Tag Archives: physical exam

Heads up Maneuver

Clinical scenario:  Patient with stroke comes in with large vessel occlusion and neuro deficits; he was placed supine for CT scan and NIHSS improved.  Vascular imaging still shows clot, but deficits are now nondisabling and NIHSS is low.  Should you proceed with thrombectomy?

Small study from UCLA used the Heads Up maneuver to select patients who should proceed to thrombectomy.

 

Patients included:

  1. stroke within 7.5h onset
  2. disabling neuro deficit on presentation
  3. improved while on CT to nondisabling deficit
  4. evidence (in MRA) of persisting large vessel occlusion

 

Heads up Maneuver: (performed in angio suite)

  1. position 90 degrees upright x 30 minutes, monitor BP/HR q5-10mins
  2. if worsened –> lower to supine, proceed with angio
  3. if remained stable –> lower to supine or 30 deg HOB; transfer to stroke unit

 

Pathophysiology of Delayed Collateral Failure:

STROKE –> increased CO / SVR –> improved flow to peri-infarct regions –> MI / CHF / dysrhythmias / sepsis / dysautonomia / drugs –> reduced CPP –> delayed collateral failure –> expansion of core infarct

 

Heads Up:

Head position influences collateral flow by increasing flow velocity in affected MCA. Impaired autoregulation allows perfusion to collateral channels to become passive-pressure dependent.  Head flat position increases CPP by 20%, improves neurologic function in 15% of patients.  Risk of aspiration PNA with head flat position is <5%.

 

Outcome:

The study found that heads up maneuver can be used to stress collateral systems and identify those patients who are vulnerable to hemodynamic failure.

  1. Only 5 patients included in the series – all had high NIHSS on arrival, improved during MRI scanning.
  2. Two patients tolerated 30 minutes, no thrombectomy performed, had excellent outcome with just medical therapy.
    1. *Spontaneous recanalization occurred within 72h (assumed that vigorous collaterals promoted recanalization).
  3. Three patients worsened with manuever and had successful recanalization and excellent outcomes as well.

 

Reference:

Ali, L., Weng, J., Starkman, S., Saver, J., Kim, D., Ovbiagele, B., Buck, B., Sanossian, N., Vespa, P., Bang, O., Jahan, R., Duckwiler, G., Viñuela, F. and Liebeskind, D. (2016). Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management. Interventional Neurology, 6(1-2), pp.8-15.

Manual Muscle Testing

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Plus (+) and Minus (-) Grades Use of a plus (+) or minus (-) addition to a manual muscle test grade is discouraged except in three instances: Fair+, Poor+, and Poor-. Scalable gradations in other instances can be described in documentation as improved or deteriorated within a given test grade (such as Grade 4) without resorting to the use of plus or minus labels. The purpose of avoiding the use of plus or minus signs is to restrict the variety of manual muscle test grades to those that are meaningful and defendable.

 

References

Hislop, Helen J et al. Daniels And Worthingham’s Muscle Testing. 1st ed. Print.

http://www.me.umn.edu/~wkdurfee/publications/wiley-chap-2006.pdf

 

Oculocephalic Reflext

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A = brainstem intact (metabolic encephalopathy)

B = R lateral pontine lesion (gaze paralysis)

C = MLF lesion (bilateral internuclear ophthalmoplegia)

D = R paramedian pontine lesion (1 1/2 syndrome)

E = midbrain lesion (bilateral)

 

Reference:

Posner, Jerome B and Fred Plum. Plum And Posner’s Diagnosis Of Stupor And Coma. Oxford: Oxford University Press, 2007. Print.

Caloric Test

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A = brainstem intact (metabolic encephalopathy)

B = R lateral pontine lesion (gaze paralysis)

C = MLF lesion (bilateral internuclear ophthalmoplegia)

D = R paramedian pontine lesion (1 1/2 syndrome)

E = midbrain lesion (bilateral)

 

 

Reference:

Posner, Jerome B and Fred Plum. Plum And Posner’s Diagnosis Of Stupor And Coma. Oxford: Oxford University Press, 2007. Print.

DDx Vital Signs

Tags:  VS, Differential Diagnosis DDx, FUO, rash, post operative fever, fever in HIV

DDx: High / Low Blood Pressure

DDx: High / Low Temperature

DDx:  High / Low RR

Low O2 Sats

DDx PE Findings

Tag:  Physical Examination, Differential Diagnosis DDx

General Observation:

Pupils:

JVD

Cervical LAD

Neck Mass

Cardiac Auscultation

Extremeties

Skin: