4 Min Neurological

8/3/2019 4 Min Neurological

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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 ConnectionsUpper Motor Neurons (UMN) are defined

as the connections of motor nerves

before they leave the spinal cordLower Motor Neurons (LMN) are defined

as after the synapse (connection) into

the peripheral nerve cell bodies.


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THE EXAMINATIONHeres what you need to examine.

Mental Status

Cranial Nerves

Motor

Sensory

Coordination

Reflexes


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Mental Status ExamFOGSFamily story of memory loss

Orientation

General Information

Spelling &/or numbersRecognition of objects


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Cranial NervesCranial 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 ofCN5 ( Trigeminal) rather than CN1


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Cranial NervesCranial Nerve 2 (optic Nerve)Central vision-Vision testinga 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 NervesPERLA- means you checked the pupil

constriction at near accommodation.

This is rarely done. Therefore it shouldread PERL.

This tests the response of each pupil to

light.


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PUPILSA 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) sothe exam light touch on both cheeks.

If you suspect a orbital injury touching

the cornea with a wisp of cotton will testthe 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 facialparalysis i.e., weakness of a corner of themouth + closing the eye + wrinkling the brow.

If the smile test is normal there is little reason tocontinue the exam.


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Crainal Nerve 8 Vestibulocochlear Nerve- Conductive defects or

sensorineural are found here.

Rubbing your fingers together next to thepatients 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 sensorineuralloss the normal ear sounds louder.


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Cranial Nerves 9 & 10Glossopharyngeal & 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 ofweakness.


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Motor Examination

Key tests:

Drift of upper & lower extremity

Hand grip & toe & foot dorsiflexionTesting 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 extremityproprioception.


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Coordination

Key Test:Finger to nose & heel to shin motions

Alternating rapid movements of hand &foot. Examples of tapping thumb & indexfingers together, or heel on floor & taptoes on floor.

Balance test- Tandem gait or Rombergtest.


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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 isconsidered +.


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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 aspectof 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 lightAbnormal 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, countback from 100, serial 7s

Cranial Nerves- C1- smellstobacco 0r soap; Visual

acuity (near/far), grossvisual fields, Opth. Exam;CN3,4,6- Pupil lightresponse; lat/vertical gaze;CN5- double stimulation;corneal reflex. CN7- Smile:

CN8-finger tips rubbing;hum; CN9,10- gag; CN11shrug; CN12-stick outtongue

Motor- drift of extremities,grasp & foot/toe dorsiflexion;

Sensory- double stimulationhands/feet; position of big toe.

Coordination- finger to toe; raidmovements of fingers/toes;Romberg, tandem gait;

Reflexes- check; Kergig orBrudzinski

U/C- V/S, hand-drop, abn. eyemovements, withdrawal,Babinski, cornea's, dolls eyereflex.


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Neuro ExamThis is a brief neurological examination.

It is not meant to replace a fullneurological examination.

This is intended to be part of thesecondary exam for pre-hospitalproviders.

This exam should not take longer than 3-4 minutes.


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How to get good doing the Exam

PRACTICE

PRACTICE

PRACTICEThanks for your patience, Don Hudson, D.O.

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