Neurological

Examination

Neurological Examination Pretest

1. Why do the Neurological examination?

2. How do I screen for memory?

3. Why do I watch the patient the patient the patient walk?

4. Why test reflexes?

5. Why do I care about the patient’s sensation?

Neurological Examination

Why do it

billing

help you find disease states/conditions

help prevent problems/lawsuits

Neurological Examination

Why do it

billing

up coding -> better exam->better billing

help you find disease states/conditions

Peripheral neuropathy can precede diabetes by years.(Aring et al,2005)

Help prevent problems/lawsuits

Diagnosis the dementia memory problem that everyone knows about keep Grandpa from getting lost.

Patient Case

• Neurology consult for dysphagia due to advanced dementia

• Pt had a history of coronary vascular disease, concussion/closed head injury

and alcoholism. Pt was admitted to hospital for pneumonia and found to fail

swallow evaluation. Neurology asked to consult.

• Spouse indicated “we knew for years there was a problem but no one found

it -> Pt goes in and talks to the doctor for five minutes gets his refills and

leaves. He is fine with small talk.

Patient Case

• Pt did not have myasthenia gravis.

• Pt had advanced dementia to the point where he did not know his own

child’s name when he was sun downing.

• Pt family and I spoke about fact these patients can look better in a familiar

environment and do awesome with social pleasantries.

General Adult Outpatient Neurological Exam

• Big Picture

• Do you know the person’s vitals including BMI ?

• Do you know medications and all the doctors they see?

• Herbal medications /supplements and “borrowing pills” count

• Do you know about health issues and surgeries?

• Concussions and cataract surgery do count

General Adult Outpatient Neurological Exam

• Big Picture

• Do you know if the patient has a living will, healthcare power of attorney

and financial power of attorney?

• Do you have permission on file to speak to someone ?

• Do you know if they manage their own medications, finances and drive

• Do they need a handicap parking sticker?

Memory

• How do I screen for memory?

General Adult Outpatient Neurological Exam

Memory

• Big Picture

• How is the patient dressed->appropriate or inappropriate?

• Did the patient arrive on the correct day?

• Is the patient socially appropriate?

• Is the patient able to shift with you in the conversational small talk?

General Adult Outpatient Neurological Exam

Memory

• General Safety questions

• What phone number to dial in case of a fire?

• What would you do if someone called and asked for your social security

number?

• How do you decide if it is safe to answer the door?

• How do you handle those letters/phone calls that ask for money?

General Adult Outpatient Neurological Exam

Memory

• General Safety questions

• What phone number to dial in case of a fire?

• What would you do if someone called and asked for your social security

number?

• How do you decide if it is safe to answer the door?

• How do you handle those letters/phone calls that ask for money?

Memory-Mini Mental Status Examination

• It was developed around 1975 and it is commonly known as Folstein testing as Marshall Folstein and others.

• It is a 30 point scale which is dependent upon education.

• A patient with an 8th grade level of education will score falsely low

• A patient with post high school education will score falsely high

Memory-Clock Drawing

• There are a wide variety of ways to score the Clock drawing test ->there are four point scales, ten points scale made popular by Sutherland however the end result is a quick and easy way to judge concentration, visual spatial awareness and executive function.

• “A study published in the January 2012 Danish Medical Journal outlines research that compared five of the most common ways to score the test. Their conclusion? The easiest scoring method provided results that were just as accurate as the more complicated scoring methods.” http://alzheimers.about.com/od/testsandprocedures/a/The-Clock-Drawing-Test.htm

The Clock Drawing Test

Have the person draw a clock by hand on a large piece of paper.

Have the person draw the face of a clock and put the numbers in the correct positions.

Then have them draw the hands to indicate 3:40 (time).

Clock Drawing Test Scoring

To score, assign the following points for each part of the drawing:

1 point for a closed circle

1 point for properly placed numbers

1 point for including all twelve numbers

1 point for properly placed hands

Source is Alzheimer's Reading room under references

Conclusions

The clock-drawing test meets defined criteria for a cognitive

screening instrument. It taps into a wide range of cognitive

abilities including executive functions, is quick and easy to

administer and score with excellent acceptability by subjects.

Together with informant reports, the clock-drawing test is

complementary to the widely used and validated Mini-Mental State

Examination and should provide a significant advance in the early

detection of dementia and in monitoring cognitive change. A

simple scoring system with emphasis on the qualitative aspects of

clock-drawing should maximize its utility.

Source http://www.ncbi.nlm.nih.gov/pubmed/10861923

Conclusions

The clock-drawing test meets defined criteria for a cognitive

screening instrument. It taps into a wide range of cognitive

abilities including executive functions, is quick and easy to

administer and score with excellent acceptability by subjects.

Together with informant reports, the clock-drawing test is

complementary to the widely used and validated Mini-Mental State

Examination and should provide a significant advance in the early

detection of dementia and in monitoring cognitive change. A

simple scoring system with emphasis on the qualitative aspects of

clock-drawing should maximize its utility.

Source http://www.ncbi.nlm.nih.gov/pubmed/10861923

Memory Testing

General Adult Outpatient Neurological Exam

• Big Picture

• How is the patient dressed->appropriate or inappropriate?

• Did the patient arrive on the correct day?

• Is the patient socially appropriate?

• Is the patient able to shift with you in the conversational small talk?

Doctors cleared gunman before

Navy Yard rampage

By Kevin Freking

Doctors cleared gunman before Navy Yard rampage

By Kevin Freking

Associated Press

WASHINGTON — The gunman who killed 12 people in last

year’s rampage at Washington’s Navy Yard convinced Veterans

Affairs doctors before the shootings that he had no mental health

issues despite disturbing problems and encounters with police

during the same period, according to a review of his con_idential

medical _iles.

Just weeks before the shootings, a doctor searching for the

source of the gunman’s insomnia noted that the patient worked

for the Defense Department but wrote hauntingly “no problem

there.”

Continue

Doctors cleared gunman before Navy Yard rampage

By Kevin Freking

Associated Press

WASHINGTON — The gunman who killed 12 people in last

year’s rampage at Washington’s Navy Yard convinced Veterans

Affairs doctors before the shootings that he had no mental health

issues despite disturbing problems and encounters with police

during the same period, according to a review of his confidential

medical files.

Just weeks before the shootings, a doctor searching for the

source of the gunman’s insomnia noted that the patient worked

for the Defense Department but wrote hauntingly “no problem

there.”

The Associated Press obtained more than 100 pages of

treatment and disability claims evaluation records for Aaron

Alexis, spanning more than two years.

They show Alexis complaining of minor physical ailments,

including foot and knee injuries, slight hearing loss and later

insomnia, but resolutely denying any mental health issues.

He directly denied suffering from stress or depression or having

suicidal or homicidal thoughts when the VA’s medical team asked

him about it three weeks before the shootings, even though he

privately wrote during the same period that he was being afflicted

by ultra-low frequency radio waves for months.

The dichotomy between Alexis’ apparently even-keeled

interactions with his doctors and the torment he was experiencing

outside the hospitals is the center of debate about whether the

Veterans Affairs Department could have better recognized the

need to intervene in his life with mental health care before the

shootings.

Congress and the Pentagon are investigating the shootings, including whether faulty security clearance procedures

allowed him to get and maintain his job.

Some lawmakers have said Alexis fell through the cracks at the VA and should have been treated by mental health

professionals, but they have stopped short of specifying what government doctors should have done differently

In a bizarre incident in Newport, R.I., Alexis told police on Aug. 7 that disembodied

voices were harassing him at his hotel using a microwave machine to prevent him from

sleeping.

After police reported the incident to the Navy, his employer, a defense contracting

company, pulled his access to classified material for two days after his mental health

problems became evident but restored it quickly and never told Navy officials.

Just 16 days later, after Alexis told a VA emergency room doctor in Providence that he

couldn’t sleep, the doctor wrote that his speech and thoughts seemed “clear and focused”

and noted that he “denies flashbacks, denies recent stress.”

GUNMAN’S FINAL WEEKS

› Aug. 7: In Newport, R.I., Aaron Alexis tells police responding

to his complaints at a hotel that he believes that people are talking

to him through the walls and ceilings of his hotel room to deprive

him of sleep.

› Aug. 23: Alexis visits the emergency room at the Providence

VA Medical Center complaining of insomnia. A doctor prescribes

trazadone and advises Alexis to follow up with a primary care

doctor.

› Aug. 28: Alexis visits the emergency room at the VA medical

center in Washington. He receives another prescription for

trazadone.

› Sept. 14: Alexis purchases the Remington shotgun he uses in

the Navy Yard shootings from a gun shop in Virginia.

› Sept. 16: Alexis guns down 12 workers at the Navy Yard, where

he was working as an information technology contractor. He is

killed in a police shootout.

— Associated Press Back

Neurology Examination and EMR

• Have a template but do customize it with each patient so that it is clear you

saw and examined that particular patient on that particular day.

http://neurologicalexam.com/

Get to know Attorney Gordon Johnson

Attorney Gordon Johnson is one of the nations leading brain

injury advocates. He is Chair of the TBILG, a national group of

more than 150 brain injury advocates. He has spoken at

numerous brain injury seminars and is the author of the most read

brain injury web pages on the internet, including

http://waiting.com and http://tbilaw.com When Attorney

Johnson talks about "recovery", he isn't talking about what a

survivor recovers in litigation, but about getting better from a

brain injury.

"No head injury is too severe to despair of, nor too trivial to

ignore."

- Hippocrates

• So if the attorney’s feel comfortable with a neurological examination

• You should also.

• The attorney’s website was pretty accurate -> he even talked about checking

for smell with head injury.

Cranial Nerve I Olfactory

• smell can be affected by head trauma

• lack of smell can be one of the early signs of cognitive decline.

•

• truth be told, I cannot recall the last time I tested for this. ?medical

school simulation lab. ?

Cranial Nerves II Optic

• Visual Acuity

• Visual Field

• Visual Field testing can help determine if it is an eye problem or a brain

problem

• Opthalmoscopic examination

Cranial Nerve III Oculomotor

• Pupil reaction

• pupillary constriction

• Eyelid movement

• Elevation of the eyelid due to levator palpbrae

• Eye movement -> along with CN IV &CNVI

• Argyll Robertson pupils are pupils that are unreactive to light, but constrict in the near

response. Argyll Robertson pupils may be seen in patients with Tabes dorsalis (caused by

neurosyphilis) or in patients with diabetes mellitus.

A Marcus Gunn pupil or relative afferent pupillary defect results from a lesion of an optic

nerve, and may seen in patients with optic neuritis that commonly results from multiple

sclerosis. A relative afferent pupillary defect may be confirmed in patients by the swinging

flashlight test. When light is presented to the normal eye, both pupils constrict, but when

the flashlight is swung to the affected eye, both pupils paradoxically dilate

• http://www.prep4usmle.com/forum/thread/16306/

Cranial Nerve IV& VI

• Trochlear ->CN IV

• Eye movement -> superior oblique

muscle

• Abducens ->CN VI

• Eye movement -> lateral rectus

muscle

Cranial Nerve V Trigeminal

• Masseter muscle

• Bite down

• Facial sensation

• Corneal reflex

• Five for sensory input

• Seven for motor response

Cranial Nerves VII Facial

• Observe facial movement

• DOES THE FOREHEAD MOVE?

• If the forehead muscles are not moving-> think “Bells”

• If the forehead muscles are moving but the lower half of the face is not ->think stroke

• Stapedius muscle is innervated by CNVII thus hyperacusis is a seven issue not an eight issue

Cranial NerveVIII Vesibulocochlear / Auditory

• Hearing

• Conversational tone or finger rub

• Weber ->tuning fork 256 hz middle of head should hear equally in both ears.

If heard louder on one side ->think conductive hearing loss on that side

• Rinne-> tuning fork 256hz place behind ear on the mastoid-> when pt can

no longer hear it move it forward-> air conduction should be more than

bone conduction.

Cranial Nerves IX Glossopharyngeal &

CN X Vagus

• Work together for swallow ->

• Glossopharyngeal-> stylopharyngeal muscle to elevate the pharynx

• Vagus-> palatoglossus muscle to control the posterior part of the tongue

• A fair number of patients do not have a gag

Cranial Nerves IX Glossopharyngeal

“Sensory fibers are also received from the carotid bodies, which detect increase

in blood pressure in the sinus of the carotid. Afferent signals can then be sent

to the medulla where the stimulation of the medulla leads to a decrease in

arterial blood pressure and heart rate. This reflex is known as the carotid sinus

reflex.”

http://12cranialnerves.wordpress.com/cranial-nerve-9-glossopharyngeal-

nerve/

Cranial Nerve X Vagus

• The vagus nerve conveys sensory information about the state of the body’s organs

to the nervous system. The vagus nerve helps to regulate the heartbeat, control

muscle movement, keep a person breathing, and to transmit a variety of chemicals

through the body. The vagus nerve controls muscles resulting in voice resonance

and also the soft palate. It is responsible for homeostasis of the digestive tract, and

contracting the muscles of the stomach. The vagus nerve controls the small and

large intestines to help process food. The vagus nerve also sends sensory signals to

the brain about what is being digested and what the body is getting out of it.

http://12cranialnerves.wordpress.com/cranial-nerve-10-vagus-nerve/

Cranial Nerves XI & XII

• Cranial Nerve XI Accessory

• Pt should turn head and shrug

shoulders.

• Cranial Nerve XII Hypoglossal

• Have the patient stick out tongue

and move it from side to side.

Strength

• Grade 5 full range of motion full strength

• Grade 4 mostly good strength and mostly good range of motion

• Grade 3 antigravity strength but unable to tolerate any resistance

• Grade 2 gravity eliminated strength and range of motion not full

• Grade 1 some strength gravity eliminated and some motion

• Grade 0 nothing

Strength

• Does the right side move like the left side?

• Is the strength good on the right and the left?

• If weakness is this new or old?

• Does the patient have joint pain ,neck pain or back pain?

• Does that pain correlate with the distribution of the weakness?

• Is evidence of muscle atrophy present?

Strength

• C5 Deltoid Axillary nerve

• C5-6 Biceps Musculocutaneous nerve

• C 6-7 Triceps Radial nerve

• C6-7 Wrist extension Radial nerve

• C8 Finger flexion Median

• T1 Finger abduction Ulnar

• C8 T1 Thumb opposition Median

Strength

• L2-3 Hip Flexion Femoral nerve

• L2-4 Hip Adduction

• L4 L5 S1 Hip Abduction Glut Max & Min

• L4-5 Hip Extension Glut Max Gluteal nerve

• L3-4 Knee Extension Quads Femoral Nerve

• L5 S1 Knee Flexion Hamstrings Sciatic Nerve

• L4-L5 Dorsiflexion Peroneal Nerve

• S1 S2 Plantarflexion Tibial Nerve

• L 5 Toe Extension

Upper versus Lower Motor Neuron

• UPPER

• Weakness

• Increased tone->spasticity

• Hyperreflexia

• LOWER

• Weakness

• Hypotonia

• Hyporeflexia

• Fasciculation

Reflexes

• Biceps: C5

• Brachioradialis: C5

• Pronator: C6

• Triceps: C7

• Finger flexor (Hoffman): C6/C7

• Quadriceps: L4

• Ankle (Gastrocnemius): S1

Reflexes

• “Reflexes are lost before weakness with

• Demyelinating neuropathies

Loss of large myelinated sensory axons: Ankle reflex commonly lost early

• Reflexes are lost with weakness

• Reflexes are generally lost in proportion to weakness

• Reflexes may be lost proximally but normal distally in muscular dystrophies”

• http://neuromuscular.wustl.edu/nother/myelin.html->source for this slide

Sensation

• Dorsal Column -> Vibration, Proprioception, Light touch

• Use 64 hz tuning fork.

• Spinothalamic-> Pain and Temperature

• Sensation does require patient cooperation

• It is often a good ide to have the patient’s eye’s closed so they do not

“visually feel” sensation.

1. posterior aspect of the shoulders (C4)

2. lateral aspect of the upper arms (C5)

3. medial aspect of the lower arms (T1)

4. tip of the thumb (C6)

5. tip of the middle finger (C7)

6. tip of the pinky finger (C8)

7. thorax, nipple level (T5)

8. thorax, umbilical level (T10)

9. upper part of the upper leg (L2)

10. lower-medial part of the upper leg (L3)

11. medial lower leg (L4)

12. lateral lower leg (L5)

13. sole of foot (S1)

2. http://informatics.med.nyu.edu/modules/pub/neurosurg

ery/sensory.html

“

” 1.Lesions of the Spinal Cord - CSUS

2.www.csus.edu/indiv/m/mckeoughd/learningmodules/SC...

Excellent online moodle for spinal cord information

Gait

• Does the patient ….

• put weight through both legs equally?

• swing arms well?

• turn well?

• is the base of support narrow or too wide?

• can the patient get up off the chair to walk?

Driving

• Driving is a “most do” in many people opinion.

• Our city is not set up easily for mass transportation.

• Safety with driving is not a socially taboo subject.

• Safety with driving is an ethical and potentially legal issues for the physician

if a patient’s safety driving is not considered.

Driving

• Stroke

• Parkinson

• Memory loss

• Peripheral neuropathy

• Seizure

• Multiple sclerosis

• Diabetes

• Arrhythmia

• Visual Disturbances

• Arthritis

• COPD

Driving

• I recommend Driving Evaluation via Dayton Rehab and Balance Center

which is part of the Kettering Network.

• A licensed occupational therapist who has taken extra work in driving evaluation.

• Another option is a local driving school

• Another option is BMV

• more complicated-> some branches will do driving eval & some do not.

Also could contact the BMV medical division ->sticky spot-> with patient confidentialy

versus public safety.

Neurological Examination Post-test

1. Why do the Neurological examination?

2. How do I screen for memory?

3. Why do I watch the patient the patient the patient walk?

4. Why test reflexes?

5. Why do I care about the patient’s sensation?

Neurological Examination

Why do it

billing

help you find disease states/conditions

help prevent problems/lawsuits

Neurological Examination

Why do it

billing

up coding -> better exam->better billing

help you find disease states/conditions

Peripheral neuropathy can precede diabetes by years.(Aring et al,2005)

Help prevent problems/lawsuits

Diagnosis the dementia memory problem that everyone knows about keep Grandpa from getting lost.

Memory

• How do I screen for memory?

Memory

• Clock Drawing

• MMSE

• And the new testing from OSU->SAGE

• In my opinion, most important, the most important is the common sense

meter

Common Sense

• A patient who was well established in a respectable profession, married, and

was in fact married to the mother of his all three of his children

• Does this scream conservative or what??

• Arrived at his long term family doctor’s office and saw his normal long term

family doctor. He was seen, examined and released to drive himself home.

• He got ill in the parking lot and required a squad to take him to the hospital

for a prolonged hospital course.

Common Sense

• The patient was wearing his PJ’s.

• This is not common sense. This does not match with his usual pattern of

behavior.

• Do not be too busy to think does this make sense.

Common sense

• Pt had a horrible infection. He may have taken a fever masking product or

his temperature was not taken . He and his wife were not pleased that after a

long term relationship with their doctor the fact he would leave the house in

PJ’s did not prompt either a call to the wife or the squad.

Why do I watch the patient walk?

• To provide insight into if the patient might benefit from an assistive device

or a referral to physical therapy

• To help discern if physical exam findings make sense->To assess leg strength

-> it takes a least grade 3 strength to put weight through the legs

• To help decide patient safety in the work place and with driving-> does

patient have the range of motion/strength needed to walk/move foot gas to

brake safely?

Why do I check reflexes?

• To help determine upper versus lower motor neuron

Why test sensation

• To help find peripheral neuropathy which can lead to consideration for

physical therapy and testing for treatable causes of peripheral neuropathy

• To help determine if patient’s condition is central or peripheral

• http://informatics.med.nyu.edu/modules/pub/neurosurgery/cranials.html

• Excellent website to review the neurological examination

References

• 1. Aring, A;Jones,D, Falko,JEvaluation and Prevention of Diabetic

Neuropathy , American Family Practice ,2005 Jun 1;71(11):2123-2128,

References

• http://alzheimers.about.com/od/testsandprocedures/a/The-Mini-Mental-

State-Exam-And-Its-Use-As-An-Alzheimers-Screening-Test.htm

• ,Doctors cleared gunman before Navy Yard rampage,Dayton Daily News,

Kevin Freking, Page A3, Saturday Feb1,2014

• Bing Images, Aaron Alexis, downloaded 2/1/2014

• http://neurologicalexam.com/

References

• http://www.alzheimersreadingroom.com/2009/12/alzheimers-clock-draw-

test-detect-signs.html

• Clock drawing:http://www.jabfm.org/content/16/5/423/F3.large.jpg

• http://alzheimers.about.com/od/testsandprocedures/a/The-Clock-

Drawing-Test.htm

• http://informatics.med.nyu.edu/modules/pub/neurosurgery/cranials.html

• Bing visual images. Mayfield Clinic

References

• http://www.prep4usmle.com/forum/thread/16306/- reference for CNIII

• Edoctoronline.com/medicalatlas.asp ->reference for image of CNVII

• http://12cranialnerves.wordpress.com/cranial-nerve-10-vagus-nerve/

• http://neuromuscular.wustl.edu/mother/reflex.html

• Ucsfsynapsemed1.blogspot/2007/0101 ->dermatome man

• http://informatics.med.nyu.edu/modules/pub/neurosurgery/sensory.html

References

• Lesions of the Spinal Cord - CSUS

• www.csus.edu/indiv/m/mckeoughd/learningmodules/SC...

• Excellent online training for spinal cords

References

• Medical Conditions and Driving - NHTSA

• www.nhtsa.gov/people/injury/research/Medical_Condition_Driving/... · PDF

file

• Medical Conditions and Driving: A Review of the Scientific Literature

(1960 - 2000) 5. Report Date ... This report, entitled Medical Conditions

and Driving: A

• This is all the same reference about driving and literature