Neuro Exam Explained Michael Nelson M.D. Providence Neurological Specialties East Primary Care Conference October 26rd, 2017 Michael Nelson M.D.

• Medical School: University of Missouri-Columbia • Residency: University of Washington completed in 2002 • Board Certified general adult neurologist • Providence Neurological Specialties East in NE Portland and Vancouver WA • Sadly I have no financial disclosures Today’s Goals

• Understand importance of the neurological exam • Reduce neurophobia (fear of the neuro exam) • Avoid common mistakes in performing the neurological exam • Explain meaning of the findings on the examination • Have fun! You Will Have Neurological Patients

• Stroke is the 3rd leading cause of Outpatient death • About 10% of visits to primary care • Alzheimer’s is the 7th leading cause are due to neurological complaints of death Inpatient • These numbers will rise as the population ages • About 20% of hospital admissions are for neurological issues Availability • Neurologists are rare and in high demand What is the most important part of the ? A proper history!

What tools do you really need?

• A bright light-ophthalmoscope • That’s it? or pen light • Is Dr. Nelson crazy? • Reflex hammer • What about the tongue depressor, vision chart, color • Tuning fork 128 Hz vision book, ice water for cold calorics, monofilaments, OKN • Stethoscope flag, Maddox rod & red lens, cloves, two point • Your two hands! discrimination tool, or that pokey wheel thing? • Good observation skills Which reflex hammer to use? Three Kinds of Neuro Exams

Screening Neuro Exam • Vital signs are still vital • I’m going to say it twice: VITAL • For no neurological symptoms SIGNS ARE VITAL Comprehensive Neuro Exam • Very high blood pressure makes it more likely to be a concerning • For patients with neurological neurological process symptoms • Feel pulse yourself (if patient isn’t • Still can be focused on your suspicion on a monitor) Altered level of consciousness • Patient can’t really participate The Screening Neurological Examination Includes at least each part of the six major components

• Mental Status • Cranial Nerves • Motor Function • Reflexes • Sensation • Cerebellar

Screening Mental Status

• Level of Alertness • Before you start make sure they can • Appropriate responses hear you. • Not a full MMSE, MOCA, SLUMS • Orientation to date and place Comprehensive Mental Status

• Level of Alertness, Orientation, • Office based memory tests can easily Concentration, Memory, and miss poor judgement. Language • Consider a full MMSE, MOCA,or SLUMS • Clock drawing • Consider referral for neuropsychological testing Screening Cranial Nerves

• Visual acuity-first ask patient about their vision • Pupillary light reflex-if unequal first ask about eye surgery or trauma history. Make sure light source is not towards one side • Eye movements-don’t be fooled by end gaze nystagmus and just remember 363-334-363 • Hearing-finger rub is okay • Facial strength-if asymmetric ask if this is an old finding. Check their driver’s license photo if not sure Comprehensive Cranial Nerves

• Olfactory-rarely tested but you cannot use something noxious or you are actually testing the 5th cranial nerve. • Fundoscopic Exam-good luck in the office. May soon be replaced with office retinal photography. • Eye movements-363 334 363. 4th nerve will give you a head tilt • Facial sensation-there are three divisions. • Facial strength-forehead okay means central, forehead involvement means peripheral (Bell’s palsy). • Say ahh! Gag is CN IX and X. Also taste. • CN XI is trapezius and XII is tongue protrusion. Screening Motor Function

• Strength-pronator drift, grip, wrist, elbows, shoulder, knees, ankles. Don’t mistake pain for weakness. Pronator drift requires pronation! • 5/5 is normal • 4/5 is weak but against resistance • 3/5 is only beyond gravity • 2/5 is no gravity • 1/5 is muscle activation with no joint movement Comprehensive Motor Function

• Expand muscle groups • Add bulk and tone • Look closely for atrophy or Screening Reflexes

• DTR Deep tendon reflexes (biceps, patella, ankle) – yes you need to do upper and lower extremities. Most important is if there a side to side difference. • Absent means no response • 1+ decreased but normal • 2+ normal • 3+ increased • 4+ clonus • Plantar responses – can be difficult to interpret (ticklish) and an upgoing toe should not just be the only finding Comprehensive Reflexes

• Expand DTR Deep tendon reflexes to include biceps, triceps, brachioradialis, patella, and ankle. • Increased reflexes=central process • Decreased reflexes=peripheral process • Plantar responses are more important to get right here. • I pretty much never check Cremaster, anal wink, or primitive reflexes like snout, palmomental, or grasp Screening Sensation

• One modality at the feet • I prefer the tuning fork which is always cold to test pain/temperature sensation in the feet. If abnormal, then test vibration sense with same tool • Sensation is frequently misleading Comprehensive Sensation

• Expand to arms and legs • Expand to include light touch, position, pain/temperature, and position sense. • Romberg testing is a sensation test (position sense) • Cortical sensory loss is some of the cool testing like stereognosis, graphesthesia, and extinction. • Again, sensation is frequently misleading Screening Cerebellar

• Primary gait and tandem if appropriate-many patient over 60 do not have normal tandem walking • Test finger nose finger and rapid alternating movements • Look at their handwriting Comprehensive Cerebellar

• Look for abnormal movements like chorea, , postural , cerebellar tremor, resting tremor, motor tics, slow movements (parkinsonism), myoclonus, , , and dystonia. • Midline cerebellar issues cause midline body symptoms (truncal , poor tandem walking) • Peripheral cerebellar issues cause peripheral body symptoms like limb ataxia, hand tremor, etc. The Altered Mental Status Neuro Exam Patient cannot participate with exam

• Mental Status-level of arousal, response to auditory, visual, and noxious stimuli. • Cranial Nerves-pupillary light reflex, oculocephalic reflex (doll’s eye), vestibulo-ocular reflex (cold calorics), gag, corneal reflex • Motor Function-voluntary and involuntary movements, withdrawal to pain. Can’t do cerebellar assessment • Reflexes-DTR and plantar • Sensation-progress to noxious stimuli Michael Nelson M.D.

• Medical School: University of Missouri-Columbia • Residency: University of Washington completed in 2002 • Board Certified general adult neurologist • Providence Neurological Specialties East in NE Portland and Vancouver WA Neuro Exam Explained Michael Nelson M.D. Providence Neurological Specialties East October 26rd, 2017