Part I: Neurological Exam Part II: Coma

1. Part I: Neurological ExamPart II: Coma Connie Chen Neurology Consultants of Dallas

2. Part INeurological Exam

3. 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”.

4. 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?

5. 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?

6. Exam Purpose • Identify the part of the “neuro-axis” involved: • link EXAM with FUNCTION • Neuro-axis: • Cortex • Subcortex • Brain stem • Spinal cord • Nerve root • Peripheral nerve • Neuromuscular junction • Muscle.

7. 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)

8. Mental status CN Motor Sensation Reflexes Coordination Gait Cortex Subcortex Brain stem Spinal cord Nerve root Peripheral nerve Neuromuscular junction Muscle Matching Exam to Location

9. 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

10. Cranial Nerves III/IV IV-VIII V, IX-XII Brainstem midbrain pons medulla Exam

11. 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 Motor Exam 0= no movement, 1= f licker, 2= gravity removed, 3= against gravity, 4-/4/4+ = grades of resistance, 5= full

12. 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

13. Reflexes • 0: absent • 1: present with distraction • 2: present without distraction • 3: spreads across more than one joint • 4: Clonus- sustained and non-sustained. PATTERNS: • “UMN”: Brain, spine (before anterior horn) • “LMN”:Spine (after anterior horn), root,nerve

14. 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

15. 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. • What are matching anatomical locations?

16. Case Revisited • 60 something yo with bilateral UE pain. • Weakness bilateral UE. • Differential? • Exam expectations?

17. 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?

18. Case series • 25 yo notes water feels “funny” on right hand, and then his right leg felt strange. • Differential? • Exam findings?

19. Case Series • 40 yo notes left face and arm feels funny since last night and notes left arm and leg weakness. • Differential? • Exam findings?

20. 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?

21. 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?

22. 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?

23. Part II: Coma

24. Coma Definition • State of sustained unconsciousness • Ascertained by exam

25. 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.

26. Coma Prognostication • Gauging coma: • History • Exam • Ancillary studies • History cannot accurately predict outcome of coma.

27. Coma Prognostication • Ancillary studies/imaging cannot accurately ascertain coma emergence • Exception: • SSEP’s performed days 1-3 after coma. • Absence of cortical response shows poor prognosis.

28. Coma Prognosis • Exam • Glascow coma score (eye opening, motor response, verbal response) rather useless in prognositication Better: • Motor: Command>purposeful>flexor>extensor>flaccid • Cranial nerves: present>absent • Roving eye movements > no spontaneous

29. Coma Prognosis: Take Home(it’s bad when…) • First 24hr post circulatory arrest: myoclonus status epilepticus • Lack of SSEP’s day 1-3 • Or by day 3: • no corneals, or • absent pupillary reaction, or • motor response is extensor or worse