Emergency Clinical Guide Presents The Neuro Exam

The Neuro Exam

The primary goal of the neuro exam is to "localize the lesion" - you need to figure out which part of the nervous system is broken. It's best to have a good, thorough routine when you perform the exam - we've included a basic outline covering the essentials. Following this, we've included some hints that will help you to figure out, at least generally, where the problem lies.

The Exam

Mental Status

Level of Consciousness (Glasgow Coma Scale)
Orientation (Time, Person, Place)
Memory (3 items recall)
Judgment (abstraction)
Cognition (serial 7's)

Cranial Nerves

Olfactory - usually not tested
Optic - can they see? Use eye chart.
Oculomotor - do their eyes move? "Follow this with your eyes, keep your head still."
Trochlear - moves superior oblique. Do eyes move normally and without rotation? Do they have double vision? Do they tilt their neck?
Trigeminal - can they chew? Do they have sensation in all three segments of the face bilaterally?
Abducens - moves lateral rectus. Can they look laterally in both eyes (past midline)?
Facial - can they smile symmetrically? Can their eyes tear? Can they salivate? Do they have feeling in the eardrum?
Auditory (Vestibulocochlear) - can they hear? Do they have balance? Rub your fingers near the ears.
Glossopharyngeal - Do they have a gag reflex? Can they feel their ears?
Vagus - is the soft palate arch symmetric ("Say 'aahh'")?
Accessory - can they shrug their shoulders against resistance?
Hypoglossal - can they stick the tongue out straight?

It's common to simply write "CN II-XII intact" in a chart if everything is OK.
Mnemonic = "Oh, Oh, Oh, To Touch And Feel A Girl's V___ - AH."

Motor

Flex and Extend all extremity joints against resistance.
Grading:

5/5 = movement against gravity with full resistance
4/5 = movement against gravity with some resisitance
3/5 = movement against gravity only
2/5 = movement with gravity eliminated
1/5 = visible/palpable muscle contraction but no movement
0/5 = no contraction

Sensory

Pain/Temp [same nerve] sharp / dull sensitivity to broken tongue depressor
Light Touch - cotton wisp
Vibration - tuning fork
Position - "Close your eyes. This is up, this is down. Where is it now?" - Be sure to hold digit (toe or finger) on the SIDE, not on the top or bottom, so as not to give cues for position.

Cerebellar

Heel to shin
Finger to nose
Rapid alternating movement
Romberg

DTR's

See reflexes page
(Triceps, Biceps, Brachioradialis, Patellar, Achilles)

Localization

General terms:
Upper motor neuron

Refers to lesions located anywhere between the cortex (outermost portion of the brain) to the anterior horn cells of the spinal cord.
Features include hyperreflexia, Babinski sign, and increased tone. NOTE: Babinski sign can be elicited from any painful stimulus on the foot or shin, not just the classic sole of the foot maneuver.

Lower motor neuron

Refers to lesions located anywhere between the anterior horn cell of the spinal cord and the neuromuscular junction.
Features include areflexia, muscle atrophy, decreased tone, and muscle fasciculations.

Heel to shin
Finger to nose
Rapid alternating movement
Romberg