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HighYieldNeurologicalExaminationVanjaDouglas,MD
Sara&EvanWilliamsFoundationEndowedNeurohospitalistChair
Director,NeurohospitalistDivisionAssociateProfessorofClinicalNeurology
UCSFDepartmentofNeurology
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Disclosures
None
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PurposeofNeuroExam
• Screenasymptomaticpatients• Screenpatientswithsymptomsthatcouldindicateafocalneurologiclesion(e.g.backpain,headache,seizure)
• Localizethelesioninpatientswithneurologicdeficits– Generateadifferentialdiagnosis– Decidewhattesttogetnext(e.g.brainMRI,spineMRI,EMG/NCS,CK)
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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
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HighYieldScreeningNeuroExam
• MentalStatus• CranialNerves• Motor• Sensory• Coordination• Reflexes• Gait
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Language
ReceptiveAphasia
Fluency Intact
Comprehension Impaired
Repetition Impaired
ExpressiveAphasia
Fluency Impaired
Comprehension Intact
Repetition Impaired
ConductionAphasia
Fluency Intact
Comprehension Intact
Repetition Impaired
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HighYieldScreeningNeuroExam
• MentalStatus:language,orientation,andattention
• CranialNerves• Motor• Sensory• Coordination• Reflexes• Gait
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ExtraocularMovements
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FacialSymmetry
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VisualFields
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HighYieldScreeningNeuroExam
• MentalStatus:language,orientation,andattention
• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor• Sensory• Coordination• Reflexes• Gait
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MotorSystem2minutescreenforuppermotorneuronweakness:• PronatorDrift• Fingertaps&Foottaps• Distalextensorpower:• Fingerextensors• Tibialisanterior
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HighYieldScreeningNeuroExam• MentalStatus:language,orientation,andattention
• CranialNerves:visualfields,eyemovements,andfacialsymmetry
• Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower
• Sensory• Coordination• Reflexes:Biceps,knees,andankles• Gait
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Coordination&Gait
• Hemispheres:– Finger-nose-finger
– Heel-knee-shin
• Vermis:– Gait
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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
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WhyDoASensoryExam?
• Iftherearesensorycomplaints• Iftherearebalancecomplaintsoragaitdisorder
• Ifthereisweakness
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SensoryTractsVibration&Jointpositionsense
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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
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LET’SPRACTICE!CaseScenarios
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ThinkLikeANeurologist
• ChiefComplaint:suspectedlocalization• History:refinethelocalization• Exam:pickmaneuversthatruleinorruleoutyoursuspicions
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Patient#1
• A23y/owomanwithahistoryofmigraineheadachesisadmittedtothehospitalwithleftlegcellulitis.Onhospitalday2,shecomplainsofanewheadache.Shesaysit’sdifferentfromherpreviousmigrainesbecauseitis“muchworse”andiswonderingifsheneedsanMRI.
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Headache
Suspectedlocalization• Focalbrainlesion
Otherpotentialpresentingsymptoms
• Seizure• Unilateralweakness• Unilateralnumbness• Dysarthria
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Hypothesis-DrivenNeuroExam
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Patient#2
• 57y/omanhospitalizedwithMIisalteredafterhiscardiaccath.Heissomnolentbutarousable,mumblingincoherently.Hisfamilyisveryconcernedthathehashadastroke.
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AlteredMentalStatus
Suspectedlocalization• Bilateralhemispheres• Brainstem
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Patient#2Exam
• Arousestotouch• Namessimpleobjects,repeatsshortphrases,followssimplecommands
• Disorientedandunabletotestattention• EOMI;facesymmetric;blinkstothreatbilaterally• Leftarmdriftsandhandisclumsy• Withdrawslessbrisklytopainintheleftleg• HeadCTisnormal
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MultifocalStrokes
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Patient#3
• A65y/omanwithprostatecancerpresentswithbilaterallegweaknessandurinaryurgency.
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BilateralLegWeakness
Suspectedlocalization• Spinalcord• Caudaequina
Otherpotentialpresentingsymptoms
• Urinaryorbowelincontinence
• Gaitdifficulty• Backpain
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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)
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SpinalCordCross-Section
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Patient#3:Exam
• DecreasedEHLpowerbilaterally• Slowfoottaps• Briskkneejerkandanklejerkreflexes• Reducedjointpositionsenseintoes• SensoryleveltopinprickatT5
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MetastasticSpinalCordCompression
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Patient#4
• A30y/owomanwithlupus,APLAS,andhistoryofendocarditisongentamycinpresentswithacutevertigo.
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Vertigo
Suspectedlocalization• Brainstem• Cerebellum• Innerear
Otherpotentialpresentingsymptoms
• Imbalance
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Hypothesis-DrivenNeuroExam
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HINTS
• HeadImpulseTest– Abnormal=peripheral
• Nystagmus– Unidirectional=peripheral– Direction-changing=central
• TestofSkew– Skewdeviation=central
• https://youtu.be/1q-VTKPweuk
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Patient#4:Exam
• Leftbeatingnystagmusinleft-gazeonly• Positiveheadthrusttesttotheright
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GentamycinToxicity
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Summary
• Highyieldscreeningexam• Hypothesisdrivenapproachto:– Suspectedfocalbrainlesion– Alteredmentalstatus– Suspectedspinalcordlesion– Vertigo
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BonusCase
• A32y/owomanpresentswithtinglinginthehandsandfeetthatprogressedtodiffuseweaknessinthearmsandlegsoverfourdays.Sheisnowsoweakshecannolongersitup.
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DiffuseWeakness
Suspectedlocalization• Highspinalcord• Neuropathy• Neuromuscularjunction• Myopathy
Otherpotentialpresentingsymptoms
• Diplopia• Dysarthria• Dysphagia• Respiratoryfailure
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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
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BonusCase
• Diffuseweaknessthroughoutbotharmsandlegsinbothflexorsandextensors
• Nosensorylevel• Decreasedpinpricksensationinthefeet• Diffuselyabsentreflexes
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NextStep?
• Lumbarpuncture:– Protein143– WBC2
• Guillain-BarreSyndrome
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Acknowledgements
• HoomanKamel• AndyJosephson• DanLowenstein• AnnPoncelet• Kameletal,Arandomizedtrialofhypothesis-drivenvsscreeningneurologicexamination.NeurologyOct2011,77(14)1395-1401.