The Neurologic Examination in the Emergency · • 4a) Dysphasia • 4b) Dysarthria • Answers • 1- mechanical disorder of speech resulting from difficulty in the production of

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Key to evaluation is HISTORY:Key to evaluation is HISTORY:

•• Time of onsetTime of onset•• Symptom progressionSymptom progression•• Associated symptomsAssociated symptoms•• Exacerbating factorsExacerbating factors

•• ““CompleteComplete”” exam is not required or exam is not required or appropriateappropriate

•• However organized framework to exam is However organized framework to exam is keykey

•• In children, indirect observation is key. In children, indirect observation is key. Such as how a child plays with a toySuch as how a child plays with a toy

Traditional Exam is three tieredTraditional Exam is three tiered

•• 1 1 –– Is there a lesion of the nervous Is there a lesion of the nervous systemsystem

•• 2 2 –– Where is the lesionWhere is the lesion•• 3 3 –– What is the lesionWhat is the lesion

Eight elements of exam:Eight elements of exam:

•• 1 1 –– Mental status testingMental status testing•• 2 2 –– Higher Cerebral functionsHigher Cerebral functions•• 3 3 –– Cranial NervesCranial Nerves•• 4 4 –– Sensory ExaminationSensory Examination•• 5 5 –– Motor SystemMotor System•• 6 6 –– ReflexesReflexes•• 7 7 –– CerebellarCerebellar TestingTesting•• 8 8 –– Gait and StationGait and Station

Mental Status TestingMental Status Testing

Mental Status Testing Mental Status Testing -- BasicBasic

•• ““ awake, alert, and awake, alert, and conservantconservant ““•• Assess emotional and intellectual functionAssess emotional and intellectual function•• Thought disorders or abnormal thought Thought disorders or abnormal thought

content such as hallucinations, mood, content such as hallucinations, mood, insight, and insight, and sensoriumsensorium (appropriate (appropriate awareness and perception of awareness and perception of consciousness)consciousness)


•• Attention and MemoryAttention and Memory•• Attention testing best performed with Attention testing best performed with

digit repetition.digit repetition.•• Average adult should be able to repeat six Average adult should be able to repeat six

digits forward and four or five backwards.digits forward and four or five backwards.•• Failure to do so may suggest confusion, Failure to do so may suggest confusion,

deleriumdelerium or problem with language or problem with language perceptionperception


•• MemoryMemory•• A complex process broken down into short and A complex process broken down into short and

long term memorylong term memory•• Long term = months or years agoLong term = months or years ago•• Short term = events of day, or three object five Short term = events of day, or three object five

minute recallminute recall•• If unable to repeat three objects immediately, it If unable to repeat three objects immediately, it

is a problem with attention not memoryis a problem with attention not memory

Mental Status Testing Mental Status Testing -- AdvancedAdvanced

•• MiniMini--Mental Status examMental Status exam•• Quick Confusion Scale Quick Confusion Scale •• Both found in chapter 229Both found in chapter 229

MiniMini--Mental Status ExamMental Status Exam

Quick Confusion ScaleQuick Confusion Scale

Higher Cerebral FunctionsHigher Cerebral Functions


•• Test Test neurologicneurologic functions that are thought functions that are thought to reside in the cerebral cortexto reside in the cerebral cortex


•• Language defines the dominant hemisphere.Language defines the dominant hemisphere.•• Majority of population is rightMajority of population is right--handed (90%), for handed (90%), for

these patients left hemisphere is dominant and these patients left hemisphere is dominant and that is where language resides. (left hemisphere that is where language resides. (left hemisphere dominant)dominant)

•• Even most left handed people are left Even most left handed people are left hemisphere dominant for speechhemisphere dominant for speech

•• Large cortical stroke in dominant hemisphere Large cortical stroke in dominant hemisphere will affect languagewill affect language


•• NondominantNondominant hemisphere is concerned hemisphere is concerned with spatial relationships.with spatial relationships.

•• I.E. Visual inattention to care provider I.E. Visual inattention to care provider approaching from one side (usually the approaching from one side (usually the left, since most patients are left left, since most patients are left hemisphere dominant)hemisphere dominant)


•• DysarthriaDysarthria –– mechanical disorder of mechanical disorder of speech resulting from difficulty in the speech resulting from difficulty in the production of sound from weakness or production of sound from weakness or incoordinationincoordination of facial or oral of facial or oral musculature. This may be motor (cortical, musculature. This may be motor (cortical, subcorticalsubcortical, brainstem, cranial nerve, or , brainstem, cranial nerve, or cerebellarcerebellar) NOT higher cerebral ) NOT higher cerebral dysfunction!dysfunction!


•• Dysphasia Dysphasia –– Problem of language resulting Problem of language resulting from cortical or from cortical or subcorticalsubcortical damage. This damage. This portion of brain is concerned with portion of brain is concerned with comprehension, processing, or producing comprehension, processing, or producing languagelanguage

Higher Cerebral Functions Higher Cerebral Functions -- BASICBASIC

•• Normal conversation and correct response Normal conversation and correct response is common screen for language disorderis common screen for language disorder

•• If abnormal, need further testingIf abnormal, need further testing


•• Comprehension Comprehension –– ability to follow simple ability to follow simple commands, and name common objectscommands, and name common objects

•• ApraxiaApraxia –– Inability to show how a common Inability to show how a common object may be used (pencil)object may be used (pencil)

•• NonfluentNonfluent aphasia (expressive aphasia) aphasia (expressive aphasia) –– speed speed of language and the ability to find the correct of language and the ability to find the correct word word –– eponymous portion of dominant cortexeponymous portion of dominant cortex

•• Fluent aphasia (receptive aphasia) Fluent aphasia (receptive aphasia) –– quantity of quantity of word production is normal or increased. Normal word production is normal or increased. Normal rhythm and intonation, but incorrect wordsrhythm and intonation, but incorrect words


•• NonNon--Dominant hemisphere may also show Dominant hemisphere may also show problems of sensory problems of sensory descriminationdescrimination, or , or auditory or visual inattentionauditory or visual inattention

Higher Cerebral Functions Higher Cerebral Functions --ADVANCEDADVANCED

•• Show patient a picture and see if what is Show patient a picture and see if what is described is correctdescribed is correct

•• Repeat a phrase: Repeat a phrase: ““No, Ifs, ands, or buts.No, Ifs, ands, or buts.””•• WernickeWernicke’’ss AphasiaAphasia•• ParaphasicParaphasic errors errors –– i.e. use the word spool i.e. use the word spool

instead of spooninstead of spoon•• A person who is aphasic in speaking will A person who is aphasic in speaking will

also be in writingalso be in writing


•• Have patient draw circle and make a Have patient draw circle and make a clock.clock.

•• Sensory perception Sensory perception –– place an object in place an object in hand and have identifyhand and have identify

•• Must also make sure patient is not Must also make sure patient is not intoxicated or has severe psych illnessintoxicated or has severe psych illness

CRANIAL NERVESCRANIAL NERVES

Cranial Nerves Cranial Nerves -- BASICBASIC

•• I (olfactory) I (olfactory) –– smellsmell•• II (Optic) II (Optic) –– Visual acuity, visual fieldsVisual acuity, visual fields•• III (III (OculomotorOculomotor) ) ––

Motor Motor –– raise eyelids, raise eyelids, extraocularextraocular musclemuscleParasympathetic Parasympathetic –– pupillarypupillary constrictionconstrictionIV (IV (TrochlearTrochlear) ) –– Downward/inward gazeDownward/inward gaze


•• V (Trigeminal) V (Trigeminal) ––Motor Motor –– jaw open, clench teeth, chewjaw open, clench teeth, chewSensory Sensory –– sensation cornea, iris, sensation cornea, iris, lacrimallacrimalglands, conjunctiva, eyelids, forehead, glands, conjunctiva, eyelids, forehead, nose, teeth, tongue, earnose, teeth, tongue, ear

VI (VI (AbducensAbducens) ) –– lateral eye movementlateral eye movement


•• VII (Facial)VII (Facial)Motor Motor –– facial expression except jaw, facial expression except jaw, close eyes . . close eyes . .

Sensory Sensory –– taste, ant 2/3 tongue, taste, ant 2/3 tongue, sensation to pharynxsensation to pharynx

VIII (Acoustic) VIII (Acoustic) –– hearing and equilibriumhearing and equilibrium


•• IX (IX (GlossopharyngealGlossopharyngeal) ) Motor Motor –– voluntary swallow, phonationvoluntary swallow, phonationSensory Sensory –– sensation sensation nasopharynxnasopharynx, gag , gag reflex, taste (post 1/3)reflex, taste (post 1/3)

Parasympathetic Parasympathetic –– carotid reflex, salivary carotid reflex, salivary secretionsecretion

Cranial Nerves Cranial Nerves --

•• X (X (VagusVagus))Motor Motor –– voluntary phonation, swallowvoluntary phonation, swallowSensory Sensory –– behind ear, external canalbehind ear, external canalParasympParasymp –– peristalsis, carotid reflex, heart, peristalsis, carotid reflex, heart, lung, digestionlung, digestion

XI (Spinal Accessory) XI (Spinal Accessory) –– Turn head, shrug Turn head, shrug shouldersshoulders

XII (Hypoglossal) XII (Hypoglossal) –– Tongue articulation (l, t, n) Tongue articulation (l, t, n) and swallowand swallow

Sensory ExamSensory Exam


•• Light touchLight touch•• PinprickPinprick•• PositionPosition•• VibrationVibration•• TemperatureTemperature


•• Usually start with touch and pinprick in Usually start with touch and pinprick in extremity, if intact stop unless . . . .extremity, if intact stop unless . . . .

•• Suspect peripheral nerve or spinal cord Suspect peripheral nerve or spinal cord injuryinjury

•• Position testing Position testing –– best for peripheral best for peripheral neuropathy or posterior spinal cord injuryneuropathy or posterior spinal cord injury

Dermatome MapDermatome Map


•• Cervical Injury = thoracic dermatomes Cervical Injury = thoracic dermatomes and upper extremityand upper extremity

•• The demonstration of a preserved island The demonstration of a preserved island of sensation around the perineum may be of sensation around the perineum may be the only sign of an incomplete spinal cord the only sign of an incomplete spinal cord injury, which has a different prognosis injury, which has a different prognosis than complete spinal cord injurythan complete spinal cord injury

Motor SystemMotor System

•• Tone Tone –– normal, decreased, increasednormal, decreased, increased•• Increased Increased –– ask patient to relax, and not ask patient to relax, and not

resist. Test Passively. I.E. resist. Test Passively. I.E. cogwheelingcogwheeling•• Arms out palms up, observe for inward Arms out palms up, observe for inward

rotation or downward drift (rotation or downward drift (pronatorpronator drift)drift)

Motor SystemMotor System

•• Compare muscle mass and bulkCompare muscle mass and bulk•• Look for atrophy, Look for atrophy, fasciculationsfasciculations•• A rating for strength 0 to 5A rating for strength 0 to 5•• 5 = normal5 = normal•• 4 = weakness w/ ability for some resistance4 = weakness w/ ability for some resistance•• 3 = complete ROM against gravity3 = complete ROM against gravity•• 2 = movement w/ gravity eliminated2 = movement w/ gravity eliminated•• 1 = minimal flicker of contraction1 = minimal flicker of contraction•• 0 = no movement0 = no movement

Muscle Muscle InnervationInnervation ChartChart

ReflexesReflexes

•• Least important part of examLeast important part of exam•• Scale 1 to 4Scale 1 to 4•• 0 = no reflex0 = no reflex•• 1 = decreased1 = decreased•• 2 = normal2 = normal•• 3 = increased3 = increased•• 4 = 4 = clonusclonus

ReflexesReflexes

•• BabinskiBabinski•• Normal = toes go downNormal = toes go down

•• ClonusClonus = Rhythmic oscillation of a body = Rhythmic oscillation of a body part elicited by brisk stretch = sign of part elicited by brisk stretch = sign of spasticityspasticity

ReflexesReflexes

•• Hyperactive, Hyperactive, babinskibabinski, , clonusclonus = upper = upper motor neurons (cortical and spinal cord motor neurons (cortical and spinal cord injuries)injuries)

•• HypoactiiveHypoactiive = Lower motor neurons, = Lower motor neurons, peripheral nerve rootsperipheral nerve roots

•• But NOT reliable and may take time to But NOT reliable and may take time to developdevelop

CerebellarCerebellar TestingTesting

CerebellarCerebellar TestingTesting

•• The cerebellum is concerned with involuntary The cerebellum is concerned with involuntary activities of the central nervous system and may activities of the central nervous system and may be simply thought of as a structure that helps be simply thought of as a structure that helps with smoothing muscle movements and aiding with smoothing muscle movements and aiding with movement coordination.with movement coordination.

•• Central Central cerebellarcerebellar structure = axial coordinationstructure = axial coordination•• Lateral Lateral cerebellarcerebellar structure = structure = appendicularappendicular

coordination (extremities)coordination (extremities)

CerebellarCerebellar Testing Testing –– BasicBasic

•• Rapidly alternating movements (rapid Rapidly alternating movements (rapid pronationpronation and and supinationsupination of hands). of hands). Should be equal and symmetricShould be equal and symmetric

CerebellarCerebellar Testing Testing -- AdvancedAdvanced

•• Finger to nose, must be done rapidlyFinger to nose, must be done rapidly•• NystagmusNystagmus

Gait and StationGait and Station


•• It has been said that if only one It has been said that if only one neurologicneurologic test could be formed, walking test could be formed, walking would be most important.would be most important.

•• See Chapter 230 for ataxia and gait See Chapter 230 for ataxia and gait disturbancedisturbance


•• CerebellarCerebellar infarct or hemorrhage is a true infarct or hemorrhage is a true emergency because it can compress on emergency because it can compress on the brain stem causing apnea and death.the brain stem causing apnea and death.

•• CerebellarCerebellar hemorrhage may cause sudden hemorrhage may cause sudden nausea, vomiting, and diaphoresisnausea, vomiting, and diaphoresis

•• CerebellarCerebellar infarct may also cause sudden infarct may also cause sudden inability to walkinability to walk

Quick ReviewQuick Review

Terminology of Mental Status Exam Terminology of Mental Status Exam list is in handout.list is in handout.

Definitions of different aphasias Definitions of different aphasias etc..etc..

References:References:

•• TintinalliTintinalli chapter 226chapter 226•• MosbyMosby’’ss Guide to physical exam 4Guide to physical exam 4thth edition edition

chapter 20.chapter 20.•• Up to Date Up to Date ““The Detailed The Detailed NeurologicNeurologic Exam Exam

in Adultsin Adults””

Questions:Questions:

•• 1) The average adult should be able to 1) The average adult should be able to repeat 6 digits forward and 4 to 5 repeat 6 digits forward and 4 to 5 backwards? T/F?backwards? T/F?

•• 2) IF unable to repeat 3 objects 2) IF unable to repeat 3 objects immediately after being told them, is this immediately after being told them, is this a problem with memory or attention?a problem with memory or attention?

•• 3) A cortical stroke in the dominant 3) A cortical stroke in the dominant hemisphere will affect language? T/F?hemisphere will affect language? T/F?

Questions:Questions:•• 4) Matching:4) Matching:•• 4a) Dysphasia4a) Dysphasia•• 4b) 4b) DysarthriaDysarthria•• AnswersAnswers•• 11-- mechanical disorder of speech resulting from mechanical disorder of speech resulting from

difficulty in the production of sound from weakness or difficulty in the production of sound from weakness or incoordinationincoordination of facial or oral musculature. This may of facial or oral musculature. This may be motor (cortical, be motor (cortical, subcorticalsubcortical, brainstem, cranial nerve, , brainstem, cranial nerve, or or cerebellarcerebellar) NOT higher cerebral dysfunction!) NOT higher cerebral dysfunction!

•• 2 2 -- Problem of language resulting from cortical or Problem of language resulting from cortical or subcorticalsubcortical damage. This portion of brain is concerned damage. This portion of brain is concerned with comprehension, processing, or producing languagewith comprehension, processing, or producing language

Questions:Questions:

•• 5) Matching5) Matching•• 5a) Expressive Aphasia (non5a) Expressive Aphasia (non--fluent)fluent)•• 5b) Fluent Aphasia (receptive)5b) Fluent Aphasia (receptive)•• AnswersAnswers•• 1 1 -- speed of language and the ability to find speed of language and the ability to find

the correct word the correct word –– eponymous portion of eponymous portion of dominant cortexdominant cortex

•• 2 2 -- quantity of word production is normal or quantity of word production is normal or increased. Normal rhythm and intonation, but increased. Normal rhythm and intonation, but incorrect words. Comprehension is impairedincorrect words. Comprehension is impaired

QuestionsQuestions

•• 6) What would the motor score (1 6) What would the motor score (1 –– 5) be 5) be if a person:if a person:

•• complete ROM against gravity, but not complete ROM against gravity, but not with any additional resistance?with any additional resistance?

AnswersAnswers

•• 1) True1) True•• 2) Attention2) Attention•• 3) True3) True•• 4a) 24a) 2•• 4b) 14b) 1•• 5a) 15a) 1•• 5b) 25b) 2•• 6) 36) 3

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The Neurologic Examination in the Emergency · • 4a) Dysphasia • 4b) Dysarthria • Answers • 1- mechanical disorder of speech resulting from difficulty in the production of