Neurologic Examination

The goal of the neurologic examination is to localize the brain lesion and rule out other neurologic disease processes. The National Institutes of Health (NIH) stroke scale is a 15-item neurologic evaluation that is reproducible, correlates to infarct volume, and can be performed in less than 7 min (see T.a.bJ.e 2.2.0.-..1..). This allows a serial, standardized neurologic evaluation of a patient over time by either a nurse or a physician. 2 The neurologic examination can be broken down into six major areas: (1) level of consciousness, (2) visual assessment, (3) motor function, (4) sensation and neglect, (5) cerebellar function, and (6) cranial nerves.

LEVEL OF CONSCIOUSNESS A patient's level of alertness should be evaluated by asking simple questions (birth date or month of the year) and by having the patient follow simple commands (close their eyes, make a fist). Patients may be alert, drowsy (requiring minor stimulation to answer or obey), lethargic (requiring repeated or painful stimulation to respond), or obtunded (postures or is totally unresponsive). Several assessments are available for the mental status examination, such as the mini-mental, or the brief mini-mental, exam. Many of the elements are contained in the NIH stroke scale.

VISUAL ASSESSMENT Evaluation of visual fields and extraocular movements can provide information regarding occipital lobe or brainstem lesions. Visual fields can be tested by confrontation, using finger counting or visual threat as appropriate. Gaze palsy can be assessed by evaluating both voluntary and reflex (by turning the patient's head) horizontal eye movements.

MOTOR FUNCTION Upper extremity motor weakness is best determined by testing for pronator drift. Patients close their eyes and extend their arms with palms facing the ceiling. The test is positive if one arm pronates or drifts lower than the other within 10 s. Lower extremity strength can be similarly evaluated by a patient's ability to elevate each leg 45 degrees individually for 5 s while lying in bed. For subtle signs of lower extremity weakness, observe the patient's gait or have patients walk on their toes and then on their heels. Facial motor weakness (facial droop) due to a central nervous system (CNS) lesion can be distinguished from a peripheral seventh nerve palsy (e.g., Bell palsy) by a patient's ability to wrinkle the forehead on the affected side.

CEREBELLAR FUNCTION Cerebellar function can be tested by observing a patient's gait, finger-to-nose testing, heel-to-shin testing, and by having patients stand with arms outstretched forward, palms up (Romberg test). These tests are all performed with the patient's eyes open and then closed to differentiate from posterior column disease (see Chap.221, "Altered Mental Status and Coma").

SENSATION AND NEGLECT Sensory deficits and neglect should be evaluated by pinprick testing, having the patient identify numbers gently written on the palm (graphesthesia), and by double-simultaneous extinction (the physician touches the patient's right and left limbs individually and then simultaneously). The double-simultaneous extinction test is positive if the patient feels the sensation in either limb individually but only on one side when touched simultaneously, and it suggests neglect. Neglect can be further confirmed by having the patient draw a box or house. Patients with neglect will often omit figures on one side of the drawing.

LANGUAGE The terms dysarthria and aphasia are often erroneously interchanged. Dysarthria is a disturbance in articulation and is due to paralysis or incoordination of muscles used for speech. Dysarthric speech is often slurred. Having a patient repeat simple nursery rhymes can identify subtle cases. In contrast, aphasia is due to a disturbance in processing language (either written or spoken) and can be receptive (difficulty in comprehension), expressive (difficulty in communicating thoughts), or both. Receptive aphasia can be tested by having patients follow simple commands (either vocal or written). Having patients identify simple objects or describe what is happening in a magazine picture assists in evaluating an expressive aphasia. Patients with expressive aphasia will use inappropriate words or use nonfluent sentences, whereas the words of patients with dysarthria will be slurred.

CRANIAL NERVES Cranial nerves should be individually tested in all patients to identify possible brainstem involvement. Unlike anterior circulation strokes, which cause contralateral motor deficits, brainstem involvement causes ipsilateral cranial nerve deficits with contralateral motor weakness.

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