Admissions | The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

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Admissions

A. Note:

Most important features are underlined, but these are guidelines only. It can be wasteful and, in emergencies, even dangerous to test everything.

General Exam

VS: BP, HR, temperature, respirations, orthostatic BP.
Skin: Petechiae, rash, striae, telangiectasias, caput medusae.
Head: For trauma exam, see p. 119.
- Eye: Papilledema, retinopathy, icterus.
- Skull: Trauma, craniotomy.
- Other: Temporal wasting or tenderness, ears, nose, throat, thrush.
Neck: Stiffness, carotids/bruits, thyroid, jugular distension, nodes.
Back: Lungs, spine tenderness, pelvic stability.
Chest: Heart, breasts, nodes.
Abdomen: Bowel sounds, bruits, palpation, nodes, liver, hernias, scars.
Genitourinary: Hair, testis size/masses, lesions, pelvic exam.
Rectal: Guaiac, masses, tenderness, tone.
Limbs: Pulses, color, edema, splinters/clubbing, calf pain, Homan's sign, range of motion, straight leg raise.

Neurological Exam

Mental status: For coma exam, see p. 30. For psychiatric mental status exam (including the Mini-Mental Status Exam), see p. 98
- Orientation: Self, date, place.
- Attention: Say months backwards; spell world backwards.
- Memory: 3 objects, presidents.
- Speech: Naming, fluency, comprehension, repetition, read/writing.
  - F test: Number of words beginning with F in 60 sec (>12 if high school education).
  - Passive construction comprehension.
- Frontal:
  - Perseveration: Go-no go task, copying Luria diagram.
  - Disinhibition: Snout, grasp, imitation behavior.
  - Abulia: Affect, response latency.
- Parietal:
  - Neglect: Limb recognition, clock draw, bisect line.
  - Calculations: Serial 7's, etc.
  - Praxis: Blowing out a match, tying a shoe.
  - Spatial orientation: Directions, commands across midline.
  - Agnosia: Finger agnosia, anosognosia, alexia without agraphia, color naming.
- Cognition: Insight, judgment, logic, proverbs, subjunctives.
- Thought content: Hallucinations, delusions, paranoia.
- Mood: SIGECAPS criteria, suicidal or homicidal ideation, mania.

P.12

Cranial nerves
- CN I: Smell.
- CN II: Pupils, fundi; fields, acuity, blink to threat, red desaturation. Pts with hysterical blindness (see p. 104) or cortical blindness have normal pupils, blink to threat.
- CN III, IV, VI: Horner's, EOMs, saccades, pursuit, optokinetic reflex, cover-uncover test, red glass test, upper lid.
- CN V: Sensation of forehead/cheek/chin, corneals, jaw.
- CN VII: Symmetry, brow raise, eye close, nose wrinkle, grimace, cheek puff, anterior taste.
- CN VIII: Tympani, hearing (see p. 54), balance B r ny's test.
- CN IX-XII: Palate, gag, sternocleidomastoid, trapezius, tongue.
Motor
- Strength: Drift, fine finger movements, heel/toe walk, knee bends.
  - Individual muscles: Include hip adductors, pronation/supination, inversion/eversion, abdominal muscles.
  - Subtle signs: Wartenberg's (pull flexed fingers; thumb flexes), stress gait (walk on outside of feet, look for posturing), mirror movements with finger sequencing, testing multiple repeats.
- Bulk: Atrophy, fasciculations.
- Tone: Rigidity, spasticity, cogwheeling, dystonic posturing, myotonia. If pt. not cooperative, drop limb to test tone (malingering pts. may not let limb hit face).
- Extra movements: Tremor, dysmetria, myoclonus, tics, dyskinesias, asterixis.
- Reflexes: Biceps, triceps, brachioradialis, knee, ankle, Babinski.
  - If brisk: Check clonus, spreading, palmomental, jaw jerk, Hoffman's sign (flick nail down, watch for thumb contraction).
  - If frontal damage: Glabellar, grasp, snout, suck.
  - If spinal cord injury: Abdominals, suprapubic, cremasteric, wink, bulbocavernosus.
- Tests for hysterical weakness: see p. 103.
Cerebellar
- Appendicular: Finger-to-nose, rapid alternating movements, fine finger movements, finger following ( mirror test ), lack of check, toe tapping, heel-to-shin, decreased tone, arm swings after shaking shoulders (nl < 3), pendular reflexes.
- Axial: Gait, tandem, axial stability, stand on line, walk in circle, march with eyes closed (advancing more than a few feet or rotating more than 30 degrees in 30 sec is abnormal).
- Voice: Dysarthria, holding a tone, la-la-la, say Methodist-Episcopal, count to 20 fast.
Sensory
- Pin: All 4 limbs; trunk for level; nerve distributions, summation.
- Light touch: Cotton wisp; 2-point discrimination.
- Proprioception: Joint position, vibration, Romberg, nose touch.
- Cortical: Dual simultaneous extinction, stereognosis, graphesthesia.
- Temperature: Try side of tuning fork or alcohol swab.
- Anal: If you suspect spinal cord lesion, check anal wink, tone, bulbocavernosus reflex.
- Tests for hysterical weakness: see p. 103.

Admission Orders

Notifications: Speak to family members; the senior resident; private neurologist; internist, floor or nurse accepting the pt.
Orders: ADCVAANDISCL.
- Admit: Service, admitting physician, resident to page.
- Diagnosis: Be specific.
- Condition: Good, fair, guarded, critical.
- Vital signs: Specify only if other than per routine.
- Allergies: List the reaction too, e.g., contrast dye anaphylaxis.
- Activity: Bedrest with head up 30 degrees? Up with assist? Ad lib?
- Nursing: Pneumo-boots? Guaiac all stools? Etc. Nurses get annoyed that MDs call this category nursing it is all nursing.
- Diet: NPO? Aspiration precautions? Low salt or cholesterol? DM? Renal? Dysphagia?
- Ins/Outs: Done automatically in most ICUs; harder to do on general wards. If it is important, consider a bladder catheter. Daily weights may need a special request outside the ICU.
- Special:
  - Oxygen or ventilator settings.
  - Bleed risk? Blood bank sample, guaiac stools, orthostatic BP, large-bore IV.
  - CHF? Strict I/Os, daily weights.
  - Chest pain? Oxygen, cardiac monitor, bedside commode, CPK/isoenzymes/troponins q8h 3.
  - Mental status change? (see p. 42) Restraint 72 h prn safety, aspiration precautions.
  - Clot risk? Pneumo-boots, SC or low MW heparin (if DVT, full anticoagulation, elevate foot, bedrest), neurovascular checks.
  - Hyper- or hypotension: BP parameters and drugs.
  - Skin care.
- Consults: Consider social service, physical therapy, occupational therapy, speech/swallow
- Tests (Labs): bid PTT? Daily PT/INR? qod electrolytes/BUN/Cr?
Drugs: Consider
- Rehydration? D5NS at 60 cc/h if concern for brain edema.
- Sleeping pill? (Avoid if pt confused). see p. 112. Zolpidem 5-10 mg, diphenhydramine 25-50 mg, or lorazepam 0.5-1.0 mg.
- Pain? Acetaminophen 650 mg q4h prn, opiate + constipation rx, etc.
- GI? E.g., senna tablets, omeprazole 20 mg qd, bisacodyl (Dulcolax) + PR qd prn, milk of magnesia 30 cc q8h prn.
- Diabetes? NPH insulin + regular (CZI) sliding scale: for BG <200: 0U; 200-249: 2U; 250-299: 4U; 300-349: 6U; 350-399: 8U; >400: 10U. Alternatively, substitute aspart or lispro at night.
  - Hypertension? E.g., captopril 25 mg PO, or metoprolol 50 mg PO bid prn SBP >180. For IV drugs, see p. 172.
  - Hypotension? IV fluids; consider midodrine 10 mg PO tid or IV drugs (see p. 172).
- Chest pain? Avoid hypotension in stroke or carotid dz.
  - SL nitroglycerine: 0.3 mg q5min prn 3 while SBP >120.
  - NTP SS: q4h for SBP <120: wipe, 120-134: 0.5 in.; 135-149: 1 in.; 150-164: 1.5 in.; >165: 2 in.
Admission note: Age, handedness, chief complaint, history of present illness, past medical history, allergies, medicines, family and social history (always include education), review of systems, physical exam, labs, assessment, plan.
- Assessment by issues: Neuro, cardiovascular (pump, rate, rhythm, valves, etc.), pulmonary, renal, fluids/electrolytes/nutrition, infectious dz, GI, GU, hematologic, endocrine, dermatologic, oncologic, orthopedic, psychiatric, rheumatologic, code status, discharge plan.
- Etiologies: Traumatic, vascular, high ICP, toxic, metabolic, psychiatric, infectious, inflammatory, neoplastic, epileptic, degenerative.