The Neurologic Examination in the Emergency Setting

The Neurologic Examination The Neurologic Examination in the Emergency Settingin the Emergency Setting

Tintinalli Chapter 226Tintinalli Chapter 226

Jason Glagola PGY2Jason Glagola PGY2

Dr Gary RichardsonDr Gary Richardson

11/8/200511/8/2005

Key to evaluation is Key to evaluation is HISTORY:HISTORY:

• Time of onsetTime of onset

• Symptom progressionSymptom progression

• Associated symptomsAssociated symptoms

• Exacerbating factorsExacerbating factors

• ““Complete” exam is not required or Complete” exam is not required or appropriateappropriate

• However organized framework to However organized framework to exam is keyexam is key

• In children, indirect observation is In children, indirect observation is key. Such as how a child plays with key. Such as how a child plays with a toya toy

Traditional Exam is three Traditional Exam is three tieredtiered

• 1 – Is there a lesion of the nervous 1 – Is there a lesion of the nervous systemsystem

• 2 – Where is the lesion2 – Where is the lesion

• 3 – What is the lesion3 – What is the lesion

Eight elements of exam:Eight elements of exam:

• 1 – Mental status testing1 – Mental status testing

• 2 – Higher Cerebral functions2 – Higher Cerebral functions

• 3 – Cranial Nerves3 – Cranial Nerves

• 4 – Sensory Examination4 – Sensory Examination

• 5 – Motor System5 – Motor System

• 6 – Reflexes6 – Reflexes

• 7 – Cerebellar Testing7 – Cerebellar Testing

• 8 – Gait and Station8 – Gait and Station

Mental Status TestingMental Status Testing

Mental Status Testing - Mental Status Testing - BasicBasic

• “ “ awake, alert, and conservant “ awake, alert, and conservant “

• Assess emotional and intellectual Assess emotional and intellectual functionfunction

• Thought disorders or abnormal Thought disorders or abnormal thought content such as thought content such as hallucinations, mood, insight, and hallucinations, mood, insight, and sensorium (appropriate awareness sensorium (appropriate awareness and perception of consciousness)and perception of consciousness)

Mental Status Testing - Mental Status Testing - BasicBasic• Attention and MemoryAttention and Memory• Attention testing best performed with Attention testing best performed with

digit repetition.digit repetition.• Average adult should be able to Average adult should be able to

repeat six digits forward and four or repeat six digits forward and four or five backwards.five backwards.

• Failure to do so may suggest Failure to do so may suggest confusion, delerium or problem with confusion, delerium or problem with language perceptionlanguage perception

Mental Status Testing - Mental Status Testing - BasicBasic• MemoryMemory

• A complex process broken down into short A complex process broken down into short and long term memoryand long term memory

• Long term = months or years agoLong term = months or years ago

• Short term = events of day, or three object Short term = events of day, or three object five minute recallfive minute recall

• If unable to repeat three objects If unable to repeat three objects immediately, it is a problem with attention immediately, it is a problem with attention not memorynot memory

Mental Status Testing - Mental Status Testing - AdvancedAdvanced

• Mini-Mental Status examMini-Mental Status exam

• Quick Confusion Scale Quick Confusion Scale

• Both found in chapter 229Both found in chapter 229

Mini-Mental Status ExamMini-Mental Status Exam

Quick Confusion ScaleQuick Confusion Scale

Higher Cerebral FunctionsHigher Cerebral Functions


• Test neurologic functions that are Test neurologic functions that are thought to reside in the cerebral thought to reside in the cerebral cortexcortex


• Language defines the dominant Language defines the dominant hemisphere.hemisphere.

• Majority of population is right-handed Majority of population is right-handed (90%), for these patients left hemisphere (90%), for these patients left hemisphere is dominant and that is where language is dominant and that is where language resides. (left hemisphere dominant)resides. (left hemisphere dominant)

• Even most left handed people are left Even most left handed people are left hemisphere dominant for speechhemisphere dominant for speech

• Large cortical stroke in dominant Large cortical stroke in dominant hemisphere will affect languagehemisphere will affect language


• Nondominant hemisphere is Nondominant hemisphere is concerned with spatial relationships.concerned with spatial relationships.

• I.E. Visual inattention to care I.E. Visual inattention to care provider approaching from one side provider approaching from one side (usually the left, since most patients (usually the left, since most patients are left hemisphere dominant)are left hemisphere dominant)


• Dysarthria – mechanical disorder of Dysarthria – mechanical disorder of speech resulting from difficulty in the speech resulting from difficulty in the production of sound from weakness production of sound from weakness or incoordination of facial or oral or incoordination of facial or oral musculature. This may be motor musculature. This may be motor (cortical, subcortical, brainstem, (cortical, subcortical, brainstem, cranial nerve, or cerebellar) NOT cranial nerve, or cerebellar) NOT higher cerebral dysfunction!higher cerebral dysfunction!


• Dysphasia – Problem of language Dysphasia – Problem of language resulting from cortical or subcortical resulting from cortical or subcortical damage. This portion of brain is damage. This portion of brain is concerned with comprehension, concerned with comprehension, processing, or producing languageprocessing, or producing language

Higher Cerebral Functions - Higher Cerebral Functions - BASICBASIC

• Normal conversation and correct Normal conversation and correct response is common screen for response is common screen for language disorderlanguage disorder

• If abnormal, need further testingIf abnormal, need further testing

Higher Cerebral Functions - Higher Cerebral Functions - BASICBASIC• Comprehension – ability to follow simple Comprehension – ability to follow simple

commands, and name common objectscommands, and name common objects• Apraxia – Inability to show how a common Apraxia – Inability to show how a common

object may be used (pencil)object may be used (pencil)• Nonfluent aphasia (expressive aphasia) – Nonfluent aphasia (expressive aphasia) –

speed of language and the ability to find the speed of language and the ability to find the correct word – eponymous portion of correct word – eponymous portion of dominant cortexdominant cortex

• Fluent aphasia (receptive aphasia) – Fluent aphasia (receptive aphasia) – quantity of word production is normal or quantity of word production is normal or increased. Normal rhythm and intonation, increased. Normal rhythm and intonation, but incorrect wordsbut incorrect words

Higher Cerebral Functions - Higher Cerebral Functions - BASICBASIC

• Non-Dominant hemisphere may also Non-Dominant hemisphere may also show problems of sensory show problems of sensory descrimination, or auditory or visual descrimination, or auditory or visual inattentioninattention

Higher Cerebral Functions - Higher Cerebral Functions - ADVANCEDADVANCED

• Show patient a picture and see if what Show patient a picture and see if what is described is correctis described is correct

• Repeat a phrase: “No, Ifs, ands, or Repeat a phrase: “No, Ifs, ands, or buts.”buts.”

• Wernicke’s AphasiaWernicke’s Aphasia• Paraphasic errors – i.e. use the word Paraphasic errors – i.e. use the word

spool instead of spoonspool instead of spoon• A person who is aphasic in speaking A person who is aphasic in speaking

will also be in writingwill also be in writing


• Have patient draw circle and make a Have patient draw circle and make a clock.clock.

• Sensory perception – place an object Sensory perception – place an object in hand and have identifyin hand and have identify

• Must also make sure patient is not Must also make sure patient is not intoxicated or has severe psych illnessintoxicated or has severe psych illness

CRANIAL NERVESCRANIAL NERVES

Cranial Nerves - BASICCranial Nerves - BASIC

• I (olfactory) – smellI (olfactory) – smell

• II (Optic) – Visual acuity, visual fieldsII (Optic) – Visual acuity, visual fields

• III (Oculomotor) – III (Oculomotor) –

Motor – raise eyelids, extraocular Motor – raise eyelids, extraocular musclemuscle

Parasympathetic – pupillary constrictionParasympathetic – pupillary constriction

IV (Trochlear) – Downward/inward gazeIV (Trochlear) – Downward/inward gaze


• V (Trigeminal) – V (Trigeminal) –

Motor – jaw open, clench teeth, chewMotor – jaw open, clench teeth, chew

Sensory – sensation cornea, iris, lacrimal Sensory – sensation cornea, iris, lacrimal

glands, conjunctiva, eyelids, forehead, glands, conjunctiva, eyelids, forehead,

nose, teeth, tongue, earnose, teeth, tongue, ear

VI (Abducens) – lateral eye movementVI (Abducens) – lateral eye movement


• VII (Facial)VII (Facial)

Motor – facial expression except jaw, Motor – facial expression except jaw,

close eyes . . close eyes . .

Sensory – taste, ant 2/3 tongue, Sensory – taste, ant 2/3 tongue,

sensation to pharynxsensation to pharynx

VIII (Acoustic) – hearing and equilibriumVIII (Acoustic) – hearing and equilibrium


• IX (Glossopharyngeal) IX (Glossopharyngeal)

Motor – voluntary swallow, phonationMotor – voluntary swallow, phonation

Sensory – sensation nasopharynx, gag Sensory – sensation nasopharynx, gag

reflex, taste (post 1/3)reflex, taste (post 1/3)

Parasympathetic – carotid reflex, Parasympathetic – carotid reflex, salivary salivary

secretionsecretion

Cranial Nerves - Cranial Nerves -

• X (Vagus)X (Vagus) Motor – voluntary phonation, swallowMotor – voluntary phonation, swallow Sensory – behind ear, external canalSensory – behind ear, external canal

Parasymp – peristalsis, carotid reflex, Parasymp – peristalsis, carotid reflex, heart, lung, digestionheart, lung, digestion

XI (Spinal Accessory) – Turn head, shrug XI (Spinal Accessory) – Turn head, shrug shouldersshoulders

XII (Hypoglossal) – Tongue articulation (l, t, XII (Hypoglossal) – Tongue articulation (l, t, n) and swallown) and swallow

Sensory ExamSensory Exam


• Light touchLight touch

• PinprickPinprick

• PositionPosition

• VibrationVibration

• TemperatureTemperature


• Usually start with touch and pinprick Usually start with touch and pinprick in extremity, if intact stop in extremity, if intact stop unless . . . .unless . . . .

• Suspect peripheral nerve or spinal Suspect peripheral nerve or spinal cord injurycord injury

• Position testing – best for peripheral Position testing – best for peripheral neuropathy or posterior spinal cord neuropathy or posterior spinal cord injuryinjury

Dermatome Dermatome MapMap


• Cervical Injury = thoracic Cervical Injury = thoracic dermatomes and upper extremitydermatomes and upper extremity

• The demonstration of a preserved The demonstration of a preserved island of sensation around the island of sensation around the perineum may be the only sign of an perineum may be the only sign of an incomplete spinal cord injury, which incomplete spinal cord injury, which has a different prognosis than has a different prognosis than complete spinal cord injurycomplete spinal cord injury

Motor SystemMotor System

• Tone – normal, decreased, increasedTone – normal, decreased, increased

• Increased – ask patient to relax, and Increased – ask patient to relax, and not resist. Test Passively. I.E. not resist. Test Passively. I.E. cogwheelingcogwheeling

• Arms out palms up, observe for Arms out palms up, observe for inward rotation or downward drift inward rotation or downward drift (pronator drift)(pronator drift)

Motor SystemMotor System

• Compare muscle mass and bulkCompare muscle mass and bulk• Look for atrophy, fasciculationsLook for atrophy, fasciculations• A rating for strength 0 to 5A rating for strength 0 to 5• 5 = normal5 = normal• 4 = weakness w/ ability for some 4 = weakness w/ ability for some

resistanceresistance• 3 = complete ROM against gravity3 = complete ROM against gravity• 2 = movement w/ gravity eliminated2 = movement w/ gravity eliminated• 1 = minimal flicker of contraction1 = minimal flicker of contraction• 0 = no movement0 = no movement

Muscle Innervation Muscle Innervation ChartChart

Muscle Innervation ChartMuscle Innervation Chart

ReflexesReflexes

• Least important part of examLeast important part of exam

• Scale 1 to 4Scale 1 to 4

• 0 = no reflex0 = no reflex

• 1 = decreased1 = decreased

• 2 = normal2 = normal

• 3 = increased3 = increased

• 4 = clonus4 = clonus

ReflexesReflexes

• BabinskiBabinski

• Normal = toes go downNormal = toes go down

• Clonus = Rhythmic oscillation of a Clonus = Rhythmic oscillation of a body part elicited by brisk stretch = body part elicited by brisk stretch = sign of spasticitysign of spasticity

ReflexesReflexes

• Hyperactive, babinski, clonus = Hyperactive, babinski, clonus = upper motor neurons (cortical and upper motor neurons (cortical and spinal cord injuries)spinal cord injuries)

• Hypoactiive = Lower motor neurons, Hypoactiive = Lower motor neurons, peripheral nerve rootsperipheral nerve roots

• But NOT reliable and may take time But NOT reliable and may take time to developto develop

Cerebellar TestingCerebellar Testing

Cerebellar TestingCerebellar Testing

• The cerebellum is concerned with involuntary The cerebellum is concerned with involuntary activities of the central nervous system and activities of the central nervous system and may be simply thought of as a structure that may be simply thought of as a structure that helps with smoothing muscle movements and helps with smoothing muscle movements and aiding with movement coordination.aiding with movement coordination.

• Central cerebellar structure = axial Central cerebellar structure = axial coordinationcoordination

• Lateral cerebellar structure = appendicular Lateral cerebellar structure = appendicular coordination (extremities)coordination (extremities)

Cerebellar Testing – BasicCerebellar Testing – Basic

• Rapidly alternating movements Rapidly alternating movements (rapid pronation and supination of (rapid pronation and supination of hands). Should be equal and hands). Should be equal and symmetricsymmetric

Cerebellar Testing - Cerebellar Testing - AdvancedAdvanced

• Finger to nose, must be done rapidlyFinger to nose, must be done rapidly

• NystagmusNystagmus

Gait and StationGait and Station


• It has been said that if only one It has been said that if only one neurologic test could be formed, neurologic test could be formed, walking would be most important.walking would be most important.

• See Chapter 230 for ataxia and gait See Chapter 230 for ataxia and gait disturbancedisturbance


• Cerebellar infarct or hemorrhage is a true Cerebellar infarct or hemorrhage is a true emergency because it can compress on emergency because it can compress on the brain stem causing apnea and death.the brain stem causing apnea and death.

• Cerebellar hemorrhage may cause Cerebellar hemorrhage may cause sudden nausea, vomiting, and sudden nausea, vomiting, and diaphoresisdiaphoresis

• Cerebellar infarct may also cause sudden Cerebellar infarct may also cause sudden inability to walkinability to walk

Quick ReviewQuick Review

Terminology of Mental Status Terminology of Mental Status Exam list is in handout.Exam list is in handout.

Definitions of different aphasias Definitions of different aphasias etc..etc..

References:References:

• Tintinalli chapter 226Tintinalli chapter 226

• Mosby’s Guide to physical exam 4Mosby’s Guide to physical exam 4thth edition chapter 20.edition chapter 20.

• Up to Date “The Detailed Neurologic Up to Date “The Detailed Neurologic Exam in Adults”Exam in Adults”

Questions:Questions:

• 1) The average adult should be able to 1) The average adult should be able to repeat 6 digits forward and 4 to 5 repeat 6 digits forward and 4 to 5 backwards? T/F?backwards? T/F?

• 2) IF unable to repeat 3 objects 2) IF unable to repeat 3 objects immediately after being told them, is immediately after being told them, is this a problem with memory or this a problem with memory or attention?attention?

• 3) A cortical stroke in the dominant 3) A cortical stroke in the dominant hemisphere will affect language? T/F?hemisphere will affect language? T/F?

Questions:Questions:• 4) Matching:4) Matching:• 4a) Dysphasia4a) Dysphasia• 4b) Dysarthria4b) Dysarthria• AnswersAnswers• 1- mechanical disorder of speech resulting 1- mechanical disorder of speech resulting

from difficulty in the production of sound from from difficulty in the production of sound from weakness or incoordination of facial or oral weakness or incoordination of facial or oral musculature. This may be motor (cortical, musculature. This may be motor (cortical, subcortical, brainstem, cranial nerve, or subcortical, brainstem, cranial nerve, or cerebellar) NOT higher cerebral dysfunction!cerebellar) NOT higher cerebral dysfunction!

• 2 - Problem of language resulting from cortical 2 - Problem of language resulting from cortical or subcortical damage. This portion of brain is or subcortical damage. This portion of brain is concerned with comprehension, processing, or concerned with comprehension, processing, or producing languageproducing language

Questions:Questions:

• 5) Matching5) Matching• 5a) Expressive Aphasia (non-fluent)5a) Expressive Aphasia (non-fluent)• 5b) Fluent Aphasia (receptive)5b) Fluent Aphasia (receptive)• AnswersAnswers• 1 - speed of language and the ability to 1 - speed of language and the ability to

find the correct word – eponymous portion find the correct word – eponymous portion of dominant cortexof dominant cortex

• 2 - quantity of word production is normal 2 - quantity of word production is normal or increased. Normal rhythm and or increased. Normal rhythm and intonation, but incorrect words. intonation, but incorrect words. Comprehension is impairedComprehension is impaired

QuestionsQuestions

• 6) What would the motor score (1 – 6) What would the motor score (1 – 5) be if a person:5) be if a person:

• complete ROM against gravity, but complete ROM against gravity, but not with any additional resistance?not with any additional resistance?

AnswersAnswers

• 1) True1) True

• 2) Attention2) Attention

• 3) True3) True

• 4a) 24a) 2

• 4b) 14b) 1

• 5a) 15a) 1

• 5b) 25b) 2

• 6) 36) 3

The Neurologic Examination in the Emergency Setting

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