1. The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York 1 1 1 1

2. Overview
Neuroanatomy
History
Physical
Clinical Scenarios 3 3 3 3

3. Introduction Facilitates communication Provides baseline
Directs testing
Identifies need for life-saving therapies
Risk management 3 3 3 3

4. Risk Management: Case #1
A 46-year-old female with a long history of migraine headaches presented c/o a severe occipital HA that was different from her past headaches in location and intensity. Neuro exam “WNL”. Patient was treated with Compazine, 10 mg IV, with “resolution of headache” and discharged home to “follow-up With PMD”.
18 hours later, patient was brought in by EMS comatose 4 4 4

5. Risk Management: Case #2
A 64-year-old male presented with lower back pain which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “mild paralumbar tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. Patient was prescribed Motrin and told to follow-up with his PMD.
Patient developed irreversible renal damage. 5 5

6. Cauda Equina Syndrom Injury to lumbosacral roots
Variable sensorimotor deficits and bowel and bladder function
Conus medullaris: s3-5: saddle anesthesia, sphincter loss, intact LE motor/sensory 5 5

7. Neuroanatomy

8. Michelangelo

9. Michelangelo

10. Neuroanatomy Central versus peripheral If central, what is the level:
symmetrical vs asymmetrical
If central, what is the level:
Cerebrum
Midbrain
Spinal cord
If peripheral, is it
Nerve
Muscle
NMJ 7 5 6 6

12. Anatomy of the Spinal Cord
Corticospinal Tracts: motor from cerebral cortex: cross in the lower medulla
Spinothalamic Tracts: pain and temperature cross 1 or 2 levels above entry
Posterior Column: proprioception and vibration 7 5 6 6

13. Cross-section

14. Brown-Sequard Usually after penetrating trauma
Ipsilateral motor paralysis
Ipsilateral loss of light touch and proprioception (anesthesia) below the level of the lesion
Ipsilateral hyperaesthesia
Contralateral loss of pain and temperature (analgesia) found one or two segments below the lesion 7 5 6 6

15. UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR
UMN muscle tone increased
LMN tone decreased, atrophy
UMN no fasciculations
LMN fasciculations 7 5 6 6

16. The Neuro Exam: History
Neuro complaints may be primary or secondary to other system disease
Infection
Overdose
Metabolic disorder
History often provides the key since the neuro exam may be normal
Subarachnoid hemorrhage
Carbon monoxide poisoning
Subdural hematoma
Nonconvulsive seizures 7 5 6 6

17. The Neuro Exam: History
Time of Onset
Type of Onset
Progression
Trauma
Associated Symptoms
Factors that make it better/worse
Past Symptoms / Events
Past Medical History
Occupational / Environ Exposures 16 10 14 14

19. The Neuro Exam: Initial Approach
Posture
Decorticate
Decerebrate
Facial or body assymetry
Hemiparesis results in external rotation of the foot to the affected sides 16 10 14 14

20. The Neuro Exam: Physical
Vital Signs
Head: Evidence of Trauma
Neck: Bruits, Rigidity
Heart: Murmurs
Abdomen: Masses / Distention
Skin / Scalp: Lesions / Tenderness 17 11 15 15

23. The Neuro Exam: Physical
Mental Status
Cranial Nerves
Motor
Sensory
Coordination
Reflexes 18 12 16 16

24. Mental Status Exam AVPU GCS Orientation
Speech (dysarthria vs aphasia)
Comprehension
Confusion assessment method (CAM)
Acute onset / fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Mini-mental status exam
Score affected by education and age
< 20 = cognitive impairment 18 12 16 16

25. Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs assymetrical18 12 16 16

26. Cranial Nerve II Visual acuity Visual fields Fundoscopy
Swinging flashlight test 18 12 16 16

33. Cranial Nerve V Sensory: corneal reflexes
Motor: jaw strength and muscle bulk
Corneal reflex may be abnormal in cerebellopontine angle lesions: test in patients with hearing deficits or vertigo 18 12 16 16

34. Cranial Nerve VII Motor Taste anterior 2/3 Smile Bury eyelashes
Nasolabial fold
Forehead has bihemispheric innervation centrally
Taste anterior 2/3 18 12 16 16

37. Cranial Nerve VIII – XII
VIII – vestibular function / hearing
IX – taste / sensation posterior pharynx
X – SCM; chin to the opposite side
XII - tongue 18 12 16 16

38. Motor Exam Strength Tone Bulk Fasciculation Tenderness
Primary concern: can patient breathe
Key test: drift of extremity
Tone
Hypertonia: subacute or chronic corticospinal lesion
Hypotonia: LMN lesion or acute UMN
Rigidity: basal ganglia disease
Bulk
Wasting correlates with LMN
Fasciculation
Anterior horn cell lesion
Tenderness
Metabolic/inflammatory muscle disease 18 12 16 16

41. Motor Exam 0 = no movement 1 = flicker but no movement
2 = movement but cannot resist gravity
3 = movement against gravity but cannot resist examiner
4 = resists examiner but weak
5 = normal 18 12 16 16

42. Sensory Exam
Pain/Temp – cross at entrance, ascend in spinal thalamic tract
Light touch – ascend in posterior column, cross in the brain stem
Vibration – posterior column, cross in the brain stem 18 12 16 16

43. Sensory Exam
Dermatomal deficit accompanied with pain suggests peripheral lesion
Central deficits are not dermatomal and usually result in loss of sensation and pain
Thalamic pain syndrome 18 12 16 16

45. Sensory Exam Distribution Pinprick versus light touch
Right vs left vs bilateral
Dermatomal
Distal versus proximal
Stocking glove
Cape like
Pinprick versus light touch 18 12 16 16

46. Sensory Exam Double simultaneous testing Establish sharp / dull
Check cheek, dorsum of hands, dorsum of feet
Test both sides simultaneously with pain
Lateralized pain, significant sensory deficit
Initially no lateralization but on repeat 15 sec later, lateralization suggest subtle deficit. 18 12 16 16

47. Coordination
Requires integration of cerebellar, motor, and sensory functions
Balance requires (2 of 3)
Vision
Vestibular sense
Proprioception
Falling with eyes open or closed = cerebellar
Falling only with eyes closed = posterior column or vestibular 18 12 16 16

48. Reflexes Symmetry / upper vs lower
0 = absent
1 = hyporeflexia
2 = normal
3 = hyperreflexia
4 = clonus (usually indicates organic disease)
Superficial reflexes (corneal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)
Pathologic reflexes: babinski 18 12 16 16

49. Pitfalls in the Neurologic Exam
Not getting a complete history utilizing family or observers
Not performing a systematic exam
Jumping to conclusions before gathering all the data
Misinterpreting old lesions for new
Misinterpreting limitations from pain as neurologic deficits 18 12 16 16

50. Pearls
Lesions of the cerebral cortex result in sensory and motor defects confined to the contralateral side of the body
Brain stem and spinal cord lesions result in ipsilateral as well as contralateral defects due to varying patterns of crossover
Unilateral pain syndromes without motor deficits suggest possible thalamic pathology
A careful exam of CN II, III, IV and V is indicated in patients with headache or suspected processes that cause increased ICP
Testing for pronator drift is the best screen for muscle weakness of central origin 18 12 16 16