SMALL GROUP SESSION 243/23 or 3/25

NEUROLOGIC EXAMINATION WORKSHOP AND CASE

Readings: Mosby’s (4TH ed.) pp 81-88 and 771-790 or (5th ed.) pp.85-92 and 782-800

Prepare by: Bringing your tuning fork, reflex hammer, cotton swabs or other device to

test sensation, and penlight. Bringing your hospital interview write-up to turn in and (if you haven’t

already done so) the written patient narrative from your preceptor visit.

Mentors should bring tongue blades and cotton swabs (and any other supplies needed)

Brief outline:

Section 1: Touch base (15 minutes)

Section 2: Discuss a case (45 minutes)

Section 3: Neurologic Examination Workshop (1-2 hrs)

Section 4: Evaluate Session (10 minutes)

Preparation for session 25 (in 3 weeks):

Readings: Vandekieft G. Breaking Bad News. American Family Physician 2001; 64:1975-8. Link:http://www.aafp.org/afp/20011215/1975.html

Bring: Research from your learning objective based on this week’s case

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SMALL GROUP SESSION 24

Section 1: Touch Base (15 minutes)Next week is exam week. How is everyone doing?

Section 2: Case: A patient with weakness (45 minutes)Objectives:

to discuss the differential diagnosis of a set of neurologic symptoms to understand some of the implications of high blood pressure

(hypertension) to correlate specific neurologic findings with areas of abnormality in the

CNS to practice using the neurologic examination as a diagnostic tool

A PATIENT WITH WEAKNESS:It is Sunday morning, and the emergency room has just called you in to meet Mr. Hal Brown. His wife, who is with him, says she called the ambulance because he awoke this morning unable to move his left side.

Mr. Brown is 55 years old. He last saw a doctor fourteen years ago, when he went to the emergency room for a broken arm. His wife recalls that they advised him to see a doctor then for his pressure, but he didn’t go. He felt well until this morning and even now tells you that he is fine and his wife is getting upset over nothing. He reports no headache.

He has never had surgery, has no known illnesses and takes no medications. He works as an accountant. He smokes one pack per day for 37 years and drinks two to three beers every night.

As you obtain the history from him and (mostly) his wife, you can easily see that all is not well. He is lying on the examining table making no spontaneous movements of his left arm or leg. His left face is sagging. He understands you and speaks appropriately, but his speech is very slurred - another new finding, his wife reports.

You look down at the nurse’s note of his vital signs: temperature 37 degrees, pulse 80, respirations 20, blood pressure 240/140.

1. What might be causing his symptoms? What additional history would help you narrow down your diagnosis?

2. What do you think of his blood pressure? What could explain it? 3. In what way could his blood pressure be related to his current symptoms?

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4. Why might he be saying that nothing is the matter?5. What physical examination do you want to do?

Do not go on until you have finished discussing this page.

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On examination, you find the following:

BP 230/140, pulse 76, respirations 16.

Mental status: he is alert and answers your questions about the date, but you can’t make out what he is saying.

Cranial nerves: II: He can’t see your fingers in his left visual field. When you cover his left eye, his right eye cannot see in the left portion of its visual field; when you cover his right eye, his left eye can see, but only in the right portion of its visual field.

VII: his left face is sagging, with saliva running from the left side of his mouth. A smile pulls his mouth to the right. When he raises his eyebrows, though, both eyebrows rise equally.

XII: His tongue protrudes to his left.

Strength: full (5/5) strength of right arm and leg. No movement of the left arm or leg (0/5); when you lift them, they drop like dead weight.

Sensation: He feels nothing to touch or pinprick in his entire left face, arm and leg.

Reflexes: He can’t sit up to test his reflexes properly, but those on the right seem normal to you (2+), while those on the left seem more brisk (3+). His plantar (Babinski) reflex is downgoing on the right and upgoing on the left.

Coordination: normal to finger to nose, heel to shin and rapid alternating movements on the right. He can’t move to test his left side and cannot stand or walk.

6. What is the significance of each of his abnormal physical findings?

7. Can you localize the area of his nervous system affected? Does this help you to narrow down your diagnosis?

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Section 3: Neurologic Examination Technique

Objectives: To practice the techniques of the screening neurologic examination, including:

mental status cranial nerves II through XII sensation strength (done already in extremity exam) deep tendon reflexes coordination

Caveat: what we are practicing today is not a complete neurologic examination. What you will practice today is a screening neurologic exam - the one in your OSCE. If any of this were abnormal, you would use the additional techniques in your text - and quite likely others as well.

Logistics:

PART 1: MENTAL STATUSAsk at least the basic orientation questions: place (city, county, building, floor) and time (month, day, year). Then, ask some of the other questions. For example:

name three items; ask the person to remember them and say them back (registration)

then: ask them to subtract 7 from 100, 7 from that answer, etc., down to 51 (calculation)

ask them to spell “world” backwards (language) ask them to recall the three items (recall).

You will have received a copy of the mini-mental status examination by now in your lectures. Feel free to use other questions from the mini-mental status exam instead. PART 2: CRANIAL NERVES

CN II: the optic nerve1. Pupils: test pupil response to light and accommodation (done as part of

the eye exam):Light: shine penlight into one eye, bringing it in from lateral to the patient’s eye. Check for equal constriction of same (direct) and other (consensual) pupil. Do not let patient look directly at the light.Accommodation: Stand where you can see both patient’s pupils, and hold your finger 2 to 4 inches from the patient’s nose. Ask the patient to look far away (e.g. at the wall), then immediately at your finger. Watch pupil reaction.

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2. Visual fields: test all four quadrants with wiggling fingers. Move your fingers in from arm’s length away while patient looks at your nose. Ask patient to tell you when s/he sees your fingers move. Patient should see them at the same time you do (confrontation test).

CN III, IV and VI: the oculomotor, trochlear and abducens nerves

Test this with extraocular movements (part of the eye exam). Ask patient to follow your finger with his/her eyes. Move your finger in all six directions that muscles move the eye:

laterally to each side: (the lateral rectus, CN VI, moves each eye laterally)

down and to the patient’s right (the superior oblique, CN IV moves the patient’s left eye this way - medially and down)

down and to the patient’s left (the right superior oblique/ CN IV) up and to the patient’s left and right. CN III, the oculomotor nerve,

innervates the other four muscles, which move each eye medially (medial rectus), up and medially (inferior oblique), up and laterally (superior rectus) and down and laterally (inferior rectus).

CN V: The trigeminal nerve

1. Masseter strength: Ask patient to clench his/her jaw. Palpate the jaw muscles (masseters).

2. Facial sensation: Test facial sensation to light touch and sharp sensation (e.g. sterile needle or broken-off end of wooden sterile cotton swab) on the forehead, cheeks and chin bilaterally

CN VII: The facial nerve

Ask patient to squeeze his/her eyes shut, wrinkle his/her forehead, frown, whistle, grimace. Look for differences between the two sides of the face.

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CN VIII: The acoustic nerveHold your fingers 3 feet from patient’s ear and rub them together; move them slowly toward the patient. Ask patient to tell you when s/he hears finger rubbing.

OR

Hold one of patient’s ears shut while whispering very softly in the other ear; ask patient what you said.

CN IX and X: Glossopharyngeal and VagusPress the tongue blade firmly on the posterior third of the patient’s tongue to elicit the gag reflex. The uvula should move symmetrically up.

CN XI: The spinal accessory nervePlace your hand on the patient’s lower face (from chin to ear). Ask patient to push his/her head sideways against your hand (sternocleidomastoid muscle). Do this on both sides.

OR

Place both hands on the patient’s shoulders and ask patient to shrug (trapezius muscle)..

CN XII: The hypoglossal nerveAsk patient to stick his/her tongue out and move it from side to side.

PART 3: SENSATION

Ask patient to close his/ her eyes for the sensory examination. For each, check on both arms/ hands and both feet/legs, alternating sides.

1. Sharp and dull: Test sharp with a sterile needle or broken-off end of a sterile cotton swab stick. Test dull sensation with a cotton swab or similar soft item. Alternate sharp and dull sensation, asking patient to identify whether it is sharp or dull when you touch him/her. Compare both forearms and hands and both calves, ankles and feet.

2. Position: Hold finger on each side and move up and down; ask patient to identify when you are moving it up or down. Do this for one finger on each side. Do this also for each great toe.

3. Vibration: Patient can open eyes for this. Place a vibrating tuning fork on patient’s finger; ask patient if s/he can feel vibration; if so, ask when it goes away. Compare fingers on both sides and toes on both sides (OR compare wrists on both sides and ankles on both sides).

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PART 4: STRENGTH

You already tested strength while examining the upper and lower extremities. No need to repeat here.

PART 5: DEEP TENDON REFLEXES

In most cases, tap with the pointed end of the reflex hammer. The flat end may work better for some reflexes (e.g. the brachioradialis). Use a light tap, letting the weight of the rubber hammer do the work. Test on each side, comparing the two sides:

the biceps: where the tendon crosses the front of the elbow the triceps: proximal to the elbow on the extensor side. For this, hold

the patient’s arm straight out from the body and have him/her drop the arm’s weight entirely on you – or have patient’s elbow flexed and forearm resting on patient’s leg or your arm.

the brachioradialis: tap on the radius, a few centimeters proximal to the wrist, while the patient sits with elbow bent, forearm resting and radius/ thumb up.

the patellar: tap on the tendon just below the patella, with the patient sitting.

the achilles: tap on the achilles tendon several centimeters above its attachment to the calcaneus

the Babinski (plantar) reflex: Use the pointed metal end of your reflex hammer. Stroke firmly on the sole of the foot, starting from the lateral heel, up to the lateral ball of foot and curving to the medial ball of foot.

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PART 6: COORDINATION

1. Finger to nose: have patient touch your index finger and his/her nose alternately with his/her index finger, going back and forth quickly several times as you move your finger. Do with each of patient’s hands.

2. Fine motor: Ask patient to touch thumb of one hand rapidly to each finger of that hand and repeat. Do with both hands.

3. Heel to shin: Ask patient to run the heel of one foot up and down the shin of the other leg. Repeat with the other foot.

4. Tandem gait: Ask patient to walk in a straight line heel-to-toe (“the drunk test”).

5. Romberg: Ask patient to stand with feet touching each other, arms stretched straight forward but not touching, palms up. Ask patient to close his/her eyes and stay there

6. Gait: Ask patient to walk several strides, turn around and come back to you.

Section 4: Evaluate Session (10 minutes)

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Physical ExaminationObjective Structured Clinical Examination (OSCE)

Neurological Examination Checklist

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt

Procedure A B C Comments

1. MENTAL STATUS: Ex asks Pt questions pertaining to his/her orientation (person, place, time, situation). Ex asks a minimum of 3 questions.

(NOTE: CNs II, III, IV AND VI ARE ASSESSED IN HNE OSCE)

2-8. CRANIAL NERVES:

2. V – Trigeminal. Ex asks Pt to clench teeth while he/she palpates the muscles of Pt’s jaw. Ex asks Pt to close his/her eyes and identify bilateral facial touch as soft or sharp.

3. VII – Facial. Ex examines Pt’s facial muscles while asking him/her to squeeze eyes shut, raise eyebrows, wrinkle forehead, frown, whistle, etc. At least one of the above expressions must be requested.

4. VIII – Acoustic. Ex asks Pt to tell him/her when Pt begins to hear the ticking of Ex’s watch or rubbing of fingers. Ex begins with watch or fingers approx. 3 feet from the side of Pt’s head and moves in closer until patient hears sound. Alternatively, Ex may ask Pt to distinguish whisper in each ear. Ex tests each ear and covers pt’s other ear while testing.

5. IX and X – Glassopharyngeal. Ex presses down on or near the posterior wall of the throat with a tongue depressor to elicit the gag reflex.

6. XI – Spinal Accessory. Ex asks Pt to push his/her head against Ex’s hand in a side-ways fashion OR asks Pt to shrug shoulders up against Ex’s hands.

7. XII – Hypoglossal. Ex asks Pt to stick his/her tongue out of the mouth and move it from side to side.

8 - 9. SENSORY FUNCTIONS: Ex tests sensory functions by touching Pt bilaterally with alternating soft and sharp OR warm and cold objects.

8. Arms/hands – forearms and hands

9. Legs/feet – calves, ankles, feet

10. POSITION SENSE: Ex holds sides of Pt’s finger with his/her two fingers. Ex then moves the finger up or down and asks Pt to say which way it is being moved. REPEATS with the big toe.

11. VIBRATION SENSE: Ex places a vibrating tuning fork against the bony prominence of Pt’s WRIST AND ANKLE OR FINGER AND TOE and asks Pt to state when the vibration stops.

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Neurological Examination OSCE (continued)

A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt

Procedure A B C Comments (NOTE: STRENGTH IS TESTED IN THE EXTREMITIES SECTION)

12. REFLEX TECHNIQUE: The movement of the hammer should be a rapid downward snap of the wrist. The hammer should not be held too firmly.

13 - 18. REFLEXES: Ex tests each of the following reflexes bilaterally:

13. Biceps

14. Triceps

15. Brachioradialis

16. Patellar

17. Achilles Tendon

18. Plantar (Babinski)

19. COORDINATION OF UPPER EXTREMITIES: Ex asks Pt to alternately touch Ex’s index finger and Pt’s nose. Ex places his/her index finger 18 inches from Pt while changing the location of his/her finger several times. This procedure should be repeated with the Pt’s other hand.

AND / OR

The Ex asks Pt to rapidly and repeatedly touch his/her thumb with each finger on the same hand. Repeats with Pt’s other hand.

21. COORDINATION OF LOWER EXTREMITIES: Ex asks Pt to run the heel of one foot up and down the shin of the opposite leg. Repeats with opposite leg.

AND / OR

Ex asks Pt to walk a straight line in a heel-to-toe fashion.

25. ROMBERG SIGN: Ex observes Pt standing with his/her arms stretched out in front or beside him/her with eyes closed.

26. GAIT: Ex observes Pt walk, turn, and return.

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