NEUROLOGICAL EXAMINATION A four minuet (or less) examination

1. NEUROLOGICAL EXAMINATIONA four minuet (or less) examination By Don Hudson, D.O., FACEP/ACOEP

2. 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.

3. 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.

4. THE EXAMINATION • Here’s what you need to examine. • Mental Status • Cranial Nerves • Motor • Sensory • Coordination • Reflexes

5. Mental Status Exam • “FOGS” • Family story of memory loss • Orientation • General Information • Spelling &/or numbers • Recognition of objects

6. 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

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

8. Examples of How to Examine

9. CRANIAL NERVES • Cranial Nerves 3, 4, 6 • Key tests: Lateral and Vertical gaze Pupillary reaction to light

10. 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.

11. 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.

12. 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

13. 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.

14. 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.

15. Cranial Nerves 9 & 10 • Glossopharyngeal & Vagus • This is basically a gag reflex check

16. Crainal Nerve 11 • Accessory Nerve • Key test: Shoulder elevation (shrug) • Rarely injured except bin neck injuries.

17. Cranial Nerve 12 • Hypoglossal Nerve • Key test- stick out your tongue • The tongue will deviate to the side of weakness.

18. 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

19. 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.

20. 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.

21. 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 +.

22. 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

23. 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

24. 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. Rapid Neuro Exam

25. 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.

26. How to get good doing the Exam PRACTICE PRACTICE PRACTICE Thanks for your patience, Don Hudson, D.O.