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Limbo Landers and Newly Diagnosed This is a place for those who are still in "limbo" and those who have been recently diagnosed with Multiple Sclerosis . A place to share your thoughts and experiences.

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  #1  
Old 09-22-2012, 03:47 AM
22cyclist 22cyclist is online now
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NEUROLOGICAL EXAM EXPLAINED

What is your neurologist looking for? It is simple really. Neurology is very localizing so everything you do from the moment you walk in to the office is being analyzed. You will not know it, but it is. The following is an explanation of the complete neurological exam for the purpose of the MS evaluation:

1. EVALUATE MENTAL STATUS/COMMUNICATION AND ATTENTION SPAN.

A. Does the patient answer questions appropriately and in a timely manner? (Slowness could mean loss of cognitive function)

B. Does the patient have dysartria? Trouble pronouncing "T, M, L, or G". (Could be a sign of IX or IX, or VII cranial nerve palsy).

C. Does the patient have dysphonia? Low voice...trailing off voice. (Could be a sign of X nerve palsy).

D. Are the sentences smooth, or are they short and choppy as seen in MS dysarthria? Are they searching for words?

2. OPTIC NERVE: Cranial nerve II

This nerve is tested by having the neurologist look into your eye with a light and actually view your optic nerve to check for inflammation. This test is limiting in that it can only test for front of the optic nerve swelling not behind the disk swelling.

3. OCULOMOTOR NERVES: Cranial nerves III, IV, and VI

These are tested together if one is not obviously in palsy. Testing is done by having you look up, down, left, right, in an H pattern.

A. A third nerve palsy is when there is a dilated pupil, an eye that deviates outward, ptosis, or a combination of these defects. The lesion is on the same side (Localizing).

B. A forth nerve palsy is when thee is an inability of the opposite side eye to look down and in.

C. A sixth nerve palsy is when the patient is unable to look toward the same side of the lesion.

4. TRIGEMINAL NERVE: Cranial nerve V: Trigeminal nerve has both sensory and motor components. For testing:

A. Sensory: The neurologist will lightly touch your face and forehead and top of scalp with sharp and dull objects on both sides to test for differences.

B. Motor: They will test your motor control by having you clench your teeth and test your jaw muscles.

C. Corneal reflex: They can test by using a wisp of cotton and touching your cornea to see if there is a response. If no response, then the trigeminal nerve is damaged.

5. FACIAL NERVE: Cranial nerve VII:

They will have you raise your eyebrows, move your face around, smile etc. Normal is symmetrical.

6. VESTIBULAR NERVE: Cranial nerve VIII:

They will rub their fingers around your ear to test your hearing. Also test for balance. This is tricky with MS but can be sorted out with other test because of its localizing value.

7. GLOSOPHARYNGEAL AND VAGUS NERVES: Cranial nerves IX and X:

Tested together, IX affects the sensory portion of the pharynx and the ability to taste in the posterior portion of the tongue. Cranial nerve X's function is mainly motor and affects speech and swallowing.

A. Testing: They will listen to your voice. Any hoarseness, or harshness may show deficit. If both sides are affected, difficulty with swallowing will be present.

B. They will look in your throat. If your tongue is not midline, this could be a sign of IX nerve palsy. If your uvula deviates to one side when you say "ah", it could be a sign of X nerve palsy.

C. They will test your gag reflex.

8. SPINAL ACCESSORY NERVE: Cranial nerve XI

This nerve controls the muscles of the neck and shoulder.

A. They will have you push against their hand with your face. Tests for weakness in this nerve.

9. HYPOGLOSSAL NERVE: Cranial nerve XII

This nerve is the motor function that controls tongue movement.

They will have you stick out your tongue. Any deviation or atrophy shows damage to this nerve and can cause problems with speech and swallowing.

ALL OF THESE ARE ROOTED IN THE BRAINSTEM AND ARE IMPORTANT IN THE TESTING OF MS.

Now for the motor part of the exam:

1. WALKING: They will observe you walk to look for subtle weakness in your legs.

2. WALKING ON HEELS: Tells them how much weakness you have in your legs.

3. WALKING ON TOES: Tells them how much spasticity you have in legs.

4. HEEL TO TOE WALKING: Tells them about your balance.

5. HOP ON ONE FOOT: Brings out subtle weaknesses.

6. Hold your arms out in front of you: This assesses three things.
1. If you have overshoot.
2. If you have spacticity in your arms.
3. If you have pronator drift (weakness in your arms).

7. ROMBERGS TEST: Often done with the hold your hands out test. Tests for balance and lesions. It really also tests for inner ear problems. A person with a positive ROMBERG will fall toward the lesion.

8. Strength: push and pull against me:

This assesses both your strength and spasticity. You can have both. In MS people have a cog-wheel spasticity. You don't want to arm wrestle us.

9. BABINSKI REFLEX:
One of the most important tests. This will by far tell the most about what is going on in your brain. Only babies and brain damaged adults have this.

This is when the doc scrapes the heel of your foot with an object and your big toe either goes up, or crunches down.

If it goes up and the other toes fan out, you have the reflex and have some sort of brain damage be it MS or otherwise. This cannot be faked if a good neurologist is doing it. It is a reflex.

10. You will also get the standard pin/cotton tests everywhere...do you feel this, more or less.

11. Vibration: With a tuning fork, the neurologist will strike a bone with this fork and ask you when you stop feeling the vibration, or if you feel it at all, or if it is the same on both sides. They are testing symmetry and lesion location.

I am sure I have missed some, but in the end, neurology is very localizing. You can almost find a lesion by exam and confirm it later by MRI. We do need MRI's, however, nothing replaces a good PE.
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Old 09-22-2012, 09:42 AM
JerryD JerryD is online now
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Thanks for this info. I knew the neuros did something, I just didn't know what.
Mine spends the time during consultation asking questions and discussing new treatments or drugs. All conversation and no treatment = $400.00 bill. Thanks for taking the time to explain the finer points of the exam process.
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Old 09-22-2012, 04:24 PM
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22cyclist Neuro Exam

I can not jump, hop, skip. If I fall I cannot get up unless someone helps me or I have something to pull me up. What does this mean? Does anyone else have this?

My whole body head to toe, literally feels numb, face, neck, shoulders, arms, back, obliques, legs feel spastic.

Scared
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Old 09-22-2012, 05:18 PM
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Quote:
Originally Posted by baydenoc View Post
If I fall I cannot get up unless someone helps me or I have something to pull me up. What does this mean? Does anyone else have this?
Yes, I do. When I fall I must have a sturdy piece of furniture nearby to pull myself up with because my legs aren't strong enough to do it on their own. It really hurts however when people try to help by pulling me up, as if my arms will rip off.
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Old 09-22-2012, 06:55 PM
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Quote:
Originally Posted by baydenoc View Post
I can not jump, hop, skip. If I fall I cannot get up unless someone helps me or I have something to pull me up. What does this mean? Does anyone else have this?

My whole body head to toe, literally feels numb, face, neck, shoulders, arms, back, obliques, legs feel spastic.

Scared
First, you would not be asked to jump or hop if your balance was that bad.

Second, if you are having all over body numbness, did it start that way, or did it start in just one area? MS generally starts in one area (one side of the body or one portion of the body).

Is your numbness constant or intermittent? Can you make it start or stop?

Have you seen a neurologist in the past? Have you had an MRI?

Sorry for answering questions with questions, but need more info.
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Old 09-22-2012, 07:41 PM
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Neuro

Thanks Holly, one more week, hope for some answers.
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Old 09-22-2012, 08:07 PM
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I have had 2 MRI's Head Neck Spine w/o contrast in the past year without so far conclusive MS dx.

All things like Lymes, Parkininsons, ie ruled out. I haven't been asked to jump or hop at appt because of balance but tried at home and am not able.

Numbness is intermittent for the most part and seems to move to me. Like right now my head is ok, shoulders and neck not hurting or feeling spastic but I am laying down.

My rIght side bothers me most and burning pain is the strongest on tops of my feet and always left back.
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Old 09-22-2012, 08:13 PM
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I am sorry I forgot, I cannot start or stop the numbness or twitching, I have videoed the twitching for my appt.
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Old 09-22-2012, 11:47 PM
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How far apart were the MRIs, how long do you have the symptoms when you have them, and how long are you without them when you don't?

Have you had an LP or any of the VEPs or BAER's?

Just a couple of questions.

Have you had your calcium checked?
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Old 09-23-2012, 10:28 AM
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I had my MRI's 1 year apart, I will bring both disks with me to my appt in Ann Arbor.

I have had VEPs, neg. I have not had BAER. Ihave not had LP because I take Lovenox for coagulation problems. So don't know how I will get the LP but the last Neuro said I may need one at UofM

My last MRI was in June all the Neuro said was the the spine was neg for lesions and said nothing about the brain but that is when he said I may need a LP.

Thank you for your help 22cyclist

I have had my calcium checked and metals, normal. I really have not been symptom free, just progressive.

I was in the hospital, cardiac unit early May for bilateral DVTs, PEs. At that time I saw a half dozen Drs and they all wanted know why no LP but could'nt do it because of my immediate need for blood thinner.
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Old 09-23-2012, 10:43 AM
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My family wants me to use a cane but this is strange to me because as soon as I try to take someone's arm which for me would be using my right arm I fall that way and become more unstable.

As bad as my walking is I am better walking alone than having someone help me. I think I would do the same with a cane, I have used a walker but then I lean forward and hold the walker tighter. Same with shopping carts but at least don't fall over.

Thanks again
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Old 09-23-2012, 12:03 PM
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Thank You 22

Your posts are very helpful.
This last one will be printed out if I ever go to another neurologist.
(I am VERY off doctors at the moment!)
And I will use it to evaluate the neuro!
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Old 09-23-2012, 12:39 PM
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Your case sounds very complicated because of the history of DVTs and such. This could all be related to vascular disease especially since there is no real let up in your symptoms: IE they move around but do not stop completely for some time.

This can happen in progressive MS but lesions (MS like lesions would have shown up over the course of that year with all of those symptoms most likely). Read your MRI report and see if the head showed any MS like lesions or ovoid lesions in IMPRESSION portion of report.

It would say something like rule out MS, demyelination etc.
Otherwise it will say nonspecific lesions like in vascular disease, migraines.

An LP can rule out other causes. They will have to be careful as you noted.

Keep us posted as to what happens.
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Old 09-23-2012, 01:09 PM
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Thank you so much.

The MRI shows 2 perventricular black holes. That was on the first one but the Neuro in Madison (his words) I can't rule out MS but I wouldn't treat it anyway.

I don't have the report on the last one but they are sending it to UofM

Again, Thank you for your time
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Old 09-23-2012, 01:56 PM
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Thank you so much.

The MRI shows 2 perventricular black holes. That was on the first one but the Neuro in Madison (his words) I can't rule out MS but I wouldn't treat it anyway.

I don't have the report on the last one but they are sending it to UofM

Again, Thank you for your time
Do you have the report? Do the black holes show up in T1? That is where black holes show up in MS. Not in T2 or Flair.

What did the impression say?
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