5/24/14 1 THE NEURO EXAM IN THE ALTERED PATIENT Hugh H. West, M.D. Associate Professor UCSF Dept. of EM HREM 5/24/2014 OBJECTIVES: • 1) REVIEW THE NEURO EXAM IN AMSE PTS • 2) DISCUSS NEURO EXAM "SIX EASY PIECES" • 3) REVIEW THE CATEGORIES OF AMSE PTS • 4) LEARN AN APPROACH TO ALL AMSE PTS • 5) LEARN TO “DANCE” W/ THE PATIENT’S CNS • 6) LEARN TO GATHER INFO ON AMSE PT'S CNS PATIENT #1 • 41 YOM BIBA intoxicated streeXighter • Not a forthcoming historian • HX is mostly exple\ve deleted • No I.D. on him, so no old records • One R.N. recognizes him • “Frequent Flier” for ETOH abuse EXAM • P=110, BP=135/85, RR=15, T=37C, Sat=99%RA • Odor of alcohol noted on his breath, red wine • Mul\ple minor abrasions on face and hands • Lungs clear, Heart no gmr, Abd bs ok, nhp • Neuro "noncoop" • Plan MTF
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5/24/14
1
THE NEURO EXAM IN THE ALTERED PATIENT
Hugh H. West, M.D. Associate Professor UCSF Dept. of EM HREM 5/24/2014
OBJECTIVES:
• 1) REVIEW THE NEURO EXAM IN AMSE PTS • 2) DISCUSS NEURO EXAM "SIX EASY PIECES"
• 3) REVIEW THE CATEGORIES OF AMSE PTS
• 4) LEARN AN APPROACH TO ALL AMSE PTS
• 5) LEARN TO “DANCE” W/ THE PATIENT’S CNS
• 6) LEARN TO GATHER INFO ON AMSE PT'S CNS
PATIENT #1
• 41 YOM BIBA intoxicated streeXighter • Not a forthcoming historian
• HX is mostly exple\ve deleted
• No I.D. on him, so no old records
• One R.N. recognizes him
• “Frequent Flier” for ETOH abuse
EXAM
• P=110, BP=135/85, RR=15, T=37C, Sat=99%RA • Odor of alcohol noted on his breath, red wine • Mul\ple minor abrasions on face and hands
• Lungs clear, Heart no gmr, Abd bs ok, nhp
• Neuro "noncoop" • Plan-‐ MTF
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NEURO EXAM TYPES
• NONCOOP (we've got this one) • NONE (NR, NA, or leave it blank) • NONFOCAL (brief needs backup) • NEUROLOGIST’S (\me and IQ)
• HIREM’S “DANCE” (more to come)
Jack Nicholson Five Easy Pieces
SIX EASY PIECES (5+1) NEURO EXAM
1. MSE – Cortex
2. CNN – Brainstem
3. MOTOR
4. SENSORY
5. DTRS – Monosynap\c reflex arc
6. COOR – Cerebellar, Gait, Sythesis
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HIREM’S NEURO EXAM “THE DANCE”
• A dance is a dialog, a conversa\on • Think about the waltz, the tango, slow dancing, boogie down
• HIREM’s Neuro Dance means that your CNS is dancing with the pa\ent's CNS
• Here's the secret, it's not voluntary for them, they can't help but dance with you!
• Right ques\ons lead to right answers
AMSE PATIENT EXAMPLES
• STRUCTURAL “The Blameless Exam” • ALTERED BASELINE “The Old CVA+ Exam”
• DEMENTED “Old Timer's Disease Exam”
• IMPAIRED “The Tox/ Metab/ Inf Exam”
• PSYCHIATRIC “The Crazy Exam”
• FABICATION “The Phony Exam”
• OTHERS “Seizure Related, Pos\ctal”
PIECE #1 THE CORTEX/ MSE
• Alert to obtunded spectrum, Remember IICP
• Oriented requires the ques\ons • The Glasgow Coma Scale is your friend – 4 EYES – spontaneous/voice/pain/none – 5 VERBAL – oriented/confused/inappropriate/incomprehensible/none
– 6 MOTOR – commands/localizes pain/withdraws to pain/flexes to pain/ extends to pain/no response
BRAINSTEM – THE CRANIAL NN
CN I – Olfactory CN VII – Facial CN II – Op\c CN VIII – Ves\bulocochlear
CN III – Oculomotor CN IX – Glossopharyngeal CN IV – Trochlear CN X – Vagus CN V – Trigeminal CN XI – Accessory