NEUROLOGICAL EXAMINATIONA four minuet (or less) examination

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

Examples of How to Examine

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.

Cranial Nerves 9 & 10

Glossopharyngeal & Vagus

This is basically a gag reflex check

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.

How to get good doing the Exam

PRACTICE

PRACTICE

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