John W. Engstrom, MD October 16, 2015 Neurologic Examination 1 Neurologic Examination John W. Engstrom, M.D. Dept. of Neurology University of California, San Francisco October 16, 2015 Overview – The Neurologic Examination • Mental status – description/questions • Cranial nerves – demonstration/questions • Motor exam – demonstration/questions • Sensory exam – demonstration and questions • “Top Ten Suggestions for a Better Neurologic Examination” The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination 1. If the patient can give a completely coherent history, then the mental status examination is probably normal The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination 1. If the patient can give a completely coherent history, then the mental status examination is probably normal 2. The neurologist says the encephalopathy is metabolic… and is almost always correct Delirium/Encephalopathy- Common Causes and Evaluation Metabolic Causes Laboratory Studies Hyponatremia, hypernatremia Na Renal failure BUN, Cr Hypoxia, ischemia PO2 Hypoglycemia, hyperglycemia Glucose Hypothyroidism, hyperthyroidism Thyroid function tests Recreational drugs Toxicology screen Alcohol intoxication / withdrawal Alcohol level, osmolarity Pharmaceutical drugs Review medications Hypercalcemia, hypermagnesia Calcium, magnesium Hyperphosphatemia Phosphate Delirium/Encephalopathy – Common Causes and Evaluation Infectious Causes Laboratory Studies Sepsis Cultures, CBC, Chest X-Ray, UA Meningitis Lumbar puncture (LP), Cultures, CBC Neurologic Causes Subarachnoid hemorrhage Brain CT, LP Cerebral infarction Brain CT or MRI Seizures, post-ictal state Consider brain CT/MRI, EEG HIV infection, encephalitis HIV testing, MRI
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John W. Engstrom, MD October 16, 2015
Neurologic Examination
1
Neurologic Examination
John W. Engstrom, M.D.
Dept. of Neurology
University of California, San Francisco
October 16, 2015
Overview – The Neurologic Examination
• Mental status – description/questions
• Cranial nerves – demonstration/questions
• Motor exam – demonstration/questions
• Sensory exam – demonstration and questions
• “Top Ten Suggestions for a Better Neurologic Examination”
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
1. If the patient can give a completely coherent history, then the mental status examination is probably normal
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
1. If the patient can give a completely coherent history, then the mental status examination is probably normal
2. The neurologist says the encephalopathy is metabolic… and is almost always correct
Delirium/Encephalopathy- Common Causes and Evaluation
Metabolic Causes Laboratory Studies
Hyponatremia, hypernatremia Na
Renal failure BUN, Cr
Hypoxia, ischemia PO2
Hypoglycemia, hyperglycemia Glucose
Hypothyroidism, hyperthyroidism Thyroid function tests
Delirium/Encephalopathy –Common Causes and Evaluation
Infectious Causes Laboratory Studies
Sepsis Cultures, CBC, Chest X-Ray, UA
Meningitis Lumbar puncture (LP), Cultures, CBC
Neurologic Causes
Subarachnoid hemorrhage Brain CT, LP
Cerebral infarction Brain CT or MRI
Seizures, post-ictal state Consider brain CT/MRI, EEG
HIV infection, encephalitis HIV testing, MRI
John W. Engstrom, MD October 16, 2015
Neurologic Examination
2
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
1. If patient gives completely coherent history, then mental status exam is probably normal
2. The neurologist says the encephalopathy is metabolic… and is almost always correct
3. Dementia-preserved attention (Normal digit span early); no disturbance of consciousness
4. Delirium-poor attention/digit span; fluctuating level of consciousness
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
5. After establishing new-onset coma, the pupillary examination is the most important initial neurologic examination test
“Fixed” Pupils and Coma
Dilated (7-9 mm) – Early brain herniation
Mid-position (3-5 mm) – Late herniation
False positives
-Drug effect (Mydriacyl, barbs)
-Adequacy of light stimulus
-Prosthetic eye
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
4. After establishing new-onset coma, the pupillary examination is the most important initial neurologic examination test
5. Visual field testing is highly informative and underutilized by the non-neurologist
Screening for Visual Field Deficits
• Cooperative patient-Move examiner finger in the center of each quadrant with patient gaze fixed– Test each eye by covering the opposite eye, present
stimulus in all 4 quadrants
• Uncooperative patient-Use a single digit to suddenly approach each half of the visual fields; normally elicits a blink– Avoid using entire hand-wind elicits corneal reflex
– Report as “Does/Does not blink to threat”
John W. Engstrom, MD October 16, 2015
Neurologic Examination
3
Assessment of Vision
• Measure acuity with glasses on/contacts in
• Establishing a visual field cut establishes a structural lesion (eye vs. brain)
• The pupils always react in cortical blindness– Afferent-retina, optic nerve/tract, brainstem
– Efferent-midbrain, third nerve, ciliary muscle
The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better Neurologic Examination
4. After establishing new-onset coma, the pupillary examination is the most important initial neurologic examination test
5. Visual field testing is highly informative and underutilized by the non-neurologist
6. There are only two types of headaches, old and new
Old Headaches vs. New Headaches
• Severity or location of headaches rarely helpful with diagnosis