NEUROLOGY

Neuro exam

Document this on each of your neuro SOAP notes and mention the patient’s age and handedness.

Mental Status	A/O x 4, language fluent/appropriate (Include good repeats, mini-mental status exam score, if done)
Cranial Nerves	PERRL, 3 mm ou (pupil size), VA 20/20 ou (acuity), VF nl (visual fields) EOMI without nystagmus, face with normal strength/sensation Hearing intact bilaterally, tongue/palate midline Discs sharp without papilledema (ou = bilateral, od = right eye, os = left eye)
Motor exam	Normal bulk/tone, 5/5 strength throughout, no involuntary movements (Strength gradations: 0 = none, 1 = flicker of strength, 2 = movement not against gravity; 3 = movement against gravity, 4 = good strength, but breakable, 5 = normal strength)
Sensory	Normal pinprick, vibration, proprioception (remember to test 6 points on the face)
Coordination	Finger à nose intact bilaterally without dysmetria, heel à shin normal bilaterally
DTRs	2+ symmetric, plantar response flexor (or toes ¯¯)
Gait	Normal; good tandem, negative Romberg

Stroke week tips

The most important thing to remember about this week is that it is pass-fail.

The second most important thing to remember is that if afternoon rounds do not begin by 5 pm, you are free to tell the residents/fellows that you have to go. Take our advice on this – you do not need to be stuck there until 8 or 9 pm, especially when you are getting there at 5 am.

Presenting ICU patients is a daunting task, but it’s not as bad as you think. Copy the following data from the huge flowsheets in the NICU:

1. Present how the patient did overnight and if there was any change in his/her neurologic status. If the patient is sedated, state that.
2. Temperature, T_max and when it happened. Antibiotics and day #.
3. CV data (give a range): HR, BP, MAP, other CV data if present.
4. Pulmonary data: ventilator settings (mode, RR, F_IO2, pressure support, PEEP), S_aO₂, most recent ABG, and yesterdays and today’s a/A ratio. a/A ratio = Pa_O2 / (713xF_IO2 – Pa_CO2/0.8)
5. Fluids: total ins and outs for the previous day and that morning
6. Labs: start out with CBC (note any trends in WBC, Hct, plt), then fluid balance panel, coags, culture data, drug peak/trough levels, etc.
7. Plan: try to discuss this with the fellow prior to rounds, but usually you won’t have time. State the obvious – i.e., “K⁺ is low, so we went ahead and replenished it, Hct is dropping, so we are hemocculting stools,” etc. If the patient’s renal function or fever are improving or the patient is tolerating tube feeds well, note those things. Then defer to the fellow…

Code stroke protocol

1. Initial assessment: include age and sex of patient, neurologic deficits, estimated time of onset, vital signs.

2. Place the patient flat in bed.

3. Administer O₂.

4. Have the patient chew and swallow an Aspirin 325 mg

5. Give IV Bolus – NS bolus 500cc, then 125 cc/hr.

6. Obtain stat EKG.

7. Obtain stat noncontrast head CT

8. Draw blood for labs.

9. Document the patient’s current medical problems.

10. DO NOT lower blood pressure (i.e. no anti-hypertensive meds)

11. DO NOT leave patient unattended.

Status epilepticus protocol

Defined as two or more convulsions without full recovery of consciousness, or a single convulsive seizure lasting over 30 minutes.

1. Initial management (0-10 min): ABC’s of airway management, check vital signs, obtain an EKG, start an IV with normal saline, and draw labs (ABG, fluid balance, calcium, magnesium, toxicology screen, and anticonvulsant levels if patient is on anticonvulsants). Fingerstick for glucose, and if low, give thiamine 50 mg IV and a 50 mL bolus of D₅₀W.

2. First drug (5-20 min): give Ativan 0.1 mg/kg IV at 2 mg/min, and monitor BP, RR, and pulse for respiratory depression and hypotension.

3. Second drug (20-40 min): if seizures continue, give Dilantin 20 mg/kg IV at 50 mg/min (or fosphenytoin – dosing is same, but can be pushed). Seizures in 90% of patients in status epilepticus should be controlled by this stage.

4. Intubation / anesthesia (40-60 min): intubate, begin EEG monitoring, and give entamicinal 20 mg/kg at 100 mg/min. If seizures persist, initiate general anesthesia with propofol 10 mg bolus followed by 0.5-1 mg/kg/hr.

Upper motor neuron vs. Lower motor neuron lesions

UMN Lesions	LMN Lesions
No muscle wasting	Muscle atrophy, fasciculations
Increased tone (clasp knife)	Decreased tone (flaccid)
Weakness (antigravity muscles)	Weakness (variable pattern)
Increased DTRs / clonus	Decreased or absent reflexes
Extensor plantar response	Flexor / absent plantar response

Stroke sites and resultant neurologic deficits

Vessel	Region supplied	Neurologic deficit
Anterior circulation
Middle cerebral artery	Lateral cerebral hemisphere, deep subcortical structures	See superior / inferior division deficits, may also see coma or symptoms of increased intracranial pressure
Superior division	Motor / sensory cortex of face, arm, hand; Broca’s area	Contralateral hemiparesis of face, arm, and hand; expressive aphasia if dominant hemisphere
Inferior division	Parietal lobe (visual radiations, Wernicke’s area), macular visual cortex	Homonymous hemianopsia, receptive aphasia (if dominant hemisphere), impaired cortical sensory functions, gaze preference, apraxias, neglect
Anterior cerebral artery	Parasagittal cerebral cortex	Contralateral leg paresis and sensory loss
Ophthalmic artery	Retina	Monocular blindness
Posterior circulation
Posterior cerebral artery	Occipital lobe, thalamus, rostral midbrain, medial temporal lobes	Contralateral homonymous heminanopsia, memory or sensory disturbances
Basilar artery	Ventral midbrain, brainstem, posterior limb of the internal capsule, cerebellum, PCA distribution	Coma, cranial nerve palsies (leading to double vision, facial numbness or weakness, dysphagia, etc…), apnea, cardiovascular instability
Deep circulation
Lenticulostriate, paramedian, thalamoperforate, circumferential arteries	Basal ganglia, pons, thalamus, internal capsule, cerebellum	Pure motor or sensory deficits, ataxic hemiparesis, “dysarthria-clumsy hand” syndrome