THE NEURO EXAM IN THE ALTERED PATIENT Hugh H. West, M.D. Associate Professor UCSF Dept. of EM HREM 5/24/2014 OBJECTIVES: • 1) REVIEW THE NEURO EXAM IN AMSE PTS • 2) LIST THE NEURO EXAMS SIX EASY PIECES • 3) REVIEW THE CATEGORIES OF AMSE PTS • 4) LEARN AN APPROACH TO ALL AMSE PTS • 5) LEARN TO “ DANCE ” W/ THE PATIENT’S CNS • 6) LEARN TO GATHER INFO ON AMSE PTS
PATIENT #1 • 41 YOM BIBA INTOXICATED STREETFIGHTER • NOT A FORTHCOMING HISTORIAN • HX IS MOSTLY EXPLETIVE DELETED • NO I.D. ON HIM, SO NO OLD RECORDS • ONE R.N. RECOGNIZES HIM • “FREQ FLYER” FOR ETOH ABUSE EXAM • P=110, BP=135/85, RR=15, T=37C, Sat=99%RA • Odor of alcohol noted on his breath, red wine • Multiple minor abrasions on face and hands • Lungs clear, Heart no gmr, Abd bs ok, nttp • Neuro noncoop • Plan ‐ MTF
NEURO EXAM TYPES • NONE (NR, NA, OR LEAVE IT BLANK) • NONCOOP (WE’VE GOT THIS ONE) • NONFOCAL (BRIEF NEEDS BACKUP) • NEUROLOGIST’S (TIME AND IQ) • HIREM’S “ DANCE ” (MORE TO COME)
(5+1) SIX EASY PIECES NEURO EXAM • MSE – CORTEX • CNN – BRAINSTEM • MOTOR • SENSORY • DTRS – MONOSYNAPTIC REFLEX ARC • COOR – CEREBELLAR, GAIT, SYNTHESIS
HIREM’S NEURO EXAM “THE DANCE” • A DANCE IS A DIALOG • THINK ABOUT THE WALTZ, THE TANGO, SLOW AND SWEET, BOOGIE DOWN AND SHAKE IT • HIREM’S NEURO DANCE MEANS THAT YOUR CNS IS IN DIALOG WITH THE PATIENT’S CNS • HERE’S THE SECRET, IT’S NOT VOLUNTARYFOR THEM, THEIR CNS CAN’T HELP BUT DANCE! • RIGHT QUESTIONS LEAD TO RIGHT ANSWERS AMSE PATIENT EXAMPLES • STRUCTURAL “THE BLAMELESS EXAM” • ALTERED BASELINE “THE OLD CVA+ EXAM” • DEMENTED “OLD TIMER’S DISEASE EXAM” • IMPAIRED “THE TOX/ METAB/ INF EXAM” • PSYCHIATRIC “THE CRAZY EXAM” • FABICATION “THE PHONY EXAM” • OTHERS “SEIZURE RELATED, POSTICTAL”
PIECE #1 THE CORTEX/ MSE • ALERT TO OBTUNDED SPECTRUM, REMEM IICP • ORIENTED REQUIRES THE QUESTIONS • THE GLASGOW COMA SCALE IS YOUR FRIEND • 4 EYES – SPONT/ VOICE/ PAIN/ NONE (4X1=4) • 5 VERBAL – ORIENTED/ CONFUSED/ INAPP/ INCOMPREHENS/ NONE • 6 MOTOR – COMMANDS/ LOCALIZ PAIN/ WITHDRAW PAIN/ FLEX PAIN/ EXT PAIN/ O BRAINSTEM – THE CRANIAL NN CN I – Olfactory CN VII – Facial CN II – Optic CN VIII – Vestibulocochlear CN III – Oculomotor CN IX – Glossopharyngeal CN IV – Trochlear CN X – Vagus CN V – Trigeminal CN XI – Accessory CN VI – Abducens CN XII – Hypoglossal
PIECE #2 TESTING THE CRANIAL NN • 1: SMELL NOT NOXIOUS SMELLING SALTS=5 • 2,3,4,6: LIGHT, THREAT, PUPILS, EOMS, EYES • 5,7: CORNEAL REFLEX (AFF 5, EFF 7) (EFF=EXIT) • 8: NOISE, CALORICS (COWS MNEMONIC) • 9,10: GAG REFLEX (AFF 9, EFF 10), PALATE • 11: SCM MM, TRAPS • 12: TONGUE WASTING, FASCICULATIONS ANISOCORIA
DISCONJUGATE GAZE LIGHT REFLECTIONS
DISCONJUGATE GAZE, NOTE LR THE REST OF THE BRAINSTEM • 5,7: CORNEAL REFLEX (AFF 5, EFF 7) (EFF=EXIT) • (MOIST COTTON SWAB, AVOID CENTRAL AXIS) • 8: NOISE, CALORICS (COWS MNEMONIC) • (COLD OPPOSITE WARM SAME QP NYSTAG) • 9,10: GAG REFLEX (AFF 9, EFF 10), PALATE • (WATCH FOR THE SUPINE EMESIS SYNDROME)
UNILATERAL WEAKNESS, CN 10 PIECES #3, 4, 5 MOT/ SENS/ DTR • SENSORY INPUT TENDON STRETCH RECEPTOR • MONOSYNAPTIC REFLEX ARC • MOTOR OUTPUT “THE MUSCLE JERK” • INVOLUNTARY AND … • ASYMMETRY IS THE ISSUE • ALSO TONE IS A PART OF THE MOTOR EXAM • FLACCED, SPASTIC, PARATONIA COG ‐ WHEEL
MOTOR EXAM POINTS • COLLAPSING WEAKNESS • ALTERNATE HEEL TEST • ARM DROP TEST • ALL SSX OF PSYCHOGENIC OVERLAY • DX OF LAST RESORT: BE CAREFUL • THE PSYCHOGENIC EXAMINATION PATIENT WITH THE CEREBELLAR LESION PIECE #6 COORDINATION • CEREBELLAR • SYNTHESIS OF PIECES 1 ‐ 5 • GAIT (THE BIG MAN TIPTOE GAIT) • REMEMBER WERNICKES TRIAD • AMSE, GAIT, EYE SIGNS ‐ CONFUS ATAX PLEGIA • REMEMBER NPHC TRIAD • AMSE, GAIT, INCONTINENCE ‐ DEMEN, ATAX,
HIREM NEURO EXAM ON PT#1 • MSE non coop (expletive deleted) • CN sl anisocoria, reactive, c/w physiologic • Disconjugate gaze? Subtle • Nystagmus (symmetrical horizontal) • Ataxia (historically wide based gait) • Increased tone (BILAT LX) • AJ Clonus 2 beats, toes +/ ‐ up (BILAT) NEW PLAN • Other etiology of AMSE? (Inf/ Metab) ‐ > FSBS • Wernicke’s triad? (MSE, eyes, gait) ‐ > thiamine • Etoh and CHI (contusion, ICH) ‐ > NC CT Head • Other etiology of AMSE? (Inf/ Metab) ‐ >Labs • Tox Labs? ‐ > Etoh Level, Utox, Anion Gap • MTF ‐ > Gait/ Verbal are the d/c criteria • Psych contribution? SI? HI? EDH? Psych eval?
RESULTS • BS=45 (Alcoholic Hypoglycemia) (AMSE ‐ >FSBS) • Wernicke’s on MRI (pericentral scarring) • Bilat subdural hematomas • Na 115 (SIADH from the CNS issues) • Admitted, NS evaluation (nonoperative) • Improved over time • D/C to SNF
PATIENT #2 • 40 YOM CCO LEGS WEAK AND NUMB • ROS POSITIVE FOR URINARY INCONTINENCE • EXAM WNL INCL MOTOR/ SENSORY/ SPHN • TEACHING POINT: RED FLAGS SUCH AS CA WITH METS/ IVDU W MRSA ABSCESSES/ IMMUNOSUPRESSION ‐ TRX, CA CHEMOTX, HIV, STEROID USE, AUTOIMMUNE, TRAUMA (THIS PT WAS OBESE W CHRONIC LBP) PATIENT #2 • SUBJECTIVE COMPLAINTS PRECEDE OBJECTIVE FINDINGS, 5/5 STRENGTH ON YOUR EXAM IS NOT GOING TO PICK UP A SUBTLE MOTOR LOSS IN AN OLYMPIC ATHLETE, A NORMAL SENSORY EXAM DOES NOT PRECLUDE SUBTLE SENSORY LOSSES, AND A NORMAL RECTAL EXAM (SQUEEZE DOWN ON MY GLOVED FINGER) DOES NOT PRECLUDE SPHINCTER DYSFUNCTION. THINK MRI. IT’S JUST A TEST.
OBJECTIVES: • 1) REVIEW THE NEURO EXAM IN AMSE PTS • 2) LIST THE NEURO EXAMS SIX EASY PIECES • 3) REVIEW THE CATEGORIES OF AMSE PTS • 4) LEARN AN APPROACH TO ALL AMSE PTS • 5) LEARN TO “ DANCE ” W/ THE PATIENT’S CNS • 6) LEARN TO GATHER INFO ON AMSE PTS NEURO EXAM OF THE AMSE PT • THE END • THANK YOU
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