Part I: Neurological Exam Part II: Coma

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Part I Neurological ExamPart II Coma

• Connie Chen
• Neurology Consultants of Dallas

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Part INeurological Exam
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Neurological ExamSome 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.

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Neurological ExamMore 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?

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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?

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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.

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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)

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Matching Exam to Location

• Mental status
• CN
• Motor
• Sensation
• Reflexes
• Coordination
• Gait

• Cortex
• Subcortex
• Brain stem
• Spinal cord
• Nerve root
• Peripheral nerve
• Neuromuscular junction
• Muscle

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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)

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Exam

• Cranial Nerves
• III/IV
• IV-VIII
• V, IX-XII

• Brainstem
• midbrain
• pons
• medulla

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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 gt distal weakness

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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

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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
• Up Cortical, spinal (before anterior horn)
• Down Root, (nerve, muscle)

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CoordinationCerebellum

• 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

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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.

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Case Revisited

• 65 yo with low back pain.
• Pain radiates down right leg.
• He notes new acute weakness in right leg.
• Differential?
• Exam expectations?

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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?

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Case series

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

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Case Series

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

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Case Series

• 78yo fell and couldnt get up. I knew I was
  going to get stuck on the floor for weeks now.
  Why is he weak?
• Differential?
• Exam findings?

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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?

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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 cant walk because she feels like Im
  drunk. She has right carotid stenosis.
• Differential?
• Exam findings?
• Right carotid stenosis relevance?

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Part II Coma
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Coma Definition

• State of sustained unconsciousness
• Ascertained by exam

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How Coma Happens

• Structural causes
• Bilateral supratentorial disruption
• Disruption of the RAS of the brainstem
• Practical thoughts (linking history, exam, and
  structure)
• metaboliccauses affect brain globally
• Vascular causes are not equal unilateral
  carotid artery vs. vertebral artery vs. basilar
  artery.

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Coma Prognostication

• Gauging coma
• History
• Exam
• Ancillary studies
• History cannot accurately predict outcome of coma.

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Coma Prognostication

• Ancillary studies cannot accurately ascertain
  coma emergence
• Exception
• SSEPs performed days 1-3 after coma.
• Absence of cortical response shows poor prognosis.

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Coma Prognosis

• Exam
• Glascow coma score (eye opening, motor response,
  verbal response)
• rather useless
• Motor Commandgtpurposefulgtflexorgtextensorgtflaccid
• Cranial nerves presentgtabsent
• Roving eye movements gt no spontaneous

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Coma Prognosis Take Home(its 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