Focused Neuro Exam

Loren BellowsNorwalk Hospital – Surgery

Rotation

Comprehensive Neuro Exam Components

• General Appearance– Posture, motor activity, speech

• Mental Status exam• Cranial Nerves• Motor Function

– Atrophy, tone, strength• Sensory

– Vibratory, Position, sharp/dull, temperature• Reflexes• Cerebellar

– Coordination, gait, Romberg’s

Focused Neuro Exam

• Three Exam Classifications– The Comatose Patient

• Unresponsive, Profound state of unconsciousness• Example: Trauma, Neurogenic Shock

– The Patient with Central Neurologic Disorder• Dysarthria, Aphasia, Partial Paralysis• Example: Stroke, Intracranial Bleed

– The Patient with Spinal Cord Disorder• Dysaesthesia, Incontinence, Pain, Weakness• Example: Disk Herniation, Spinal Cord Compression,

Brown-Sequard Syndrome

Focused Exam: The Comatose Patient

• Glasgow Coma Scale6 5 4 3 2 1

Eyes N/A N/A Opens eyes spontaneously

Opens eyes in response to voice

Opens eyes to painful stimuli

Does not open eyes

Verbal N/A Oriented, converses normally

Confused, disoriented

Utters inappropriate words

Incompre-hensible sounds

Makes no sounds

Motor Obeys commands

Localizes painful stimuli

Withdraws from painful stimuli

Decorticate posturing upon painful stimuli

Decerebrate posturing upon painful stimuli

Makes no movements

Interpretation: GCS < 8 = Severe,

GCS 9-12 = Moderate,

GCS > 13 = Minor

Focused Exam: The Comatose Patient (con’t)

• Brain Reflexes– Oculocephalic Reflex (Doll’s eyes)– Babinski– Gag Reflex (CN 9, 10)– Corneal Reflex (CN 5)– Cold Calorics

• Pupillary Response• Response to Pain• DTRs• Gaze (Ping-Pong Gaze)

Focused Exam: Central Neuro Disorder

• CNs• Speech• Coordination• Pronator Drift• Motor• Sensation• Proprioception• Graphesthesia• Stereognosis

Focused Exam: Spinal Cord Disorder

• Sensation• Motor• Hot/Cold• Vibratory Sense• Proprioception• Gait• DTRs• Rectal Tone• Hoffman’s Sign

Motor Function Testing

• Lack of Consistency:– Patient: 90 y/o female vs. 20 y/o male– Examiner

• Motor Weakness helps to pinpoint spinal cord lesion

Keys to the Motor Exam

• Have patient perform movement First!• One side at a time; Compare R vs L• Examiner: Use the same hand throughout

exam• Examiner: Don’t be a wimp! Use full and

consistent strength (unless there is known injury).– Use single muscle group, i.e. don’t use your

body weight to oppose.

• Important to assign a specific response to a set grade

• Test Certain Muscle Groups

Grading Strength

• 5/5: Examiner is unable to overcome patient• 4/5: Examiner is able to overcome patient;

patient demonstrates moderate resistance• 3/5: Patient able to overcome gravity only• 2/5: Patient unable to overcome gravity, but

can move joint• 1/5: Muscle “fires”, but no joint movement• 0/5: No muscle response• May use +/- to differentiate further

Strength Testing: The Muscle Groups• Upper extremities:

Action Nerve Root / Spinal Level

Shoulder Abduction C5

Elbow Flexion C5/C6

Elbow Extension C6/C7/C8

Wrist Extension C6

Wrist Flexion C7

Grip Strength (Finger Flexion)

C8

Interosseous (Finger Ab/Adduction)

T1

Strength Testing: The Muscle Groups• Lower Extremities:

Action Nerve Root / Spinal Level

Hip Flexion L1

Knee Extension L3

Ankle Dorsiflexion L4

Great Toe Extension L5

Ankle Plantarflexion S1

Nerve Root Landmarks

• C3 – Front of Neck• T 4 – Nipples• T 10 – Umbilicus• L3 – Knee• L4 – Medial LE• L5 – Lateral LE &

Great Toe

Questions??