THE NEURO EXAM IN THE ALTERED PATIENT Hugh H. West, M.D. Associate - - PDF document

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