Neuro Exam ExplainedMichael Nelson M.D.

Providence Neurological Specialties East

Primary Care ConferenceOctober 26rd, 2017

Michael Nelson M.D.• Medical School: University of Missouri-Columbia• Residency: University of Washington completed in 2002• Board Certified general adult neurologist• Providence Neurological Specialties East in NE Portland and

Vancouver WA• Sadly I have no financial disclosures

Today’s Goals• Understand importance of the neurological exam• Reduce neurophobia (fear of the neuro exam)• Avoid common mistakes in performing the neurological exam• Explain meaning of the findings on the examination• Have fun!

You Will Have Neurological Patients

Outpatient• About 10% of visits to primary care

are due to neurological complaints

Inpatient• About 20% of hospital admissions

are for neurological issues

Availability• Neurologists are rare and in high

demand

• Stroke is the 3rd leading cause of death

• Alzheimer’s is the 7th leading cause of death

• These numbers will rise as the population ages

What is the most important part of the neurological What is the most important part of the neurological examination? examination? A proper history!

What tools do you really need?

• A bright light-ophthalmoscopeor pen light

• Reflex hammer• Tuning fork 128 Hz• Stethoscope• Your two hands!• Good observation skills

• That’s it?• Is Dr. Nelson crazy?• What about the tongue

depressor, vision chart, color vision book, ice water for cold calorics, monofilaments, OKN flag, Maddox rod & red lens, cloves, two point discrimination tool, or that pokey wheel thing?

Which reflex hammer to use?

Three Kinds of Neuro Exams

Screening Neuro Exam• For no neurological symptoms

Comprehensive Neuro Exam• For patients with neurological

symptoms• Still can be focused on your suspicion

Altered level of consciousness• Patient can’t really participate

• Vital signs are still vital• I’m going to say it twice: VITAL

SIGNS ARE VITAL• Very high blood pressure makes it

more likely to be a concerning neurological process

• Feel pulse yourself (if patient isn’t on a monitor)

The Screening Neurological Examination

• Mental Status• Cranial Nerves• Motor Function• Reflexes• Sensation• Cerebellar

Includes at least each part of the six major components

Screening Mental Status• Level of Alertness• Appropriate responses• Not a full MMSE, MOCA, SLUMS• Orientation to date and place

• Before you start make sure they can hear you.

Comprehensive Mental Status• Level of Alertness, Orientation,

Concentration, Memory, and Language

• Consider a full MMSE, MOCA,orSLUMS

• Clock drawing• Consider referral for

neuropsychological testing

• Office based memory tests can easily miss poor judgement.

Screening Cranial Nerves• Visual acuity-first ask patient about their vision• Pupillary light reflex-if unequal first ask about eye surgery or

trauma history. Make sure light source is not towards one side• Eye movements-don’t be fooled by end gaze nystagmus and just

remember 363-334-363• Hearing-finger rub is okay• Facial strength-if asymmetric ask if this is an old finding. Check

their driver’s license photo if not sure

Comprehensive Cranial Nerves• Olfactory-rarely tested but you cannot use something noxious or

you are actually testing the 5th cranial nerve.• Fundoscopic Exam-good luck in the office. May soon be

replaced with office retinal photography. • Eye movements-363 334 363. 4th nerve will give you a head tilt• Facial sensation-there are three divisions.• Facial strength-forehead okay means central, forehead

involvement means peripheral (Bell’s palsy).• Say ahh! Gag is CN IX and X. Also taste.• CN XI is trapezius and XII is tongue protrusion.

Screening Motor Function• Strength-pronator drift, grip, wrist, elbows, shoulder, knees,

ankles. Don’t mistake pain for weakness. Pronator drift requires pronation!

• 5/5 is normal• 4/5 is weak but against resistance• 3/5 is only beyond gravity• 2/5 is no gravity• 1/5 is muscle activation with no joint movement

Comprehensive Motor Function• Expand muscle groups• Add bulk and tone• Look closely for atrophy or fasciculations

Screening Reflexes• DTR Deep tendon reflexes (biceps, patella, ankle) – yes you need

to do upper and lower extremities. Most important is if there a side to side difference.

• Absent means no response• 1+ decreased but normal• 2+ normal• 3+ increased• 4+ clonus• Plantar responses – can be difficult to interpret (ticklish) and an

upgoing toe should not just be the only finding

Comprehensive Reflexes• Expand DTR Deep tendon reflexes to include biceps, triceps,

brachioradialis, patella, and ankle. • Increased reflexes=central process• Decreased reflexes=peripheral process• Plantar responses are more important to get right here. • I pretty much never check Cremaster, anal wink, or primitive

reflexes like snout, palmomental, or grasp

Screening Sensation• One modality at the feet • I prefer the tuning fork which is always cold to test

pain/temperature sensation in the feet. If abnormal, then test vibration sense with same tool

• Sensation is frequently misleading

Comprehensive Sensation• Expand to arms and legs• Expand to include light touch, position, pain/temperature, and

position sense. • Romberg testing is a sensation test (position sense)• Cortical sensory loss is some of the cool testing like stereognosis,

graphesthesia, and extinction.• Again, sensation is frequently misleading

Screening Cerebellar• Primary gait and tandem if appropriate-many patient over 60 do

not have normal tandem walking• Test finger nose finger and rapid alternating movements• Look at their handwriting

Comprehensive Cerebellar• Look for abnormal movements like chorea, athetosis, postural

tremor, cerebellar tremor, resting tremor, motor tics, slow movements (parkinsonism), myoclonus, hemiballismus, alien hand syndrome, and dystonia.

• Midline cerebellar issues cause midline body symptoms (truncal ataxia, poor tandem walking)

• Peripheral cerebellar issues cause peripheral body symptoms like limb ataxia, hand tremor, etc.

The Altered Mental Status Neuro Exam

• Mental Status-level of arousal, response to auditory, visual, and noxious stimuli.

• Cranial Nerves-pupillary light reflex, oculocephalic reflex (doll’s eye), vestibulo-ocular reflex (cold calorics), gag, corneal reflex

• Motor Function-voluntary and involuntary movements, withdrawal to pain. Can’t do cerebellar assessment

• Reflexes-DTR and plantar• Sensation-progress to noxious stimuli

Patient cannot participate with exam

Michael Nelson M.D.• Medical School: University of Missouri-Columbia• Residency: University of Washington completed in 2002• Board Certified general adult neurologist• Providence Neurological Specialties East in NE Portland and

Vancouver WA

Neuro Exam ExplainedMichael Nelson M.D.

Providence Neurological Specialties EastOctober 26rd, 2017