NEUROLOGICAL

EXAMINATION
A four minuet (or less) examination

By
Don Hudson, D.O., FACEP/ACOEP
 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
PRACTICE
Thanks for your patience, Don Hudson, D.O.