NEUROLOGICAL EXAMINATION A four minuet (or less) examination

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NEUROLOGICAL EXAMINATIONA four minuet (or less)
examination

• By
• Don Hudson, D.O., FACEP/ACOEP

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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.

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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.

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THE EXAMINATION

• Heres what you need to examine.
• Mental Status
• Cranial Nerves
• Motor
• Sensory
• Coordination
• Reflexes

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Mental Status Exam

• FOGS
• Family story of memory loss
• Orientation
• General Information
• Spelling /or numbers
• Recognition of objects

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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

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Cranial Nerves

• Cranial Nerve 2 (optic Nerve)
• Central vision- Vision testing a chart, i.e.
  Snellen.
• Peripheral Vision- Test one eye at a time

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Examples of How to Examine
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CRANIAL NERVES

• Cranial Nerves 3, 4, 6
• Key tests
• Lateral and Vertical gaze
• Pupillary reaction to light

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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.

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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.

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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

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Crainal Nerve 7 (Facial Nerve)

• This is a critical part of the neuro exam.
• Smile- note any weakness on either side of the
  mouth
• Bells 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.

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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.

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Cranial Nerves 9 10

• Glossopharyngeal Vagus
• This is basically a gag reflex check

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Crainal Nerve 11

• Accessory Nerve
• Key test Shoulder elevation (shrug)
• Rarely injured except bin neck injuries.

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Cranial Nerve 12

• Hypoglossal Nerve
• Key test- stick out your tongue
• The tongue will deviate to the side of weakness.

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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

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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.

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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.

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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 .

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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

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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

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Rapid Neuro Exam

• Mental Status- FOGS, count back from 100, serial
  7s
• 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, dolls eye reflex.

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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.

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How to get good doing the Exam

• PRACTICE
• PRACTICE
• PRACTICE
• Thanks for your patience, Don Hudson, D.O.