Neuro Exam

00:01 Let’s get back to the nervous system because one of the first things you do when you start talking to a person is make sure that they’re a good historian.

00:10 Make sure that you can trust what they’re saying, or if you’re not going to trust what they’re saying, establish that early.

00:18 When I talk to patients in another language, I often have trouble telling if they’re confused or not because it doesn’t feel the same when it’s not in your native tongue.

00:30 If somebody’s oriented to time, place and person that’s the basics to start a conversation, but if you say what time is it? Or what day is it? Or what year is it? They look at you funny but there are ways of saying, “What’s your name?” Checking the name and make sure that the armband is the same name the person is giving you.

00:50 It is a quality control that matters.

00:53 Place—what brings you here? What brings you to the hospital? What part of the hospital? Have you been to the hospital before? Those are some basics.

01:02 Oriented x4 tests whether or not they understand the seriousness of their event, the seriousness of their condition, and whether they are capable of making decisions.

01:12 In the emergency room, this is a lot more important than in the office.

01:15 In the office, most people are oriented, much more so than in the ER, where you don’t have substance abuse issues to deal with as much.

01:25 But it’s always important to establish that the person understands they are sick, and that if they have chest pain and confusion, they can’t leave.

01:34 Or if they’re just scared, it’s good to know that too.

01:39 The musculoskeletal system.

01:42 We tend to look at the muscles and examine the joints, but we need to examine both of them in the same way We need to look at how the muscles are functioning.

01:51 Is there free motion? Are they in Fryette’s rule #1 which is fluid motion sidebend right, rotate left, push the weight control and the weight on as much of the vertebrae as possible looking fluid, and assessing any limitations? So can they do 90°, 90°, 45°, 45°, flex to 90° and extend to 15°.

02:15 Do you have full functional motion? Is there a single spot or region that’s standing out, that the person is protecting, or splinting or guarding against the exam? It’s a good thing to notice early on and did this change and is this pain or problem there all the time or sometimes? Does it develop as they’re doing something for long periods of time? Those are very helpful aspects to the musculoskeletal exam.

02:45 The other thing that’s unique to the musculoskeletal exam, is that things tend to spread.

02:52 When somebody hurts themselves, they can identify it easily.

02:55 They punch something, they hurt— they can identify it.

02:58 A couple hours later it tends to spread and they tend to have a harder time saying exactly where the pain is, and they’ll expand the range of what they’re complaining of, and that’s when touching the area involved noticing any tenderness, any warmth, any tissue texture change, will help.

03:17 Another question is, when do you expose the area and examine the skin? And when do you need to see the skin? And it’s hard that we can’t give a consistent answer because if someone’s wearing yoga pants, it’s easy to examine them and get a sense of what their motion is.

03:33 If they’re wearing jeans, it’s harder and you may not be able to get a good sense of what the tissue texture is, if there is tenderness, if there are areas of mushiness or softness of the muscle, because the cloth will matter.

03:47 So if there’s ever a question, it's important to get someone undressed and examine them that way.

03:56 Again, we try and standardize how we assess muscles.

03:59 Most people in the office are going to have a muscle strength of 5/5.

04:03 And that means they move well against gravity and they’re able to function, lift weights, and move things around.

04:11 If you’re in the hospital, and somebody is unable to move— that you can’t even get a contraction, might be central or might be peripheral, but that’s a 0.

04:20 No muscle contraction is 0 muscle strength.

04:24 If they can contract, but they can’t move, if you see them making an effort, that’s a 1/5 muscle strength.

04:31 If they can move the limb but it falls down quickly, that’s a 2.

04:37 They can lift it but they can’t sustain the lift against gravity.

04:41 It’s a 3/5 muscle strength if they can move against gravity.

04:46 It’s a 4/5, if you can push down and it can resist you.

04:49 And it’s a 5/5 muscle strength if they have full strength and can move around comfortably.

04:56 We also assess deep tendon reflexes to tell us how their innervation is and what’s going on.

05:01 If they have no response, no deep tendons—that’s a 0, mild reflex is 1, normal reflex is 2, hyperreflexia is 3, and clonus is when you have the clapping and the multiple muscle movements.

05:17 So there is an ARTT to examining the musculoskeletal system and assessing muscles.

05:22 You look for any asymmetry, any difference between the left and right side, top and bottom.

05:26 You look for range of motion abnormalities, a long of motion and a loss of ability.

05:31 And you look for tenderness, tissue texture changes or temperature changes.

05:36 Those are the ARTT that you have to practice to see whether the musculoskeletal system is affected.

05:43 A lot of times, people will come to osteopathic physicians because they know we’ll focus on the musculoskeletal system.

05:49 Others don’t think the musculoskeletal system is part of their routine physical exam and they don’t bring it up to us because they don’t see that as the problem, that’s something they live with.

06:01 There is so much back pain out there.

06:02 There’s so much musculoskeletal difficulty that it tends to get glossed over as everyday life.

06:10 And when you start examining and doing the physical exam, every part gets inspected, gets palpated or touched, gets percussed to sense the thickness of what’s inside, and auscultation where you can listen and hear heart/lungs lung sounds, that’s part of the full exam.

06:29 In the musculoskeletal exam again, it’s a little bit more diffuse exam and you may need to expand both 1 joint above and 1 joint below.

06:37 A lot of times people will focus on their joints they use the most and not the ones they just damaged.

06:44 So you don’t want to miss a broken elbow because you’re examining the wrist.

06:48 So always examine 1 joint above and 1 joint below.

06:51 Splinting or stopping motion is very common and you need to look for that as well.