Neuro Exam Explained

Transcription

1 Neuro Exam Explained Michael Nelson M.D. Providence Neurological Specialties East Primary Care Conference October 26 rd, 2017

2 Michael Nelson M.D. Medical School: University of Missouri-Columbia Residency: University of Washington completed in 2002 Board Certified general adult neurologist Providence Neurological Specialties East in NE Portland and Vancouver WA Sadly I have no financial disclosures

3 Today s Goals Understand importance of the neurological exam Reduce neurophobia (fear of the neuro exam) Avoid common mistakes in performing the neurological exam Explain meaning of the findings on the examination Have fun!

4 You Will Have Neurological Patients Outpatient About 10% of visits to primary care are due to neurological complaints Inpatient About 20% of hospital admissions are for neurological issues Stroke is the 3 rd leading cause of death Alzheimer s is the 7 th leading cause of death These numbers will rise as the population ages Availability Neurologists are rare and in high demand

5 What is the most important part of the neurological examination? A proper history!

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8 What tools do you really need? A bright light-ophthalmoscope or pen light Reflex hammer Tuning fork 128 Hz Stethoscope Your two hands! Good observation skills That s it? Is Dr. Nelson crazy? What about the tongue depressor, vision chart, color vision book, ice water for cold calorics, monofilaments, OKN flag, Maddox rod & red lens, cloves, two point discrimination tool, or that pokey wheel thing?

9 Which reflex hammer to use?

10 Three Kinds of Neuro Exams Screening Neuro Exam For no neurological symptoms Comprehensive Neuro Exam For patients with neurological symptoms Still can be focused on your suspicion Vital signs are still vital I m going to say it twice: VITAL SIGNS ARE VITAL Very high blood pressure makes it more likely to be a concerning neurological process Feel pulse yourself (if patient isn t on a monitor) Altered level of consciousness Patient can t really participate

11 The Screening Neurological Examination Includes at least each part of the six major components Mental Status Cranial Nerves Motor Function Reflexes Sensation Cerebellar

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13 Screening Mental Status Level of Alertness Appropriate responses Not a full MMSE, MOCA, SLUMS Orientation to date and place Before you start make sure they can hear you.

14 Comprehensive Mental Status Level of Alertness, Orientation, Concentration, Memory, and Language Consider a full MMSE, MOCA,or SLUMS Clock drawing Consider referral for neuropsychological testing Office based memory tests can easily miss poor judgement.

15 Screening Cranial Nerves Visual acuity-first ask patient about their vision Pupillary light reflex-if unequal first ask about eye surgery or trauma history. Make sure light source is not towards one side Eye movements-don t be fooled by end gaze nystagmus and just remember Hearing-finger rub is okay Facial strength-if asymmetric ask if this is an old finding. Check their driver s license photo if not sure

16 Comprehensive Cranial Nerves Olfactory-rarely tested but you cannot use something noxious or you are actually testing the 5 th cranial nerve. Fundoscopic Exam-good luck in the office. May soon be replaced with office retinal photography. Eye movements th nerve will give you a head tilt Facial sensation-there are three divisions. Facial strength-forehead okay means central, forehead involvement means peripheral (Bell s palsy). Say ahh! Gag is CN IX and X. Also taste. CN XI is trapezius and XII is tongue protrusion.

17 Screening Motor Function Strength-pronator drift, grip, wrist, elbows, shoulder, knees, ankles. Don t mistake pain for weakness. Pronator drift requires pronation! 5/5 is normal 4/5 is weak but against resistance 3/5 is only beyond gravity 2/5 is no gravity 1/5 is muscle activation with no joint movement

18 Comprehensive Motor Function Expand muscle groups Add bulk and tone Look closely for atrophy or fasciculations

19 Screening Reflexes DTR Deep tendon reflexes (biceps, patella, ankle) yes you need to do upper and lower extremities. Most important is if there a side to side difference. Absent means no response 1+ decreased but normal 2+ normal 3+ increased 4+ clonus Plantar responses can be difficult to interpret (ticklish) and an upgoing toe should not just be the only finding

20 Comprehensive Reflexes Expand DTR Deep tendon reflexes to include biceps, triceps, brachioradialis, patella, and ankle. Increased reflexes=central process Decreased reflexes=peripheral process Plantar responses are more important to get right here. I pretty much never check Cremaster, anal wink, or primitive reflexes like snout, palmomental, or grasp

21 Screening Sensation One modality at the feet I prefer the tuning fork which is always cold to test pain/temperature sensation in the feet. If abnormal, then test vibration sense with same tool Sensation is frequently misleading

22 Comprehensive Sensation Expand to arms and legs Expand to include light touch, position, pain/temperature, and position sense. Romberg testing is a sensation test (position sense) Cortical sensory loss is some of the cool testing like stereognosis, graphesthesia, and extinction. Again, sensation is frequently misleading

23 Screening Cerebellar Primary gait and tandem if appropriate-many patient over 60 do not have normal tandem walking Test finger nose finger and rapid alternating movements Look at their handwriting

24 Comprehensive Cerebellar Look for abnormal movements like chorea, athetosis, postural tremor, cerebellar tremor, resting tremor, motor tics, slow movements (parkinsonism), myoclonus, hemiballismus, alien hand syndrome, and dystonia. Midline cerebellar issues cause midline body symptoms (truncal ataxia, poor tandem walking) Peripheral cerebellar issues cause peripheral body symptoms like limb ataxia, hand tremor, etc.

25 The Altered Mental Status Neuro Exam Patient cannot participate with exam Mental Status-level of arousal, response to auditory, visual, and noxious stimuli. Cranial Nerves-pupillary light reflex, oculocephalic reflex (doll s eye), vestibulo-ocular reflex (cold calorics), gag, corneal reflex Motor Function-voluntary and involuntary movements, withdrawal to pain. Can t do cerebellar assessment Reflexes-DTR and plantar Sensation-progress to noxious stimuli

26 Michael Nelson M.D. Medical School: University of Missouri-Columbia Residency: University of Washington completed in 2002 Board Certified general adult neurologist Providence Neurological Specialties East in NE Portland and Vancouver WA

27 Neuro Exam Explained Michael Nelson M.D. Providence Neurological Specialties East October 26 rd, 2017