Junior Neurology Clerkship

Passport

Name

Block

Stephen Deputy, MD

Program Director

2014-2015 Neurology Resident Yearly Schedule

Rotation Month

LSU Clinic St. Charles

ILPH LSU Clinics @ L&T

Touro Infirmary Children's Hospital

JUL Oganisyan/Edwards Baras Martinez Rajendra Williams

AUG Khursheed Martinez Williams Rajendra/Lalan

SEP Lalan Williams Khursheed Rajendra/Edwards

OCT Edwards Khursheed Lalan/Martinez Rajendra/Miller

NOV Baras Lalan Oganisyan/Edwards Rajendra/Miller

DEC Edwards Edwards Williams Baras

JAN Khursheed/Martinez Oganisyan Baras/Lalan Rajendra/Miller

FEB Baras Williams Edwards Khursheed

MAR Khursheed Miller Williams Rajendra

APR Williams Baras Khursheed Oganisyan

MAY Khursheed Edwards Lalan Martinez

JUN Martinez Miller Edwards Rajendra

 

 

 

 

 

 

 

 

WELCOME TO THE LSU SCHOOL OF MEDICINE NEUROLOGY CLERKSHIP!

Students rotating on their Surgery Clerkship will have a 3 week-long Neurology Clerkship experience either during weeks 1-3, 4-6, 7-9, or 10-12. During your 3 weeks with us, you will be assigned to a Neurology rotation at University Hospital (ILH), Children’s Hospital, The Neurology Faculty Clinics at St Charles Hospital, the inpatient and consultation service at Touro Hospital, or Our Lady of the Lake Hospital in Baton Rouge.

Students will be performing clinical duties every day of their rotation except for Thursday afternoons when didactics will be given at 1542 Tulane Avenue, Room 756. Students rotating in Baton Rouge will participate via videoconference. Didactics generally begin at 11:30AM (though be sure to check your lecture schedule for changes).

On week #1, didactics include: Neurology Case Review (section A) followed by How to Perform the Neurological Examination.

On week #2, didactics include: Neurology Case Review (section B) followed by Applicable Neuroradiology, followed by Professor’s Rounds (remember that students assigned to University Hospital are responsible for presenting a patient for Professor’s Rounds).

On week #3, didactics include Neurology Case Review (section C) and then the Neurological Review lecture to help you prepare for the SHELF Examination.

This Neurology Passport contains important information to help you successfully navigate requirements of the Neurology Clerkship.

· Basic Competencies: Neurological Examination

· Basic Competencies: Neurological History Taking

· Student Presentations

· Patient log

The Passport also includes useful reference material to help you with your clinical responsibilities:

· The Neurological Examination handout

· Differential Diagnosis by Disease Category List

· Sensory Dermatomes

· Useful Muscles to Test for Peripheral Nervous System Disorders

· Developmental Milestones for Children

· NIH Stroke Scale

  

 

 

 

The Neurological Examination

Stephen Deputy, MD

Introduction

The Neurological Examination is, by necessity, long and cumbersome. That does not mean that every patient with a neurological chief complaint needs to undergo a “complete” Neurological exam. (Can you imagine testing each and every sensory dermatome for all modalities of primary sensation and doing a Cremaster reflex on a patient presenting with headaches?). The purpose of the Neuro Exam is to answer questions gleaned from the History, to identify any neurological deficits, and to localize those deficits on the basis of pertinent findings. With this in mind, it is essential to “touch base” within each of the fundamental realms of the Neurological Examination (Mental Status, Cranial Nerves, Motor, Coordination, Sensory, and Gait) in order to cover the entire neuroaxis, which ranges from the cortex, subcortical white matter, deep grey matter structures, brainstem, cerebellum, spinal cord, peripheral nerves, neuromuscular junction and muscles. What one does within each of these realms with regards to examination depends on the clinical situation. The redundancy of the Neuro Exam helps one to confirm deficits. Pertinent “negatives” are just as important as “positive” findings to aid in localization.

With that said, consider doing a “screening” Neuro Exam on every patient that you encounter to touch base within each of the fundamental realms. Next, expand the Neuro Exam to answer questions gleaned from the history. Finally, take advantage of the redundancy of the Neuro Exam to confirm or refute any abnormal findings.

Don’t just do the Neurological Exam to please or impress your resident or attending with your “completeness”. Rather, always use the Neuro Exam as a tool to answer questions and to localize deficits.

Mental Status

The Mental Status exam is really looking at cognition, which is a cortical function. The following examination techniques are based on localization of discreet deficits. Neurocognitive testing is not included here, though it does have a value in localization and diagnosis for disorders of higher cognitive functioning. Likewise, the field of psychiatry uses essentially an expanded mental status exam to evaluate mood disorders, anxiety disorders, and abnormalities of thought process, which, while very important to patient care, do not have the same discreet localization as the following Mental Status techniques provide. The Mini Mental Status Exam can be a useful tool to quantify a patient’s overall mental status when dementia is a clinical consideration.

Alertness and Orientation

“A and O x 3” is often seen on physical exam statements. The patient’s level of alertness is a subjective impression by the examiner. Is the patient fully alert and responsive? If not, using terms such as “somnolent”, “sleepy”, “obtunded” etc. are not very helpful as they are difficult to quantify. It is better to use descriptions such as “the patient appears to be awake, though he is agitated and often provides confused responses to questions”, or “the patient has closed eyes, but opens them to verbal stimulation”, or “the patient only opens his eyes briefly to noxious, painful stimulation”. Coma has a very specific definition which is that of “unarousable unresponsiveness”. Other, lesser degrees of impaired consciousness should be described more descriptively.

Orientation should be listed as to the specific items for which the patient is oriented to. Common useful questions include: “What is your name?” “Do you know where you are right now?” “What is today’s date?” “What day of the week is it?” “How old are you?” At the end of these questions, one can write in the chart, “The patient is alert and oriented to name, place and date” which is more specific than “A and O x 3”.

The patient’s level of alertness and orientation needs to be established before any other aspect of the MS (Mental Status) is tested. This is because, if the patient is not fully alert and oriented, then the localizing value of the rest of the MS exam no longer becomes valid. (For example, disoriented, confused patients who cannot properly identify a watch do not necessarily suffer from anomia, which may otherwise be localized to the Broca’s region of the dominant hemisphere).

Concentration

The evaluation of concentration require that a patient “remain on task” during a sustained mental activity. Some of the more common tasks include “serial sevens” (where the patient is asked to mentally subtract sevens from one hundred in a sequential manner) as well as to spell the word “World” backwards. Of course, the patient needs to have the mental capabilities in basic math and spelling to validate these as “concentration” tasks. One challenging task that I like to use is to ask the patient to state the months of the year forward and backwards. As with any neuro exam task, start with the most difficult task and if the patient cannot complete it, try to quantify the deficit by asking them to try and complete easier tasks (for example, if the patient cannot complete serial 7’s, then try serial 3’s. Or, if they cannot do the months of the year backwards, then try the days of the week backwards, etc.).

As with Alertness and Orientation, if a patient’s Concentration is off, then the localizing value of the rest of the Mental Status exam comes into question. Therefore, one should perform tasks of Alertness and Orientation as well as tasks of Concentration before moving on to the rest of the Mental Status exam.

Memory

While there are many different types of memory which can be better settled with neurocognitive testing, we will focus on short-term memory and long-term memory here. Long-term memory is the most ingrained with any sort of encephalopathy and is therefore, the most resilient and “last to go”. Asking historical questions about where the patient went to high school, their birth date, their wedding anniversary, the names of their parents, etc. is the best way to evaluate long-term memory.

Short-term memory, on the other hand, is evaluated by having a patient recall 3 objects after several minutes. Each of you should pick your own unique set of 3 objects for use in this task. These objects should be readily familiar to most patients and come from different “categories”. For example, I use “piano” “baseball bat” and the color “blue” (These are my unique 3 objects. Pick your own!) Whatever objects you choose to use, stick with them (so you won’t forget the objects that you asked the patient to recall!). Make sure that the patient can accurately and immediately repeat the objects and tell them that you will be asking them to recall them in a few minutes. If the patient cannot immediately accurately recall each of the three objects, then this is a deficit of registration (not short-term memory) which is really a task of concentration and not of short-term memory. Assuming registration is intact, if the patient cannot recall one or more of the objects after several minutes, then give them a clue. The patient’s performance on the short-term memory task can be reported as “Short-term memory intact with 3/3 objects recalled after 5 minutes” or “STM = 3/3” or “STM = 2/3 plus 3/3 with prompting” etc.

Language

As with memory, language is complex and best “broken down” through neurocognitive testing. For the purposes of a general neurological examination however, we will stick to “expressive language”, “receptive language”, and “repetition”. Language function is mostly confined to the dominant hemisphere. This is essentially the left hemisphere for right handed individuals and may be the right hemisphere, left hemisphere or have bilateral representation for left handed individuals. This is why it is important to note whether an individual is right or left handed in their HPI description. Recall that “language” itself is not confined to spoken language. Patients with “aphasias” will have difficulty not only with spoken language, but also with reading, writing, sign language, and facial expressions or hand gestures that are used to communicate meaning. “Dysarthria” is a term that describes intact “language” along with a motor production deficiency of clear

speech. Dysarthria does not localize to the language areas of the brain but may be secondary to motor functions in the frontal lobe, deep sub-cortical basal ganglia regions, brainstem or their connections.

“Expressive language” is a function of Broca’s area cortex. This is localized to the dominant hemisphere insular frontal cortex. Patients with a “Broca’s aphasia” or an “expressive aphasia” will have fluency problems as well as word finding deficits (non-fluent aphasia). Once again, try to quantify the deficit by having the patient try to name easier objects (such as a watch or thumb) then move on to more difficult names (such as a watch band or index finger).

“Receptive language” is a function of Wernicke’s area (angular gyrus region of the parietal lobe) of the dominant hemisphere. As a “language” function, injury to Wernicke’s area results in deficits of understanding language (whether that be spoken language, reading, or understanding gestures). Good ways to test expressive language include asking a patient to perform a multi-step task. Remember that a 3-step task is more difficult than a one-step task and that midline tasks (such as “open your mouth”) are easier than appendicular task (such as “show me the thumb on your left hand”). Having the patient perform a task that they need to read is also helpful in distinguishing alexia from aphasia. Patients with Wernicke’s aphasia not only have a difficult time understanding others’ language, but also with understanding their own language. The result is a fluent aphasia, where the patient rambles on in a incoherent fashion. Neologisms and inappropriate word substitutions are also part of Wernicke’s aphasia.

Finally, the task of “repetition” requires that language be comprehended (through Wernicke’s area of the parietal lobe), successfully transmitted (through the angular gyrus and the arcurate fasiculus), and reach Broca’s area (in the insular cortex) to be spoken. Therefore, a good screening task for all of these areas is to ask the patient to repeat a complex sentence. I always use “today is a sunny day in the city of New Orleans”, though other phrases such as “there are no ifs, ands, or buts about it” are commonly used. Make sure the sentence is somewhat complex and if the patient cannot repeat it accurately, move towards an easier sentence.

Cranial Nerves

The cranial nerve exam reflects the function of the brainstem and can help to co-localize long track findings. It is best to go “in order” when examining the cranial nerves (I-XII) in order to look into midbrain, pons, and medullary function sequentially.

CN # I: The Olfactory Nerve.

This nerve is rarely tested except in cases of closed head injury where shearing forces can sever branches coming off the olfactory nerves as they transverse the skull base at the cribiform plate. There is a direct air communication in the superior nasal passageways so that it is difficult to isolate deficits of the olfactory nerve to the right or left side exclusively. Noxious stimulation (such as smelling ammonium salts) actually irritates the nasal mucosa which is supplied by the Maxillary division of the Trigeminal Nerve. Therefore, to test olfactory function, the patient should be asked to distinguish between smells such as coffee and cinnamon or other spices.

CN #2: The Optic Nerve

The optic nerve relays signals derived from retinal cells to the Lateral Geniculate Nucleus of the Thalamus. From there, visual information is transmitted to the Visual Cortex. The Optic Chiasm sends fibres reflecting visual input from the lateral visual fields from each eye to the contralateral Lateral Geniculate Nucleus. Nasal fields remain ipsilateral.

There are four ways to examine the Optic Nerve.

Visual Acuity: Make sure to test each eye individually with a Snellen Eye Chart and provide a quantitative visual assessment for each eye (i.e. 20/25 OD, 20/40 OS at near corrected).

Visual Fields: Compare the patient’s visual fields against your own through direct confrontational testing. “VFFTC” stands for “Visual Fields Full to Confrontation”.

Pupillary Light Reflex: Recall that the afferent portion of the pupillary light reflex runs through the Optic Nerve and jumps off at the Edinger-Westphal Nucleus. From there, the efferent component (parasympathetic nervous system) travels along the Oculomotor Nerve to reach the pupillary constrictor muscles. An “afferent pupillary defect” suggests dysfunction of the Optic Nerve with an intact Oculomotor Nerve. A patient with an “APD” will demonstrate an intact consensual pupillary light reflex but neither pupil will constrict when light is shined in the affected eye. “PEERLA” stands for “Pupils Equal and Equally Reactive to Light and Accommodation”. When patients are asked to look at an object very near to their eyes, their eyes will converge and their pupils will constrict (Accommodation).

Fundoscopic Exam: Guess what. You can actually directly see the head of the optic nerve with fundoscopic examination. Observation should note any swelling or elevation (papilledema) or pallor or atrophy of the optic nerve head.

CN’s III, IV, and VI: The Oculomotor, Trochlear, and Abducens Nerves

These nerves are responsible for controlling eye movements. The Trochlear Nerve innervates the Superior Oblique muscle for each eye which results in medial downward deviation and intortion of the eye. The Abducens Nerve innervates the Lateral Rectus muscle which abducts the eye. The Oculomotor Nerve innervates the rest of the eye muscles, provides parasympathetic fibres responsible for pupillary constriction, and aids with eyelid opening. Injury to the Trochlear Nerve results in an extorted eye which is accommodated for by the patient tilting their head towards the opposite side. Injury to the Abducens Nerve results in medial deviation (adduction) of the eye. Injury to the Oculomotor Nerve results in an eye that is “Down and Out” (laterally deviated and depressed), a “Blown Pupil”, and ptosis.

The extraocular muscles are tested for by having the patient look in all of the 6 Cardinal directions of gaze. Ask about diplopia during this part of the exam. Remember that the degree of diplopia will be greatest when the patient is looking into the direction corresponding to the action of the impaired muscle.

CN # V: The Trigeminal Nerve

The Trigeminal Nerve is composed of a Branchial Motor component and a general sensory component. The motor component supplies innervations to the muscles of mastication (Temporalis and Masseters) and the Lateral Pterygoid muscles (keeps jaw open). The sensory nerve is broken down into the Ophthalmic (V1), Maxillary (V2), and Mandibular (V3) divisions. Each of these three divisions can be tested for all modalities of primary sensation (light touch, position sense, vibration, and pain and temperature). The afferent component of the Corneal Blink Reflex comes from V1 stimulation of the corneal nerve.

CN VII: The Facial Nerve

The Facial Nerve supplies not only innervation to all of the facial muscles, but also has visceral motor branches to the submandibular and sublingual glands as well as to the nasal mucosa (parasympathetic innervations). It has a little known sensory division supplying input for primary sensory modalities from the skin from part of the auricle, a patch of skin behind the ear and from the external surface of the tympanic membrane. A “lower motor neuron” deficit of CN VII (e.g. Bell’s Palsy) will affect the upper and lower facial muscles ipsilateral to the site of injury. An “upper motor neuron” lesion affecting the contralateral corticobulbar tracts will result in weakness of the lower part of the face with sparing of the upper part of the face (secondary to bilateral innervation of the forehead muscles). Bifacial paresis is more difficult to pick up

due to the lack of asymmetry of deficits. These patients will have difficulty with forced eyelid closure and difficulty holding air in puffed out cheeks.

CN VIII: The Vestibulocochlear Nerve

This nerve sends signal from the cochlear gland (hearing) and vestibular gland (balance) to their respective brainstem nuclei where processed signals are sent via way of the Thalamus to the superior temporal gyrus (hearing) and cerebellum (balance). The “Vestibulocochlear Reflex” aka the “Vestibulo-Ocular Reflex” aka “Doll’s Eye Maneuver” aka “Cold Calorics” attains its afferent input from stimulation to the vestibular apparatus with efferent outputs going to the muscles affecting lateral eye movements. Hearing can be assessed by asking if the patient can hear a soft sound (such as rubbing fingers together) in each ear. The Weber Test (where the tuning fork is placed in the middle of the vertex of the skull) will result in the patient hearing the loudest sound to the ear that has ipsilateral conduction deficits or contralateral sensory-neural deficits. The Renee´ Test will tell if Air Conduction is louder than Bone Conduction (which it should be). If Bone Conduction is louder, this suggests a conduction deficit to the ipsilateral ear.

CN IX and X: The Glossopharyngeal and Vagus Nerves

While the Glossopharyngeal Nerve has Branchial Motor branches (to the stylopharyngeus muscle), Visceral Motor branches (parasympathetic innervation to the Parotid Gland), Visceral Sensory branches (input from the carotid body and carotid sinus), General Sensory branches (primary sensory inputs from the posterior 1/3 of tongue, skin of the external ear and the inner surface of the tympanic membrane) and Special Sensory branches (taste from the posterior 1.3 of the tongue) it is usually only tested for integrity through the afferent component of the gag reflex.

The Vagus Nerve, likewise has many functions such as Branchial Motor branches to several of the striated muscles of the pharynx, tongue and larynx, Visceral Motor input to smooth muscle and glands of the pharynx, larynx, and abdominal viscera (down to the middle of the transverse colon), Visceral Sensory branches from the pharynx, larynx, and abdominal viscera as well as from stretch receptors and chemoreceptors from the aortic arch, and a minimal General Sensory input from part of the ear and external ear canal.

Despite the complex functions of these nerves, their integrity is assessed primarily through assessment of the gag reflex (Afferent = Glossopharyngeal Nerve and Efferent = Vagus Nerve innervation to the palate).

CN XI: The Accessory Nerve

The Accessory Nerve supplies Motor branches to the Trapezius and Sternocleidomastoid muscles. Shoulder shrug and lateral head rotation are ways to check these muscles. Remember that there is bilateral neck flexion weakness in several myopathies so check for neck flexion weakness if indicated.

CN XII: The Hypoglossal Nerve

The Hypoglossal Nerve supplies Somatic Motor innervation to all intrinsic and extrinsic muscles of the tongue. A CN XII deficit will result in ipsilateral deviation of the protruded tongue (along with ipsilateral weakness and atrophy).

Motor Examination

The Motor Examination consists of several different components (Strength, Tone, Posture, Fine Motor Coordination, DTR’s, Plantar Responses, and Involuntary Movements). Each will be reviewed in their turn.

Strength can best be assessed by isolating an individual muscle group and comparing your power with that of the patient. A standardized Medical Research Council (MRC) score can be noted for any muscle group tested. A score of 5/5 is full strength. A score of 4/5 (or 4+ or 4- ) implies weakness with enough strength to

overcome varying degrees of physical resistance. 3/5 means that the patient can overcome gravity but not resistance. 2/5 implies that the limb can be moved only when gravity is taken out of the equation. 1/5 is muscle activation without limb movement. 0/5 is no muscle activation whatsoever.

Tone is the resistance that the examiner subjectively experiences when moving a patient’s limb passively. It can be normal, increased, or decreased (not “good” or “bad”). Causes of increased tone include Spasticity (Due to Corticospinal Tract dysfunction), Rigidity (Basal Ganglia dysfunction), Dystonia (Basal Ganglia) or Paratonia (inability to relax due to cognitive processing difficulties). Spasticity has a velocity and directional component. In other words, rapid changes in limb position will result in a “spastic catch” (the Jack-Knife phenomenon). Extension of the arms (at the elbow) and flexion of the legs (at the knees) is more likely to bring out increased resistance. Rigidity has increased tone in all directions that is not velocity-dependent. Dystonia is caused by over activation of agonist and antagonist muscles of the same joint concurrently (and hence is not really a “tone”issue). Patients with Dystonia tend to keep their limbs forcefully twisted in an uncomfortable position. Paratonia is inconsistent changes in tone secondary to a patient’s inability to relax fully when being examined.

Posture is best observed and is important in pediatric neurology. A “Frog leg” position of the legs shows abducted, flexed, and externally rotated legs and suggests hypotonia. “Scissoring” of the legs with vertical suspension suggests increased adductor tone which is usually caused by spasticity.

Fine Motor Coordination is assessed by the patient’s dexterity and speed in performing fine motor tasks. Injury to the Corticospinal Tract results in distal slowing and incoordination of fine finger movements. Likewise, many children with cognitive delays will have immature fine motor skills (fine motor dyspraxia) due to a more global “hardwiring” problem of the motor system.

Deep Tendon Reflexes (DTR’s) can be graded on a 4 point scale with 1 and 2 being normal, 3 suggesting pathological briskness (with “spread”) and 4 suggesting clonus. Exaggerated DTR’s suggests corticospinal tract dysfunction causing disinhibition of the locally-mediated spinal reflex. Absent or suppressed DTR’s may be a sign of an underlying peripheral neuropathy or myopathy.

Plantar Responses are normal if the great toe moves in a plantar (downward) fashion following an irritating stimulus to the foot. An “Extensor Plantar Response” results in extension of the great toe followed by abduction “fanning” of the rest of the toes. An “Extensor Plantar Response” suggests dysfunction to the Corticospinal Tract.

Involuntary Movements are usually due to dysfunction of the Basal Ganglia or their connections. A useful website for more information about movement disorders can be found at www.mdvu.org.

Chorea comes from the Greek word “Khoreia” which means literally “to dance”. Patients with chorea have rapid, near-continual, activation of regional muscle groups that move around in an unpredictable fashion. Even when sitting in a relaxed position, the erratic muscle contractions and limb movements can be felt by the examiner. Voluntary activation of the skeletal muscles of a limb (such as in performing a specific movement) will exaggerate the “choreaform” movements.

Athetosis suggests a more distal “snake-like” writhing movement with twisting and incoordination. Pathological processes causing chorea will also result in athetoid movements.

Tremor is an oscillatory back-and-fourth movement with equal amplitudes and frequencies in both directions of movement. Tremor can be broken down into “postural”, “ataxic” and “resting” subtypes.

Postural Tremor (4-11 Hz) needs to be distinguished from an “exaggerated” physiological tremor. Causes include autosomal dominant Familial Essential Tremor, caffeine or sympathomimetic drug use, and hyperthyroidism. Familial Essential Tremor likely localizes to dysfunction of the Subthalamic Nucleus. Postural Tremor is brought out by voluntary activation of the skeletal muscles (by having the patient extend

their arms in the air) and does not necessarily become more prominent with pointing toward a target. Action tremor should disappear when the limbs are completely rested.

Cerebellar Tremor (or “Action Tremor” or “Intention Tremor”) (3-10 Hz) is caused by dysfunction to the ipsilateral cerebellar hemisphere. The quality of this tremor is that it increases as the patient is approaching an object with an extended index figure. Patients may also have truncal ataxia and “titubation” (back-and-fourth rocking movements when trying to stand or sit) with midline or “pan-cerebellar” dysfunction). Nystagmus may also be a clue to cerebellar dysfunction.

Resting Tremor (3-6Hz) is a much slower tremor that is exaggerated when the patient is awake and the limbs are at rest. It dampens during voluntary movements. It is localized to dysfunction of the Basal Ganglia (e.g. Parkinson’s disease).

Tics are “un-voluntary” movements that tend to be stereotypic and affect localized groups of muscles or result in vocalizations. The can be differentiated from chorea by their stereotypic nature and their tendency to wax and wane over time (with new tics replacing older ones and older ones returning at future dates). Tourette syndrome is diagnosed in individuals having both motor and vocal tics (though not necessarily concurrently) for greater than one year duration.

Parkinsonism is defined by the symptom complex of bradykinesia, rigidity, resting tremor, and postural instability. These symptoms can be seen in Parkinson’s Disease (due to degeneration of the Substantia Nigral Dopaminergic innervations into the Corpus Striatum) or from other pathological processes affecting dopaminergic transmission in the Basal Ganglia. Medication-induced Parkinsonism is most common cause of Parkinsonism not due to Parkinson’s Disease. Bradykinesia is defined as a paucity of movement. Bradykinetic patients will have “masked facies”, a decreased spontaneous blink rate (closer to 12 per minute compared to 24 per minute in normal individuals), a “magnetic gait”, and be slow to get up when sitting in a chair. Rigidity differs from spasticity in that the increased resistance to passive range of motion is felt equally in flexion and extension and does not have a velocity-dependent component. Postural instability is a major cause of falls in patients with Parkinson’s disease. It can be elicited by having a patient stand upright and then applying mild backward pressure on their shoulders and seeing how well they retain their upright posture (verses falling backwards into the arms of the examiner).

Dystonia is really a misnomer as it is not a disorder of tone as much as an over action of antagonist and agonist muscles concurrently at an individual joint. Patients with dystonia tend to keep their limbs fixed in a twisted uncomfortable posture. As with other movement disorders (except for myoclonus) dystonia disappears with sleep and is more pronounced when a patient is agitated or uncomfortable. Dystonia can be further broken down into focal (a regional group of muscles), segmental (muscles from contiguous regional groups), and generalized (at least one foot/leg plus trunk or upper extremity involvement) distributions. Dystonia is often action-induced and many focal dystonias (such as writer’s cramp) are induced by very specific actions.

Myoclonus is a brief, shock-like contraction of a group of muscles. It may be generalized or involve focal muscle groups. Some causes of myoclonus are epileptic, though other causes may be due to metabolic disturbances (hepatic encephalopathy), or structural causes (palatal myoclonus due to injury of Mollaret’s triangle).

Hemiballismus is a violent, large amplitude flinging movement with arm abduction and extension. It is usually caused by ipsilateral damage to the Subthalamic Nucleus.

Sensory Examination

The sensory exam should be broken down into primary sensory modalities and cortical sensory modalities. Primary sensory modalities include light touch, vibration perception, joint position sense, and pain and temperature sensation. Deficits of primary sensory modalities are due to injury/dysfunction anywhere from

the skin receptors for these modalities, the peripheral sensory nerves, the ascending spinal sensory tracts all the way up to the Thalamus. The posterior columns carry ipsilateral vibration and joint position sensation. Position sense can be tested by gently moving the patient’s big toe in either flexion or extension and asking them which way the toe moved. Likewise, the Romberg sign (which is assessed by having the patient stand with arms extended and eyes closed to see if they keep their balance when vision is removed) is a function of perception of where the body is in space. Vibration sensation is assessed using a 128 Hz tuning fork and comparing your own sense with that of the patient as the vibration fades. Pain and temperature sensation are carried by small myelinated and unmyelinated sensory nerves which enter the spinal cord via the dorsal root ganglia to travel up and down 2 to 3 segments in Lissauer’s Tract. From there, second order neurons originating in dorsal lamina I, IV, and V cross the midline at the anterior commissure to travel up the contralateral lateral spinothalamic tract (pain and temperature sensation) and anterior spinothalamic tract (light touch sensation) to finally reach the Thalamus. Pain sensation should be distinguished from light touch by using a sharp pin (one per patient) and cold sensation can be differentiated from warm sensation using a cold object.

Cortical processing of primary sensory input results in further processing of the “raw data” primary sensory modalities. Deficits in cortical sensory function will result in contralateral difficulties in two-point discrimination, asterognosis, agraphesthesia, and extinction. Two-point discrimination is tested by providing either a single stimulus or two side-by-side stimuli concurrently. Stereognosis is tested by placing a coin or another familiar object into the contralateral hand of the affected patient and then by asking them to identify it by touch only. Graphesthesia is tested by writing numbers (without using ink) on the contralateral palm of the patient. Extinction occurs when patients can identify stimuli individually on the right or left side of their body, but not when stimuli are simultaneously presented bilaterally.

Coordination

Coordination essentially looks at cerebellar function. From a simplistic perspective, the cerebellum can be broken down into midline functions and hemisphere functions. The cerebellar midline structures provide balance input to the truncal musculature. Midline cerebellar deficits result in truncal ataxia, an ataxic speech, impairments with tandem gait, and truncal titubation. Cerebellar hemisphere dysfunction results in ipsilateral intention tremor, dysdiadochokinesis, hypotonia, excessive rebound, and nystagmus. Intention tremor can be evaluated by having the patient point their finger from their nose to the examiner’s finger. The “heel-knee-shin” test examines this function in the lower extremities. Dysdiadochokinesis is defined as difficulty with alternating supination/pronation hand movements. Rebound is the patient’s ability to keep their limb in a fixed position when the examiner suddenly releases their grip on the limb. Nystagmus is commonly seen with disorders of the cerebellum or its inputs/outputs.

Gait

Gait essentially puts together a lot of different neurological functions including vision, balance, joint position sense, strength, and postural tone. Ask the patient to walk back and forth across the room a few times. With each pass, check on a different aspect of their gait. Note the width of the base of the gait. Look for steadiness with balance. Look for fluidity in arm swing. Note if there is any crouching to the gait. Look for a well-placed heel strike with each foot and for equal amounts of time spent with each foot on the ground. When this is complete, one may wish to have the patient walk on their heels and toes and to perform an attempt at tandem walking. Classic gait abnormalities include the hemiparetic gait, the spastic diplegic gait, the high stepping gait, the waddling gait, the shuffling gait, and the ataxic gait. Try to imitate the patient’s “limp” and figure out exactly what mechanics lay behind their deficits.

 

 

Basic Competencies: Pertinent History Taking Skills

Adult Neurology: Minimum Criteria

The history contains enough information to begin the process of localization The history contains enough information to gain an understanding of the chronology and

severity of the disease process Information is obtained concerning psychosocial functioning of the patient as it pertains to

his/her illness Medication dosages and allergies are accurately listed

Child Neurology: Minimum Criteria

The history contains enough information to begin the process of localization The history contains enough information to gain an understanding of the chronology and

severity of the disease process A thorough developmental history/school performance history is identified Medication dosages and allergies are accurately listed

Aster demonstrating a thorough, yet pertinent Neurological History, sign in to your New Innovations page and click on the “Evaluations” tag. From there you can send a request to the resident or attending physician who heard your Neurological History to receive credit for completing this Basic Competency.

 

 

 

 

 

 

 

 

 

 

 

 

Basic Competencies: Neurological Examination Skills Adult Neurology: Minimum Criteria

The Neurological Examination demonstrates completeness by:

Containing components from each of the six sub-sets of the neuro exam (mental status, cranial nerves, motor, sensory, coordination and gait)

Application of the Neurological Examination by:

Correctly interpreting normal and abnormal findings to aid in localization of the disease process

Use of the neurological examination to quantify the severity of any neurological deficits identified.

Professionalism:

The approach to the patient during the examination shows respect for the patient’s privacy and dignity.

Child Neurology: Minimum Criteria

The Neurological Examination demonstrates completeness by:

Containing components from each of the six sub-sets of the neuro exam (mental status, cranial nerves, motor, sensory, coordination and gait), even if just by observation.

Pertinent “non-neurological” aspects of the examination are demonstrated (head circumference, dysmorphic features, cutaneous findings, etc).

Application of the Neurological Examination by:

Correctly interpreting normal and abnormal findings in an age-specific fashion

Use of the neurological examination to aid in localization of the disease process

Professionalism:

The approach to the patient shows courtesy and respect for the child’s modesty and parental concerns

Aster demonstrating a thorough Neurological Examination, sign in to your New Innovations page and click on the “Evaluations” tag. From there you can send a request to the resident or attending physician who watched you perform your Neurological Examination to receive credit for completing this Basic Competency.

 

 

Patient Log

The Liaison Committee on Medical Education requires that Clerkships specify the number and kinds of patients that students must evaluate in order to achieve the objectives of the clerkship. The Neurology Clerkship Grading Committee has determined that each student must be involved in the care of at least two patients with the following conditions:

Paroxysmal Disorders

Adult Neurology example include: Headaches, Seizures, Epilepsy, Channelopathies, etc

Child Neurology examples include: Headaches, Seizures, Epilepsy, Myotonia or other Channelopathies, etc

Vascular Disorders

Adult Neurology examples include: Stroke, Intracranial Hemorrhage, Hypertensive Encephalopathy, and Hypoxic-Ischemic Encephalopathy

Child Neurology examples include: Childhood Stroke, Neonatal Intraventricular Hemorrhage or Periventricular Leukomalacia, Hypoxic-Ischemic Encephalopathy

Neuromuscular Disorders

Adult Neurology examples include: Myopathies, Guillain-Barre Syndrome, CIDP, Charcot-Marie-Tooth, Diabetic Neuropathy, Amyotrophic Lateral Sclerosis, Traumatic or Focal Neuropathies, etc

Child Neurology examples include: Congenital Myopathies, Muscular Dystrophy, Guillain-Barre Syndrome, Spinal Muscular Atrophy, Charcot-Marie-Tooth Disease, Myasthenia Gravis, Erb’s Palsy, etc

Progressive Degenerative Disorders

Adult Neurology examples include: Alzheimer’s disease and other Dementia’s, Huntington’s disease, Parkinson’s disease, Vascular Dementia, etc

Child Neurology examples include: Leukodystrophies, Neurodegenerative Disorders, Metabolic Disorders, Brain Tumors, etc

It would be ideal to have experience caring for patients from each of the four categories within your three week rotation; however, this is not always possible given the relatively short duration of this clerkship and the different clinical settings in which each of you will encounter patients. As such, students will not be penalized if patients from each of these categories are unavailable to be seen and cared for by the student.

Documentation of your patient log is also contained within your New Innovations page under “Logger”. Be sure to put the age and diagnosis of your patient as well as the clinical setting in which they were seen within the appropriate disease category box (Paroxysmal, Vascular, Neuromuscular, or Progressive/Degenerative disorders).

 

Student Presentations

Students are required to give at least one short presentation covering topics that directly pertain to the diagnosis, treatment, pathogenesis, and/or prognosis of disorders that their patients are suffering from. Taking the initiative to educate yourself and others on your team is an important aspect of self-directed learning. Documentation of your presentation will be made through your New Innovations page under the tag of “Logger”. From there, you may send a request to the attending physician or resident who heard your presentation to receive credit for completing this clerkship requirement.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Identification. ___ ___-___ ___ ___-___ ___ ___

Pt. Date of Birth ___ ___/___ ___/___ ___

Hospital ________________________(___ ___-___ ___)

Date of Exam ___ ___/___ ___/___ ___

Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ________________________________(___ ___)

Time: ___ ___:___ ___ [ ]am [ ]pm Person Administering Scale _____________________________________ Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).

Instructions Scale Definition Score

1a. Level of Consciousness: The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

0 = Alert; keenly responsive. 1 = Not alert; but arousable by minor stimulation to obey,

answer, or respond. 2 = Not alert; requires repeated stimulation to attend, or is

obtunded and requires strong or painful stimulation to make movements (not stereotyped).

3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic.

______

1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.

0 = Answers both questions correctly. 1 = Answers one question correctly. 2 = Answers neither question correctly.

______

1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.

0 = Performs both tasks correctly. 1 = Performs one task correctly. 2 = Performs neither task correctly.

______

2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.

0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in one or both eyes,

but forced deviation or total gaze paresis is not present. 2 = Forced deviation, or total gaze paresis not overcome by the

oculocephalic maneuver.

______

Rev 10/1/2003

1

Patient Identification. ___ ___-___ ___ ___-___ ___ ___

Pt. Date of Birth ___ ___/___ ___/___ ___

Hospital ________________________(___ ___-___ ___)

Date of Exam ___ ___/___ ___/___ ___

Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ________________________________(___ ___)

3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11.

0 = No visual loss. 1 = Partial hemianopia. 2 = Complete hemianopia. 3 = Bilateral hemianopia (blind including cortical blindness).

______

4. Facial Palsy: Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.

0 = Normal symmetrical movements. 1 = Minor paralysis (flattened nasolabial fold, asymmetry on

smiling). 2 = Partial paralysis (total or near-total paralysis of lower

face). 3 = Complete paralysis of one or both sides (absence of

facial movement in the upper and lower face).

______

5. Motor Arm: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.

0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before

full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or

maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity.

3 = No effort against gravity; limb falls. 4 = No movement. UN = Amputation or joint fusion, explain: _____________________ 5a. Left Arm 5b. Right Arm

______ ______

6. Motor Leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.

0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does

not hit bed. 2 = Some effort against gravity; leg falls to bed by 5

seconds, but has some effort against gravity. 3 = No effort against gravity; leg falls to bed immediately. 4 = No movement. UN = Amputation or joint fusion, explain: ________________ 6a. Left Leg

6b. Right Leg

______

Rev 10/1/2003

2

Patient Identification. ___ ___-___ ___ ___-___ ___ ___

Pt. Date of Birth ___ ___/___ ___/___ ___

Hospital ________________________(___ ___-___ ___)

Date of Exam ___ ___/___ ___/___ ___

Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ________________________________(___ ___)

______

7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position.

0 = Absent. 1 = Present in one limb. 2 = Present in two limbs. UN = Amputation or joint fusion, explain: ________________

______

8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, “severe or total sensory loss,” should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item.

0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient feels pinprick is

less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched.

2 = Severe to total sensory loss; patient is not aware of

being touched in the face, arm, and leg.

______

9. Best Language: A great deal of information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands.

0 = No aphasia; normal. 1 = Mild-to-moderate aphasia; some obvious loss of fluency

or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response.

2 = Severe aphasia; all communication is through fragmentary

expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response.

3 = Mute, global aphasia; no usable speech or auditory

comprehension.

______

10. Dysarthria: If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for this choice. Do not tell the patient why he or she is being tested.

0 = Normal. 1 = Mild-to-moderate dysarthria; patient slurs at least some

words and, at worst, can be understood with some difficulty.

2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric.

UN = Intubated or other physical barrier, explain:_____________________________

______

Rev 10/1/2003

3

Patient Identification. ___ ___-___ ___ ___-___ ___ ___

Pt. Date of Birth ___ ___/___ ___/___ ___

Hospital ________________________(___ ___-___ ___)

Date of Exam ___ ___/___ ___/___ ___

Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ________________________________(___ ___)

11. Extinction and Inattention (formerly Neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.

0 = No abnormality. 1 = Visual, tactile, auditory, spatial, or personal inattention

or extinction to bilateral simultaneous stimulation in one of the sensory modalities.

2 = Profound hemi-inattention or extinction to more than

one modality; does not recognize own hand or orients to only one side of space.

______

______ ______

Rev 10/1/2003

4

5

You know how. Down to earth. I got home from work. Near the table in the dining

room. They heard him speak on the

radio last night.

6

7

,; ~ 1\ I, 1c_---

I~ \

I ~I \ j ,

I

\ \' ,\ ~ I

MAMA

TIP – TOP

FIFTY – FIFTY

THANKS

HUCKLEBERRY

BASEBALL PLAYER

8

 

 

 

 

 

 

 

 

 

 

Useful Muscles to Test: Lower Extremities

Muscle Limb Function Nerve Root

Iliopsoas Hip Flexion roots L1, L2

Hip Adductors Hip Adduction Obturator Nerve L2, L2

Glut Medius and Minimus

Hip Abduction Sciatic -> Inf. Glut.

Nerve L4, L5, (S1)

Gluteus Maximus Hip Flexion Sciatic -> Sup. Glut.

Nerve L5, S1, (S2)

Hamstrings Knee Flexion Sciatic Nerve S1

Quadriceps Knee Extension Femoral Nerve L3, L4

Tibialis Anterior Ankle Dorsiflexion Deep Peroneal Nerve L4

Gastrocs/Soleus Ankle Plantar flexion Tibial Nerve S1, S2

Tibialis Posterior Ankle Inversion Tibial nerve L4, L5

Peronei Muscles Ankle Eversion Superficial Peroneal

Nerve L5, S1

Ext Dig Longus/Brevis Toe Extension Deep Peroneal Nerve L5, S1

Intrinsic Foot Muscles Toe Flexion Med. and Lat.

Plantar Nerves S1, S2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sensory Dermatomes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Differential Diagnosis by Disease Category

Toxic/Metabolic Includes: Endogenous disorders (glucose or electrolyte abnormalities, liver failure, renal disease, endocrine abnormalities, IEM’s) and exogenous exposures (medications, drugs, toxins, radiation, poisons, etc).

Infectious/Post-Infectious/Auto-Immune Includes: CNS infections (meningitis, encephalitis, brain abscess, neurosyphyllis, TORCH infections, etc.) and systemic infections with CNS complications. Also includes Demyelinating disorders, Guillain-Barre syndrome, and other autoimmune diseases (SLE, sarcoid, vasculitis, etc).

Neoplastic/Paraneoplastic Includes: Primary and Metastatic CNS tumors and Paraneoplastic syndromes (OMS, limbic encephalitis, Lambert Eaton, and other Paraneoplastic disorders).

Trauma Includes: Contusions, Concussion, TBI, Intracranial Hemorrhage, etc.

Vascular Includes: Ischemic and Hemorrhagic Stroke, Vasculitis, Vasculopathies, Venous Sinus Thrombosis, Artery Dissection, and Watershed Infarction, Hypoxic-Ischemic Encephalopathy (IVH and PVL in preemies).

Structural Includes: Hydrocephalus, Pseudo tumor Cerebri, Chiari Malformation, Syringomyelia, Spina Bifida, Spinal Stenosis, Spondylosis, Nerve Entrapment Syndromes, Developmental Brain Malformations, etc.

Paroxysmal Includes: Seizures, Epilepsy, Headache Syndromes, Channelopathies, Paroxysmal Movement Disorders, etc.

Psychiatric Includes: Conversion Disorders and Malingering, Mood Disorders, etc.

Degenerative/Genetic Includes: Neurodegenerative Disorders (Dementias, Parkinson’s, Huntington’s disease, Leukodystrophies, ALS, SMA, etc.) and Genetic Disorders (Down syndrome and other chromosomal disorders, Rett syndrome, Fragile X, Myotonic Dystrophy, Duchene Muscular Dystrophy, Charcot-Marie-Tooth, etc.)

Basically any disorder of the central or peripheral nervous system should fit into one or more of these disease “categories”. Use this list to expand your differential diagnoses and to help keep you from neglecting to think about certain disorders that did not immediately pop into your mind.

Developmental Milestones

AGE Gross Motor Fine Motor Language Social

1M Raises head from prone position

Visually fixatesClenches fists tightly

Brings hands to mouth & face

Alerts to sounds Regards face

2M Lists chest off table

Brings hands to mid -line (to mouth)

Tracks 180° No longer clenches fist

tightly

Coos in response Social smile

3M Supports on forearms in

prone Holds head and chest up

Holds hands open Holds object placed in hands Babbles randomly

Anticipates feedings Reaches for familiar

objects

4M Rolls over front to back Achieves Head control

Supports on wrist

Reaches out for object with both hands

Hands to midline Laughs aloud Enjoys looking

around

5M Rolls back to front Transfers Reaches out unilaterally Razzes

6M Sits when placed, Anterior

propping Helps hold bottle

Raking grasp Babbles rhythmically Stranger anxiety

7M Gets in to sitting posture by self Orients to Bell

indirectly

8M Commando crawl Finger Feeds “Dada” indiscriminately

9M

Lateral propping Pulls to stand

Crawls with legs underneath body

Cruises

Immature pincer grasp Holds Bottle

Throws Objects

“Mama” indiscriminately

Understands own name

Gesture games “Pat-a-cake”

Waves “Bye-Bye”

10M Walks when both hands held Orients to Bell directly

11M Walks with one hand held One word plus “Mama / Dada” specifically

 

 

 

 

 

 

AGE Gross Motor Fine Motor Language Social

12M

Walks alone

Posterior propping

Drinks from sippy cup Marks paper with crayon

Mature Pincer Grasp

One step command with gesture

2 other words Babbles with inflection

Enjoys imitating Cooperates with

dressing

15M

Creeps upstairs

Plays with ball

Stoops to flore and recovers

Line with crayon 2 bloc tower 4-6 words Uses spoon and cup

independently

18M

Runs

Stairs with hand held

Throws overhand

Scribbles spontaneously 3 block tower

7-20 words 5 body parts

2 word combination

Copies task (ej. Dusting, swiping)

24M

Runs well

Kicks ball

Walks up & down stairs w/o help

Vertical jump

Turns pages one at a time Removes shoes / pants

7 bloc tower

50 word vocabulary Speech 50%

intelligible Pronouns (I, you, me)

Parallel play Uses spoon adequately

3Y

Alternates feet going up stairs

Pedals tricycle

Unbuttons Copies circle

Undresses completely

250 words 3-5 word sentence

Speech 75% intelligible

Knows name, age & gender

Interactive play

4Y Hops / Skips Copies cross, square Dresses self

Colors, shapes, ABC song

Speech 100% intelligible

Cooperative play

5Y Swings / Climbs Dresses and undresses

unassisted Prints some letters

May print name Recalls part of story

Abides by rules Helps with chores

 

NOTE: Pre-school 4 ½ to 5 yrs.:

Alphabet song, some letters Count to 10 Knows most colors and shapes Recognizes domestic animals May spell first name

Useful Motor Developmental Milestones & Concentration Tasks in School Age Children

 NOTE:

Posturing with stressed gait is considered abnormal past 10yrs of age Motor overflow (Synkinesis) is considered normal until 10yrs of age  Other cognitive, months of year forward & backwards greater than 10yrs of age

 

AGE Gross Motor Fine Motor Digit Span Motor Sequence

5-6Y

Skips Walks on heels

Tandem forward Hops in place

Opens and closes hands in sequence 4 Forward

Simultaneous open & close both hands, arms

extended

6-7Y Tandem backwards Stand on one foot

ShoelacesAlternates L&R index to

nose with arms extended

4-5 Forward Open close hands in sequence

7-8Y

Crouch on tiptoes eyes closed 10 sec

Hop 2x on each foot in succession 3 cycles

Sequential finger opposition (F&B) 5 sec 5 Forward

9-10Y Catch ball in air Tandem sideways

Make paper ball with one hand

6 Forward4 Reverse

11-12Y

Balance tiptoes eye closed 15 sec

Jump and clap hand 3x

Place pennies in box one at a time

6 Forward 5 Reverse

Imitate hand edge on knee, palm knee then

clenched fist (4 cycles)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stephen Deputy, MD - Clerkship Director, sdeput@lsuhsc.edu (504) 913-4964

James Breazeale - Clerkship Administrator, jbre11@lsuhsc.edu (504) 568-4090  

Neurology Residents Phone Email

Raisa Martinez, MD, Chief 787-529-8941 rmarti@lsuhsc.edu

Faraz Khursheed, MD, 267-506-0852 fkhurs@lsuhsc.edu

Frank Williams, MD, 504-343-3934 fwill2@lsuhsc.edu

Gelasio Alberto Baras, MD, 786-683-6651 gbaras@lsuhsc.edu

Christopher Edwards, MD, 504-235-2972 cedwa3@lsuhsc.edu

Saurabh Lalan, MD, 504-261-3159 slalan@lsuhsc.edu

George Oganisyan, MD, 360-991-5759 zogani@lsuhsc.edu

Child Neurology

Rashimi Rajendre, MD 334-294-9985 rrajen@lsuhsc.edu

Daniella Miller, MD 631-252-1842 dmill4@lsuhsc.edu

 

Children’s Hospital

200 Henry Clay, Ste. 3040

New Orleans, LA 70118

(504) 896-9283

Interim LA Public Hospital

2021 Perdido Street, 4th Floor

New Orleans, LA 70112

(504) 903-3000

LSUHealth Clinic @ L&T

1340 Poydras Street, 3rd Floor

New Orleans, LA 70112

(504) 903-1965

LSUHealth Faculty Medical Practice

3700 St Charles Ave, 4th Floor

New Orleans, LA 70115

(504) 412-1517

LSUHealth @ Touro

1401 Foucher Street

New Orleans, LA 70118

2014-2015 Core Clinical Conditions Internal Medicine

Progress Note Feedback

Student, John Q

(1314MEDI01340890162)

Criteria:May occur with inpatient progress note or outpatient clinic note.

Must be signed by a faculty member.

________________________________________________Faculty Signature

I reviewed and provided feedback on this student’s progress note.

Internal MedicineAbdominal Pain

2013-2014 Core Clinical Conditions

Adams, Mason

(1314MEDI01340890102)Diagnosis: ______________________________________

______Actual Patient

Age/Sex of Patient _________

_________________________________________Faculty/Resident Signature Required

______DxR Case Sam Greene

Date Case Completed _________

Internal MedicineAcid-Base Disorder

2013-2014 Core Clinical Conditions

Adams, Mason

(1314MEDI01340890103)Diagnosis: ______________________________________

______Actual Patient

Age/Sex of Patient _________

_________________________________________ Faculty/Resident Signature Required

______DxR Case Anita Brown

Date Case Completed _________

Internal MedicineAcute Renal Failure

2013-2014 Core Clinical Conditions

Adams, Mason

(1314MEDI01340890104)Diagnosis: ______________________________________

______Actual Patient

Age/Sex of Patient _________

_________________________________________Faculty/Resident Signature Required

______DxR Case Crystal Bates

Date Case Completed _________

DRAFT