Station • Basic • Could be most informative single test. • Observation of walking • Observation of posture • Covered in “Ataxia” lecture • Sudden inability to walk – always consider cerebellar infarct / bleed. N/V and diaphoresis also common in these patients. This is a true emergency that may respond well to surgery.

25. Questions?