NEUROLOGICAL
EXAMINATION
A four minuet (or less) examination
By
Don Hudson, D.O., FACEP/ACOEP
Organic Disease ?
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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
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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
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Here’s what you need to examine.
Mental Status
Cranial Nerves
Motor
Sensory
Coordination
Reflexes
Mental Status Exam
 “FOGS”
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Family story of memory loss
Orientation
General Information
Spelling &/or numbers
Recognition of objects
Cranial Nerves
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Cranial nerve 1 (Olfactory)
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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
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Cranial Nerves
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Cranial Nerve 2 (optic Nerve)
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Central vision- Vision testing a chart,
i.e. Snellen.
Peripheral Vision- Test one eye at a
time
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Examples of How to Examine
CRANIAL NERVES
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Cranial Nerves 3, 4, 6
Key tests:
Lateral and Vertical gaze
Pupillary reaction to light
Cranial Nerves
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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
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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)
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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)
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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
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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
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Glossopharyngeal & Vagus
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This is basically a gag reflex check
Crainal Nerve 11
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Accessory Nerve
Key test: Shoulder elevation (shrug)
Rarely injured except bin neck injuries.
Cranial Nerve 12
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Hypoglossal Nerve
Key test- stick out your tongue
The tongue will deviate to the side of
weakness.
Motor Examination
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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
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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
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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
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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
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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.
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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
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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
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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
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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 34 minutes.
How to get good doing the Exam
PRACTICE
PRACTICE
PRACTICE
Thanks for your patience, Don Hudson, D.O.