NEUROLOGICAL EXAMINATION A four minuet (or less) examination By Don Hudson, D.O., FACEP/ACOEP
Dec 16, 2015
Organic Disease ?
Signs &/or symptoms that cannot be faked must be examined closely.
Examples include, asymmetry in pupils, abnormal retinal exams, nystagmus, muscle atrophy, and muscle fasciculation.
Where are the Connections
Upper Motor Neurons (UMN) are defined as the connections of motor nerves before they leave the spinal cord
Lower Motor Neurons (LMN) are defined as after the synapse (connection) into the peripheral nerve cell bodies.
THE EXAMINATION
Here’s what you need to examine. Mental Status Cranial Nerves Motor Sensory Coordination Reflexes
Mental Status Exam
“FOGS” Family story of memory loss Orientation General Information Spelling &/or numbers Recognition of objects
Cranial Nerves
Cranial nerve 1 (Olfactory) The sense of smell rarely identifies any
significant pathology. Use tobacco, soap, smelling salts, etc for
some idea to get some idea if they smell. Ammonia stimulates pain endings of
CN5 ( Trigeminal) rather than CN1
Cranial Nerves
Cranial Nerve 2 (optic Nerve) Central vision- Vision testing a chart,
i.e. Snellen. Peripheral Vision- Test one eye at a
time
CRANIAL NERVES
Cranial Nerves 3, 4, 6 Key tests:
Lateral and Vertical gaze
Pupillary reaction to light
Cranial Nerves
PERLA- means you checked the pupil constriction at near accommodation. This is rarely done. Therefore it should read PERL.
This tests the response of each pupil to light.
PUPILS
A large dilated pupil on one side with no other ocular abnormalities may be normal. (check license)
A dilated pupil in the presence of AMS suggests herniation of the temporal lobe against C3 & the brain stem.
Constricted pupils may indicate pontine injuries, narcotics i.e. Demerol, Morphine.
Cranial Nerve 5 (Trigeminal)
A lesion that effects C5 will usually effect all three segments (ophthalmic,maxillary,&mandibular) so the exam light touch on both cheeks.
If you suspect a orbital injury touching the cornea with a wisp of cotton will test the corneal reflex. This tests C5 + transfer to the brain stem then on to C7
Crainal Nerve 7 (Facial Nerve)
This is a critical part of the neuro exam. Smile- note any weakness on either side of the
mouth Bell’s Palsy- Where the nerve is injured
between pons & face there is total facial paralysis i.e., weakness of a corner of the mouth + closing the eye + wrinkling the brow.
If the smile test is normal there is little reason to continue the exam.
Crainal Nerve 8
Vestibulocochlear Nerve- Conductive defects or sensorineural are found here.
Rubbing your fingers together next to the patients ear. Blocked EAC with wax are examples of conductive loss.
Ask the patient to hum- in the conductive loss the blocked ear sounds louder, in sensorineural loss the normal ear sounds louder.
Crainal Nerve 11
Accessory Nerve Key test: Shoulder elevation (shrug) Rarely injured except bin neck injuries.
Cranial Nerve 12
Hypoglossal Nerve Key test- stick out your tongue The tongue will deviate to the side of
weakness.
Motor Examination
Key tests: Drift of upper & lower extremity Hand grip & toe & foot dorsiflexion Testing of other muscles when their
proper function is in question
Sensory Extremity Examination
Key Test: Pain Sensation- Use simultaneous
stimulation (sharp, dull, etc.) Proprioception- Test big toe (position).
MS, neurosyphilis, & pernicious anemia may cause loss of lower extremity proprioception.
Coordination
Key Test: Finger to nose & heel to shin motions Alternating rapid movements of hand &
foot. Examples of tapping thumb & index fingers together, or heel on floor & tap toes on floor.
Balance test- Tandem gait or Romberg test.
Romberg Test
Key test: Be sure to check orthostatic (B/P) for changes
first Balance is maintained by vision, vestibular
sense & proprioception. These feed into the cerebellum either directly or indirectly. If a patient sways with eyes open or close it is considered +.
Reflexes
Key tests: Triceps, biceps, knee jerk, Achilles & Babinski
are the major reflexes. Asymmetry is usually a sign of major
pathology. Babinski- This points to a upper motor neuron
lesion. A positive test is when the lateral aspect of the foot is scratched & the big toe dorsiflexes & the other toes fan out
Examination of Unconscious Pt.
Key test: Hand-drop over head Pupillary size & response to light Abnormal eye movements Grimacing, withdrawal to noxious stimuli Babinski reflex V/S, Cardiac, Respiratory & metabolic status
Rapid Neuro Exam Mental Status- FOGS, count
back from 100, serial 7’s Cranial Nerves- C1- smells
tobacco 0r soap; Visual acuity (near/far), gross visual fields, Opth. Exam; CN3,4,6- Pupil light response; lat/vertical gaze; CN5- double stimulation; corneal reflex. CN7- Smile: CN8-finger tips rubbing; hum; CN9,10- gag; CN11 shrug; CN12-stick out tongue
Motor- drift of extremities, grasp & foot/toe dorsiflexion;
Sensory- double stimulation hands/feet; position of big toe.
Coordination- finger to toe; raid movements of fingers/toes; Romberg, tandem gait;
Reflexes- check; Kergig or Brudzinski
U/C- V/S, hand-drop, abn. eye movements, withdrawal, Babinski, cornea's, doll’s eye reflex.
Neuro Exam This is a brief neurological examination.
It is not meant to replace a full neurological examination.
This is intended to be part of the secondary exam for pre-hospital providers.
This exam should not take longer than 3-4 minutes.