Sunday, August 15, 2010
NewFNP has a few more pearls she brought home that she thought she would share with her NP colleagues and students. They pertain to neurology.
NewFNP was recently visiting BostonFNP who noted that if a patient can climb up onto the exam table, half of her neuro exam was done. An exaggeration, sure, but it makes a point: a busy clinician needs a high yield and fast exam. So, here you go.
Regarding Mental Status -- The MMSE tests the hippocampus only. In a screening test, if the patient can give a 100% coherent history, the mental status exam is likely normal. One must test fluency, comprehension and repetition to determine if language is intact.
Regarding Cranial Nerves -- The cute and funny neurologist at the CME extravaganza notes that visual field testing is extremely informative and underutilized by generalists. In patients who are unable to cooperate, the examiner may point one finger towards the eye of the patient. This should elicit a blink in both eyes and can be recorded as blinking or not blinking to threat.
Regarding Upper Motor Neuron/Pyramidal Weakness -- Assess for pronator drift as the supinator muscle is an extensor muscle which are weaker than flexor muscles. Assess fine finger movements and toe tapping. Is one side faster than the other? If so, problem. Assess one muscle in each of the four extremities. Position the patient in the desired position and tell them, "Don't let me push you down." Test the fingers and big toes bilaterally and you're set.
Regarding Sensory Testing -- Pick either vibration or position sense and temperature or pinprick and test each big toe. Done. Because if your patient is losing sensation, it's starting distally. If the exam is positive, you can move it on up. You can trace a pin up a patient's abdomen and ask him if there is a spot where the sensation changes. If so, map it out with your dermatomes and you'll know where the spinal lesion is.
Ankle clonus indicates a severe upper motor neuron lesion.
To distinguish between true and psychogenic weakness, have the patient bend their arm and you move it down. If a patient is truly weak, the examiner should be able to overcome the patient smoothly. If it's psychogenic or weakness from fatigue, you will note breakaway weakness -- the patient resists at first and the movement is jerky and then the patient no longer resists and the movement is smooth.
The Romberg is a hell of a good test. All you have to do is ask a patient to stand, put their feet together and close their eyes. If they can't stand, you know that their vestibular and/or motor system is jacked. If they can't put their feet together, their cerebellum is effed up. If they fall when they close their eyes, their proprioception is on the fritz and you have a positive Romberg.
And finally, BostonFNP was right -- the single most useful neuro exam is ambulation. Have the patient walk, turn and walk again. Have them walk on their tippy-toes and have them tandem walk.
NewFNP cannot believe that she is back in her urban abode and having to work a real day tomorrow. Thank goodness Gap of all places had some new flattering trousers and a cute stripy boatneck top to ease newFNP back into her work week.