# Neurological tests



## thatJeffguy (Aug 26, 2010)

Dispatched to a fall victim.  70yo W male, had fallen earlier in the day and the ambulance crew provided a lift assist and got a refusal.  Five hours later we were sent out again.

Entered the house, well-kept and clean, to find pt sitting in recliner with a walker nearby.  He was able to tell us his name and provide a description of the fall (left leg "went numb" when he stood up, fell to the carpeted floor, landed on his left shoulder, didn't hit anything on the way down and didn't hit his head, no loss of consciousness".  I had him show me a big, toothy grin and noticed no facial droop.  He was able to, on instruction, hold his hands outstretched in front of him palms up and support them for five seconds.  He could squeeze both my hands on instruction and the strength was equal and appropriate for his age.   His pupils were equal, round, reactive and he followed my finger-tip in an H pattern.  He knew the date, day and the rough time.  He recalled he'd eaten a few hours before but did not recall what he ate.    His left leg was bent away from his body and he claimed he had little strength and ability to move it.  He could wiggle his toes on both feet and identify when stimulus was applied.  His left foot felt cooler to the touch than the rest of his skin.  Physical exam showed no deformities, no discoloration, nothing remarkable, patient claims no pain felt upon palpation of the affected leg.  Cap refil time is a bit slower in affected foot than non affected foot.  BP 212/110 (checked three times) and 214/108 at hospital.  Pt states he hasn't seen a doctor since 1952, takes no medications, has no allergies.  He engages in appropriate conversation for the whole ride.

-  

That's a spur-of-the-moment narrative, leaving out information that doesn't pertain to my specific question;

What more could I have done to assess his neurological state?  The hospital I'd taken him to isn't equipped to deal with CVA's and we could have taken him to another hospital that is equipped.  What other tests exist that rule in/out specific destination hospitals?

Thanks again,


----------



## Shishkabob (Aug 26, 2010)

Just because a patient doesn't show symptoms of a CVA doesn't mean you shouldn't still go to a CVA interventional facility for possible neurological conditions.  CVA facilities still have CAT scans and neurologist on staff for other things that might pop up.


Was sensation equal to both limbs? Needs to be more specific than just a "He could tell when touched" type of test.


Any history of the "leg felt numb before falling" condition, as if has it happened before?  Neurological hx in the family?  Orthopedic injuries at all when he was younger?


----------



## thatJeffguy (Aug 26, 2010)

Linuss said:


> Just because a patient doesn't show symptoms of a CVA doesn't mean you shouldn't still go to a CVA interventional facility for possible neurological conditions.  CVA facilities still have CAT scans and neurologist on staff for other things that might pop up.
> 
> 
> Was sensation equal to both limbs? Needs to be more specific than just a "He could tell when touched" type of test.
> ...




 I can't believe I forgot to mention this but he stated he had nerve damage "behind ... right ear" due to a MVA in 1950.  Other than that, no medical history.

For the sensory tests I lightly pinched the skin on the top of his hand and asked him what I was doing and to which hand.  I didn't specifically ask if the sensation was the same.  What do you recommend for this?

How would you have treated the patient and to which facility would you transport (Level II Trauma 30m, local hospital no full coverage neuro doc)?  Should I summon ALS?

Also, he never described the pain as more than just "weakness".  He said it'd felt this way for "a long time" and that he can't recall when, or if, it had gotten any worse.  I think his wife was more concerned than he was and her insistence on transport was the primary reason he was in the ambulance.


----------



## JPINFV (Aug 26, 2010)

I'll sum up a neuro exam later (crunched for time right now), but one thing to remember is that brains shrink with age. This is important for two reasons, first there's more movement which increases the likelihood of coup contercoup injury (this is when the head hits a fixed object and the brain slams against both the front and back of the cranial vault, causing brain injury on both the side of the impact and the opposite side) and the increased movement increases the likelihood of injuring bridging veins, which results in a sub-arachnoid bleed. Sub-arachnoid bleeds are slow bleeds with lots of space to fill, so signs and symptoms of the bleed won't be obvious until a while after the actual injury was occurred.


----------



## Shishkabob (Aug 26, 2010)

JPINFV said:


> I'll sum up a neuro exam later (crunched for time right now), but one thing to remember is that brains shrink with age.



You sure?  My partner would argue that my head gets bigger and bigger... :unsure:


----------



## reaper (Aug 26, 2010)

Dvt!


----------



## Akulahawk (Aug 26, 2010)

A head bleed is one of the concerns. Given the cool to touch, diminished sensation, and general weakness... I'm thinking more of a perfusion problem. Wiggling toes means that there's some motor ability there... but it doesn't tell me much beyond that. I'd want to know about equality of sensation, temperature, muscle strength...

I'd have wanted to get him to a facility that can take care of strokes. Why? They're also likely to have a vascular team available as well.


----------



## Aprz (Aug 26, 2010)

Linuss said:


> You sure?  My partner would argue that my head gets bigger and bigger... :unsure:


Yeh, your _head_, but your brain size is inversely correlated to your head size.  I'm kidding.


----------



## clibb (Aug 26, 2010)

thatJeffguy said:


> Dispatched to a fall victim.  70yo W male, had fallen earlier in the day and the ambulance crew provided a lift assist and got a refusal.  Five hours later we were sent out again.
> 
> Entered the house, well-kept and clean, to find pt sitting in recliner with a walker nearby.  He was able to tell us his name and provide a description of the fall (left leg "went numb" when he stood up, fell to the carpeted floor, landed on his left shoulder, didn't hit anything on the way down and didn't hit his head, no loss of consciousness".  I had him show me a big, toothy grin and noticed no facial droop.  He was able to, on instruction, hold his hands outstretched in front of him palms up and support them for five seconds.  He could squeeze both my hands on instruction and the strength was equal and appropriate for his age.   His pupils were equal, round, reactive and he followed my finger-tip in an H pattern.  He knew the date, day and the rough time.  He recalled he'd eaten a few hours before but did not recall what he ate.    His left leg was bent away from his body and he claimed he had little strength and ability to move it.  He could wiggle his toes on both feet and identify when stimulus was applied.  His left foot felt cooler to the touch than the rest of his skin.  Physical exam showed no deformities, no discoloration, nothing remarkable, patient claims no pain felt upon palpation of the affected leg.  Cap refil time is a bit slower in affected foot than non affected foot.  BP 212/110 (checked three times) and 214/108 at hospital.  Pt states he hasn't seen a doctor since 1952, takes no medications, has no allergies.  He engages in appropriate conversation for the whole ride.
> 
> ...




He takes no medications for his high blood pressure? That would scream stroke to me. Especially since his leg went numb and then he fell.
Also, what was his hear rate? Did you put on a 12-lead on this patient? What was the rhythm? 

You stated that the his left leg was bent away from the body and then that there was no deformities. Well, what about the leg being bent away from the body? Is that normal? 

Does he have diabetes? What was his blood sugar level at?

Why does Linuss recommend sensation examination? Well, it's to compare and contrast. I usually ask "Do you have any numbness or tingly sensation" if they say yes, then I suspect spinal cord injury. I was taught a simple finger test to check and see if the spine is in good shape. Here's a link that will explain what does what http://www.train.tcu.edu/ross/cspine.htm 



> How would you have treated the patient and to which facility would you transport (Level II Trauma 30m, local hospital no full coverage neuro doc)?  Should I summon ALS?


Depends on your protocol. Our says that if we didn't witness the fall we should c-spine the patient, ESPECIALLY if he has less sensory on one part of his body. Since you guys had already been there during the day for a fall and the patient did reject treatment and now he falls again and you're dispatched there again. This is a call where I think I would go emergent, CAT scan, and a trauma team is questionable, I would definitely feel more comfortable with one activated for this patient. 
Why trauma team? Well, he fell twice and this time it's bad. I don't know how hard of a fall and if he really "remembers" the fall. 



Akulahawk said:


> A head bleed is one of the concerns. Given the cool to touch, diminished sensation, and general weakness... I'm thinking more of a perfusion problem. Wiggling toes means that there's some motor ability there... but it doesn't tell me much beyond that. I'd want to know about equality of sensation, temperature, muscle strength...
> 
> I'd have wanted to get him to a facility that can take care of strokes. Why? They're also likely to have a vascular team available as well.



Agreed. I honestly think this is a stroke victim but he's not showing the "usual" signs of the stroke scale.


----------



## Akulahawk (Aug 26, 2010)

clibb said:


> He takes no medications for his high blood pressure? That would scream stroke to me. Especially since his leg went numb and then he fell.
> Also, what was his hear rate? Did you put on a 12-lead on this patient? What was the rhythm?
> 
> You stated that the his left leg was bent away from the body and then that there was no deformities. Well, what about the leg being bent away from the body? Is that normal?
> ...


That link is to a great site about evaluating cervical/spinal cord injury. I've done most of those special tests... seriously. I did NOT see any "simple finger test" on that page to help determine whether or not the spinal cord is in good condition. The more I read the OP's description of what the patient said what had happened, the more I'm convinced that this is a perfusion issue and not a stroke. Delayed cap refill, cooler to touch, numb upon standing, that doesn't say stroke to me... it says blood vessel occlusion more than anything. I would almost bet that the patient had been sitting down for several hours prior to his attempt to stand and walk around.

Of course, I'm not there to see the patient for myself. I'd also wonder about whether or not the patient has regained sensation in his leg and how quickly that is progressing, if at all.


----------



## BayArea (Aug 27, 2010)

I'm thinking DVT too...


----------



## JPINFV (Aug 27, 2010)

Ok, neuro exam. I'm going to focus on tests that can readibly be done with equipment on ambulances (unless, of course, you have an eye chart, tuning fork, and reflex hammer) and can be done quickly (somethings just take too much time to do):

CNS:

AVPU and orientation.

Frontal lobe: Ask to describe things like de

Memory: Ask the patient to remember 3 objects or numbers. Have them repeat it back to you. Ask to repeat it back to you in 5 minutes. Pro tip: If you use the same three things (say, dog, cat, and elephant) for every patient, you can easily remember it.

Cerebellar functioning can be tested by rapid alternating tests. A good quick one is have the patient put their hands on their thighs, and then have them alternating touching their thigh with their palm followed by the back of their hand. 

Cranial nerve exam:
CN1 (olfactory): not easily done

CN2 (optic nerve): Can they read at a decent distance? Next test would be to start with your fingers near the ears and bring them forward until the patient can see them to test periphreal vision. 

CN3 (Ocularmotor), 4 (trochlear), and 6 (abduncens): These nerves test extra ocular motor function and is tested with the "H" test (have the patient follow your finger with their eyes only as you trace an H). If the eye stays adducted (near the nose), then the abducens (CN6) is damaged. If the eye won't move down and towards the nose, then it's a problem with the superior oblique muscle and CN 4 (trochlear). 

CN5 (Trigeminal): Test for loss of sensation or weakness for opening the mouth (CN5 is sensation and muscles of mastication).

CN7 (Facial): Smile, frown, other facial movements not involving moving the jaw since CN7 provides the rest of the superficial muscle innervation. 

CN8: (vestibulocochlear): Provides hearing and balance. Is the patient dizzy? Can the patient hear you rub your fingers outside of their ear equally? 

CN9 (Glossopharyngeal) and CN10 (Vagus): Together they provide motor innervation to the muscles of the laryngeal and pharyngeal muscles, the back 1/3 of the tongue (only CN9), and the gag reflex arch. To test, does the back of the mouth raise up when the patient says, "Ahh." Is the back 1/3 of the tongue numb (only CN9)? Does the patient have a gag reflex (not really practical to test prehospitally?

CN 11: Spinal Accessory muscle. Can the patient shrug their shoulders? 

CN 12: Hypoglossal nerve: Can the patient stick their tongue out and wiggle it?




PNS:

Check for both dull touch and sharp touch. 

If you want to, you can use your stethoscope as a poor man's reflex hammer. A simple way to remember reflexes is starting at the foot, 1-2, 3-4, 5-6, 7-8. Achilles Tendon is Sacral 1-2, petallar reflex is lumbar 3-4, bicepts is cervical 5-6, and tricepts is cervical 7-8. Reflexes are scored out of 4 with a 2 being normal, and 4 being hyperreflexive (seen in patients with upper neuron damage, so below a spinal cord injury for example). 

Check dermatones if you know where they are (dermatones can be important for some other diseases, such as Shingles (Herpes Zoster), break out in dermatonal patterns. 

Finally, muscle strength. Scored on a scale of 5 with 5 being normal, 4 being weaker, 3 being unable to move only against gravity, 2 being unable to overcome any resistance, and 1 being unable to move that muscle.


Here's a good resource for learning a more indepth neuro exam. http://www.neuroexam.com/

A lot of this seems like a lot, however with practice the time requirement shrinks drastically.


----------



## clibb (Aug 27, 2010)

JPINFV, thanks for that! That's awesome! Something I'll be studying a lot! Thanks again!


----------

