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Part I: Neurological
Exam
Part II: Coma
Connie Chen
Neurology Consultants of Dallas
Part I
Neurological Exam
Neurological Exam:
Some Basics
Purpose of exam: differential diagnosis
The mantra:
– History comes first!
– Exam is next best option.
– “Pan-scanning” is a poor substitute for exam.
– “Pan-scanning” results in “missing the boat”.
Neurological Exam:
More Basics
Lecture goal:
– Moving past medical school --see the forests,
not the trees.
– Tailor your exam to meet your needs.
– Full neurological exams will waste your time?
Case example
65 yo with low back pain.
Pain radiates down right leg.
He notes new acute weakness in right leg.
Differential?
How can the exam support/aid in
diagnosis?
Exam Purpose
Identify the part of the “neuro-axis” involved:
– link EXAM with FUNCTION
Neuro-axis:
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Cortex
Subcortex
Brain stem
Spinal cord
Nerve root
Peripheral nerve
Neuromuscular junction
Muscle.
The Exam Itself
Components:
– Mental status
– CN
– Motor (tone, bulk, strength)
– Sensation (soft touch/temp/pinprick vs
vib/proprio)
– Reflexes
– Coordination
– Gait (stressed gaits, base, arm swing, turn)
Exam
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Mental status
CN
Motor
Sensation
Reflexes
Coordination
Gait
Matching
to
Location
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Cortex
Subcortex
Brain stem
Spinal cord
Nerve root
Peripheral nerve
Neuromuscular
junction
– Muscle
Exam
Mental status
– Level of alertness
– Orientation
– Language (naming,
fluency, repetition,
comprehension, reading)
– Calculations
– Memory
– Judgement/insight
– Executive
function/Abstract thought
– Visualspacial ability
Cortex (Frontal,
parietal,
temporal,
occipital)
Subcortex (white
matter, thalamus)
Exam
Cranial Nerves
– III/IV
– IV-VIII
– V, IX-XII
Brainstem
– midbrain
– pons
– medulla
Motor Exam
0= no movement, 1= f licker, 2= gravity removed,
3= against gravity, 4-/4/4+ = grades of resistance, 5= full
PATTERNS:
Corticospinal tract: strength “stroke pattern”
– tone and bulk change later
– spinal cord: spinal shock
Anterior horn: weakness at level, fasciculation
Root: weakness in all muscles involving root
Nerve: weakness in all muscles involving nerve
Muscle: proximal > distal weakness
Sensation Exam
Notoriously painful for all involved.
Patterns: Central, cord, peripheral
Main pointers:
– Dorsal columns: late cross, vib/proprio
– Spinal thalamic tract: early cross, ST/temp/PP
Reflexes
0:
1:
2:
3:
4:
absent
present with distraction
present without distraction
spreads across more than one joint
Clonus- sustained and non-sustained.
PATTERNS:
Up: Cortical, spinal (before anterior horn)
Down: Root, (nerve, muscle)
Coordination=Cerebellum
Rapid alternating movements
(dysdiadokinesia)
Past pointing
Dysmetria: finger nose/heel to shin
??romberg-- not really
Wide based stance
(nystagmus at primary gaze)
***Pre-existing weakness can fool you
Gait
The best part of exam
Evaluates strength, coordination,
sensation
look at arm swing, base of stance, steps,
turn,
stressed gaits will bring out subtleties.
Case Revisited
65 yo with low back pain.
Pain radiates down right leg.
He notes new acute weakness in right leg.
Differential?
Exam expectations?
Case Series
67 yo fell off of a horse and has developed
bilateral LE weakness over the course of
days.
Differential?
Exam findings?
What other pertinent HPI questions would
have helped?
Case series
25 yo notes water feels “funny” on right
hand, and then his right leg felt strange.
Differential?
Exam findings?
Case Series
40 yo notes left face and arm feels funny
since last night and notes left arm and leg
weakness.
Differential?
Exam findings?
Case Series
78yo fell and couldn’t get up. “I knew I
was going to get stuck [on the floor] for
weeks now.” Why is he weak?
Differential?
Exam findings?
Case Series
26 yo notes stumbling when walking and
an inability to make his jump shots with
basketball over the course of 2 days. His
toes tingle.
Differential?
Exam findings?
Case series
74 yo wm notes left face and arm weakness that
lasts only 30 minutes. Later that day she
develops vertigo, slurred speech, and diplopia.
She can’t walk because she feels “like I’m
drunk.” She has right carotid stenosis.
Differential?
Exam findings?
Right carotid stenosis relevance?
Part II: Coma
Coma Definition
State of sustained unconsciousness
Ascertained by exam
How Coma Happens
Structural causes:
– Bilateral supratentorial disruption
– Disruption of the RAS of the brainstem
Practical thoughts (linking history, exam, and
structure):
– “metabolic”causes affect brain globally
– “Vascular” causes are not equal: unilateral carotid
artery vs. vertebral artery vs. basilar artery.
Coma Prognostication
Gauging coma:
– History
– Exam
– Ancillary studies
History cannot accurately predict outcome
of coma.
Coma Prognostication
Ancillary studies cannot accurately
ascertain coma emergence
Exception:
– SSEP’s performed days 1-3 after coma.
– Absence of cortical response shows poor
prognosis.
Coma Prognosis
Exam
– Glascow coma score (eye opening, motor
response, verbal response)
rather useless
– Motor:
Command>purposeful>flexor>extensor>flaccid
– Cranial nerves: present>absent
– Roving eye movements > no spontaneous
Coma Prognosis: Take Home
(it’s bad when…)
First 24hr post circulatory arrest:
myoclonus status epilepticus
Or by day 3:
– no corneals, or
– absent pupillary reaction, or
– motor response is extensor or worse