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HighYieldNeurologicalExaminationVanjaDouglas,MD
Sara&EvanWilliamsFoundationEndowedNeurohospitalist Chair
Director,NeurohospitalistDivisionAssociateProfessorofClinicalNeurology
UCSFDepartmentofNeurology
Disclosures
None
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PurposeofNeuro Exam
Screenasymptomaticpatients Screenpatientswithsymptomsthatcouldindicateafocalneurologiclesion(e.g.backpain,headache,seizure)
Localizethelesioninpatientswithneurologicdeficits Generateadifferentialdiagnosis Decidewhattesttogetnext(e.g.brainMRI,spineMRI,EMG/NCS,CK)
TypicalScreeningNeuro Exam 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:Fingernosefinger,heelkneeshin Gait:Observegait,includetandem,heel,andtoewalking
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HighYieldScreeningNeuro Exam
MentalStatus CranialNerves Motor Sensory Coordination Reflexes Gait
Language
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HighYieldScreeningNeuro Exam
MentalStatus:language,orientation,andattention
CranialNerves Motor Sensory Coordination Reflexes Gait
Extraocular Movements
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VisualFields
HighYieldScreeningNeuro Exam MentalStatus:language,orientation,andattention
CranialNerves:visualfields,eyemovements,andfacialsymmetry
Motor Sensory Coordination Reflexes Gait
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MotorSystem
HighYieldScreeningNeuro Exam MentalStatus:language,orientation,andattention
CranialNerves:visualfields,eyemovements,andfacialsymmetry
Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucis longus power
Sensory Coordination Reflexes:Biceps,knees,andankles Gait
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HypothesisDrivenNeuro Exam
HighYieldScreeningNeuro Exam MentalStatus:language,orientation,andattention CranialNerves:visualfields,eyemovements,andfacial
symmetry Motor:Pronator drift,fingerandfoottaps,finger
extensorandextensorhallucis longus power Sensory Coordination:Fingernosefingerandheelkneeshin
(canreplaceHKSwithgait) Reflexes:Biceps,knees,andankles Gait
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WhyDoASensoryExam?
Iftherearesensorycomplaints Iftherearebalancecomplaintsoragaitdisorder
Ifthereisweakness
SensoryTracts
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HighYieldScreeningNeuro Exam MentalStatus:language,orientation,andattention CranialNerves:visualfields,eyemovements,andfacial
symmetry Motor:Pronator drift,fingerandfoottaps,finger
extensorandextensorhallucis longus power Sensory:(Ifdone,dopainORtemp+vibrationORJPS) Coordination:Fingernosefingerandheelkneeshin
(canreplaceHKSwithgait) Reflexes:Biceps,knees,andankles Gait
HighYieldScreeningNeuro Exam MentalStatus:language,orientation,andattention CranialNerves:visualfields,eyemovements,andfacial
symmetry Motor:Pronator drift,fingerandfoottaps,finger
extensorandextensorhallucis longus power Sensory:(Ifdone,dopainORtemp+vibrationORJPS) Coordination:Fingernosefingerandheelkneeshin
(canreplaceHKSwithgait) Reflexes:Biceps,knees,andankles Gait:Observegait(base,stride,posture,armswing,
turn),tandem
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LETSPRACTICE!CaseScenarios
ThinkLikeANeurologist
ChiefComplaint:suspectedlocalization History:refinethelocalization Exam:pickmaneuversthatruleinorruleoutyoursuspicions
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Patient#1
A23y/owomanwithahistoryofmigraineheadachesisadmittedtothehospitalwithleftlegcellulitis.Onhospitalday2,shecomplainsofanewheadache.ShesaysitsdifferentfromherpreviousmigrainesbecauseitismuchworseandiswonderingifsheneedsanMRI.
Headache
Suspectedlocalization Focalbrainlesion
Otherpotentialpresentingsymptoms Seizure Unilateralweakness Unilateralnumbness Dysarthria
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HypothesisDrivenNeuro Exam
Patient#2
57y/omanhospitalizedwithMIisalteredafterhiscardiaccath.Heissomnolentbutarousable,mumblingincoherently.Hisfamilyisveryconcernedthathehashadastroke.
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AlteredMentalStatus
Suspectedlocalization Bilateralhemispheres Brainstem
Patient#2Exam
Arousestotouch Namessimpleobjects,repeatsshortphrases,followssimplecommands
Disorientedandunabletotestattention EOMI;facesymmetric;blinkstothreatbilaterally Leftarmdriftsandhandisclumsy Withdrawslessbrisklytopainintheleftleg HeadCTisnormal
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Patient#3
A65y/omanwithprostatecancerpresentswithbilaterallegweaknessandurinaryurgency.
BilateralLegWeakness
Suspectedlocalization Spinalcord Cauda equina
Otherpotentialpresentingsymptoms Urinaryorbowel
incontinence 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)
SpinalCordCrossSection
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Patient#3:Exam
DecreasedEHLpowerbilaterally Slowfoottaps Briskkneejerkandanklejerkreflexes Reducedjointpositionsenseintoes SensoryleveltopinprickatT5
Patient#4
A30y/owomanwithlupus,APLAS,andhistoryofendocarditis ongentamycinpresentswithacutevertigo.
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Vertigo
Suspectedlocalization Brainstem Cerebellum Innerear
Otherpotentialpresentingsymptoms Imbalance
HypothesisDrivenNeuro Exam
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HINTS
HeadImpulseTest Abnormal=peripheral
Nystagmus Unidirectional=peripheral Directionchanging=central
TestofSkew Skewdeviation=central
https://youtu.be/1qVTKPweuk
Patient#4:Exam
Leftbeatingnystagmus inleftgazeonly Positiveheadthrusttesttotheright
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Summary
Highyieldscreeningexam Hypothesisdrivenapproachto:
Suspectedfocalbrainlesion Alteredmentalstatus Suspectedspinalcordlesion Vertigo
BonusCase
A32y/owomanpresentswithtinglinginthehandsandfeetthatprogressedtodiffuseweaknessinthearmsandlegsoverfourdays.Sheisnowsoweakshecannolongersitup.
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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
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BonusCase
Diffuseweaknessthroughoutbotharmsandlegsinbothflexorsandextensors
Nosensorylevel Decreasedpinpricksensationinthefeet Diffuselyabsentreflexes
NextStep?
Lumbarpuncture: Protein143WBC2
GuillainBarreSyndrome
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Acknowledgements
Hooman Kamel AndyJosephson DanLowenstein Kamel etal,Arandomizedtrialofhypothesisdrivenvs screeningneurologicexamination.NeurologyOct2011,77(14)13951401.
ImagesfromWikimediaCommons
