HighYieldNeurologicalExaminationVanjaDouglas,MD
Sara&EvanWilliamsFoundationEndowedNeurohospitalistChair
Director,NeurohospitalistDivisionAssociateProfessorofClinicalNeurology
UCSFDepartmentofNeurology
Disclosures
None
PurposeofNeuroExam
• Screenasymptomaticpatients• Screenpatientswithsymptomsthatcouldindicateafocalneurologiclesion(e.g.backpain,headache,seizure)
• Localizethelesioninpatientswithneurologicdeficits– Generateadifferentialdiagnosis– Decidewhattesttogetnext(e.g.brainMRI,spineMRI,EMG/NCS,CK)
Typical“Screening”NeuroExam• MentalStatus:Levelofalertness,orientation,attention,
language,memory• CranialNerves:IIthroughXII• Motor:Bulk,tone,powerinallmusclesinbotharmsand
legs• Sensory:Lighttouch,vibration/jointpositionsense,pain/
temperature,Romberg• Reflexes:Biceps,triceps,brachioradialis,knees,ankles,
plantarresponse• Coordination:Finger-nose-finger,heel-knee-shin• Gait:Observegait,includetandem,heel,andtoewalking
HighYieldScreeningNeuroExam
• MentalStatus• CranialNerves• Motor• Sensory• Coordination• Reflexes• Gait
Language
ReceptiveAphasia
Fluency Intact
Comprehension Impaired
Repetition Impaired
ExpressiveAphasia
Fluency Impaired
Comprehension Intact
Repetition Impaired
ConductionAphasia
Fluency Intact
Comprehension Intact
Repetition Impaired
HighYieldScreeningNeuroExam
• MentalStatus:language,orientation,andattention
• CranialNerves• Motor• Sensory• Coordination• Reflexes• Gait
ExtraocularMovements
FacialSymmetry
VisualFields
HighYieldScreeningNeuroExam
• MentalStatus:language,orientation,andattention
• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor• Sensory• Coordination• Reflexes• Gait
MotorSystem2minutescreenforuppermotorneuronweakness:• PronatorDrift• Fingertaps&Foottaps• Distalextensorpower:• Fingerextensors• Tibialisanterior
HighYieldScreeningNeuroExam• MentalStatus:language,orientation,andattention
• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower
• Sensory• Coordination• Reflexes:Biceps,knees,andankles• Gait
Coordination&Gait
• Hemispheres:– Finger-nose-finger
– Heel-knee-shin
• Vermis:– Gait
HighYieldScreeningNeuroExam• MentalStatus:language,orientation,andattention• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower
• Sensory• Coordination:Finger-nose-fingerandheel-knee-shin(canreplaceHKSwithgait)
• Reflexes:Biceps,knees,andankles• Gait:Observegait(base,stride,posture,armswing,turn),tandem
WhyDoASensoryExam?
• Iftherearesensorycomplaints• Iftherearebalancecomplaintsoragaitdisorder
• Ifthereisweakness
SensoryTractsVibration&Jointpositionsense
HighYieldScreeningNeuroExam• MentalStatus:language,orientation,andattention• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower
• Sensory:(Ifdone,dopainORtemp+vibrationORJPS)• Coordination:Finger-nose-fingerandheel-knee-shin(canreplaceHKSwithgait)
• Reflexes:Biceps,knees,andankles• Gait:Observegait(base,stride,posture,armswing,turn),tandem
LET’SPRACTICE!CaseScenarios
ThinkLikeANeurologist
• ChiefComplaint:suspectedlocalization• History:refinethelocalization• Exam:pickmaneuversthatruleinorruleoutyoursuspicions
Patient#1
• A23y/owomanwithahistoryofmigraineheadachesisadmittedtothehospitalwithleftlegcellulitis.Onhospitalday2,shecomplainsofanewheadache.Shesaysit’sdifferentfromherpreviousmigrainesbecauseitis“muchworse”andiswonderingifsheneedsanMRI.
Headache
Suspectedlocalization• Focalbrainlesion
Otherpotentialpresentingsymptoms
• Seizure• Unilateralweakness• Unilateralnumbness• Dysarthria
Hypothesis-DrivenNeuroExam
Patient#2
• 57y/omanhospitalizedwithMIisalteredafterhiscardiaccath.Heissomnolentbutarousable,mumblingincoherently.Hisfamilyisveryconcernedthathehashadastroke.
AlteredMentalStatus
Suspectedlocalization• Bilateralhemispheres• Brainstem
Patient#2Exam
• Arousestotouch• Namessimpleobjects,repeatsshortphrases,followssimplecommands
• Disorientedandunabletotestattention• EOMI;facesymmetric;blinkstothreatbilaterally• Leftarmdriftsandhandisclumsy• Withdrawslessbrisklytopainintheleftleg• HeadCTisnormal
MultifocalStrokes
Patient#3
• A65y/omanwithprostatecancerpresentswithbilaterallegweaknessandurinaryurgency.
BilateralLegWeakness
Suspectedlocalization• Spinalcord• Caudaequina
Otherpotentialpresentingsymptoms
• Urinaryorbowelincontinence
• Gaitdifficulty• Backpain
UMN LMN
Pattern of Weakness Pyramidal Variable
Function/Dexterity Slow alternate motion rate Impairment of function is mostly due to weakness
Tone Increased Decreased
Tendon Reflex Increased Decreased, absent or normal
Other signs Babinski sign, other CNS signs (e.g. aphasia, visual field cut)
Atrophy (except with problem of neuromuscular junction)
SpinalCordCross-Section
Patient#3:Exam
• DecreasedEHLpowerbilaterally• Slowfoottaps• Briskkneejerkandanklejerkreflexes• Reducedjointpositionsenseintoes• SensoryleveltopinprickatT5
MetastasticSpinalCordCompression
Patient#4
• A30y/owomanwithlupus,APLAS,andhistoryofendocarditisongentamycinpresentswithacutevertigo.
Vertigo
Suspectedlocalization• Brainstem• Cerebellum• Innerear
Otherpotentialpresentingsymptoms
• Imbalance
Hypothesis-DrivenNeuroExam
HINTS
• HeadImpulseTest– Abnormal=peripheral
• Nystagmus– Unidirectional=peripheral– Direction-changing=central
• TestofSkew– Skewdeviation=central
• https://youtu.be/1q-VTKPweuk
Patient#4:Exam
• Leftbeatingnystagmusinleft-gazeonly• Positiveheadthrusttesttotheright
GentamycinToxicity
Summary
• Highyieldscreeningexam• Hypothesisdrivenapproachto:– Suspectedfocalbrainlesion– Alteredmentalstatus– Suspectedspinalcordlesion– Vertigo
BonusCase
• A32y/owomanpresentswithtinglinginthehandsandfeetthatprogressedtodiffuseweaknessinthearmsandlegsoverfourdays.Sheisnowsoweakshecannolongersitup.
DiffuseWeakness
Suspectedlocalization• Highspinalcord• Neuropathy• Neuromuscularjunction• Myopathy
Otherpotentialpresentingsymptoms
• Diplopia• Dysarthria• Dysphagia• Respiratoryfailure
LocalizationofWeaknessPattern of weakness
Tone Bulk Reflexes Sensory Loss
Other
Upper Motor Neuron
Pyramidal Spastic Normal Increased Varies
Anterior Horn Cell
Pyramidal or myotomal
Spastic or normal
Atrophy Increased or decreased
None Fascic-ulations
Peripheral Nerve
In distribution of root or nerve
Normal or reduced
Atrophy Decreased Prominent
Neuro-muscular Junction
Diffuse Normal Normal Normal (myasthenia) or Absent (botulism)
None Ptosis and ophthalmo-paresis
Muscle Proximal > Distal
Normal Normal or patterned atrophy
Normal None
BonusCase
• Diffuseweaknessthroughoutbotharmsandlegsinbothflexorsandextensors
• Nosensorylevel• Decreasedpinpricksensationinthefeet• Diffuselyabsentreflexes
NextStep?
• Lumbarpuncture:– Protein143– WBC2
• Guillain-BarreSyndrome
Acknowledgements
• HoomanKamel• AndyJosephson• DanLowenstein• AnnPoncelet• Kameletal,Arandomizedtrialofhypothesis-drivenvsscreeningneurologicexamination.NeurologyOct2011,77(14)1395-1401.