Neuro Exam

Universal Exams

Non-intubated exams

EOS
Ox3
PERRL, EOMI, FS, TML
55555/55555
55555/55555
No drify
SILT
No Hoffman’s hyperreflexia, clonus
 
EOS
Ox3
PERRL, EOMI, FS, TML
5/5
5/5
No drift
SILT
Eyes
EOS
Orientation
Ox3
Cranial nerves
PERRL, EOMI, FS, TML
Motor exam
see below
Pronator Drift
1) Generally, this is useful for detecting subtle weakness not picked up on confrontational testing (e.g. someone can be 55555 in RUE but have a RUE drift). 
2) NOTE: it should not be assumed that everyone with proximal UE weakness is going to have a pronator drift.
Sensation
SILT
Long-tract signs
No Hoffman / clonus / hyperreflexia
Notes:
  • do not put FC x 4 if a patient has a motor exam (that's implied)
  • for spine patients, always put full muscle groups, even if intact. For cranial patients, ok to put a lumped limb rating. However if you are the consult resident seeing the patient for the first time, document full muscle group breakdown on every single patient.
  • Do not document things you didn’t test, like cranial nerves on a spine patientIntubated

Intubated Exams

Component
Example
TOF
4 beats on train of four
Sedation
prop at 75 held > 20 min
Ventilation
Int AC 40/5 
TV (trach vent) AC 40/5
Eyes
ETP
Pupils (OD/OS)
NPI (OD/OS)
5R/4NR
4.2/0.3
Protectives
+ cough/+gag/+corneal
Motor exam
Loc / Loc 
Wd / Wd
Notes:
  • don't forget to document ethanol level if it's high
  • HHFNC = heated high flow nasal cannula, include liters and percent
 
 
Disc
C4-5
C5-6
C6-7
C7-C8
C8-T1
Root
C5
C6
C7
C8
T1
Pitt syntax
D
WrE
T
HI
ASIA syntax
B
WrE
T
Finger flexor
finger ABd
Muscle
Deltoid
Biceps
Brachialis (elbow flexion)
Long extensor
Triceps
(elbow extension)
FDP
Abdudctor digiti minimi
Nerve
Axillary
Musculocutaneous
Radial (posterior interosseous)
Radial
Median (1-3)
Ulnar (4-5)
Ulnar
Sensory-arm
lateral arm
lateral forearm
medial forearm
Sensory-fingers
1-2
thumb, index
3
middle
4-5
ring
pinky
 
 
 
Disc
L1-L2
L2-3
L3-4
L4-5
L5-S1
S1-S2
Root
L1
L2
L3
L4
L5
S1
PITT
HF
KE
ㅤ
DF
EHL
PF
Muscle
Iliopsoas
Iliopsoas
Quads
Quads
ㅤ
gastro
Reflex
ㅤ
ㅤ
ㅤ
ㅤ
ㅤ
ㅤ
Parasthesia
anterior upper thigh medial thigh
lower thigh crossing knee medial thigh
medial shin
lateral shin
calf
ㅤ
Foot
ㅤ
ㅤ
ㅤ
dorsum and medial
lateral and back
ㅤ

Comatose Exams

Big picture, motor exams on the comatose are all about establishing symmetry.
The most meaningful exam changes to neurosurgeon nare:
Following commands --> Localize/withdrawing --> Posturing --> Flicker --> Flaccid
  • localize/withdraw is actually a very good exam in the comatose, it means motor function is intact, they just don't have the cognition to be following commands be that because of a brain injury or from sedation or critical illiness/infection/etc. The point is all of that is reversible/may get better with improved level of arousal.
Localizing - this is generally a motor response we use to describe in UEs. Technically people can localize in lowers if you apply stim on thigh and they kick their other leg up but this is very unlikely.
Withdrawing -  this can happen in any four extremities, it's just waht it sounds like. The patient withdraws from peripheral stimulation (i.e. on their fingers/toes) but does not cross midline in UEs enough to call it a localize.
Posturing- these are descriptions of upper extremities.
1. Flexing:
2. Withdrawing:
Triple Flex: this is a spinal reflex of LEs and the way to differentiate it from withdraw is that a person will continue to withdraw as you continue stimulation (i.e. if you keep pinching them they keep moving and feeling it) while in the TF, it is just a transient flexion of ankle, knee, hip, and it will not persist as you continue pinching, i.e. it is temporary and they are not really feeling you.
Flaccid vs. Flicker
  • frankly the actual motor response between flaccid and flicker is academic, both generally do not move. The more important distinction is that flaccid people both don't move and have zero tone with

Specialty Exam Components

Optho exams

Relative afferent Pupillary defects

How to test for a relative afferent pupillary defect (RAPD) - PMC
Normal test (no RAPD): pupils constrict equally regardless of which eye is stimulated.
Abnormal test (positive RAPD): less constriction in affected eye
  • positive RAPD means afferent pathway pathology due to retinal or optic nerve disease.

EEA / Skull Base

Document/present this entire blue box for every single EEA patient every single day.
OD
OS
Field
Full to confrontation
Full to confrontation
Acuity1
20/25
20/25
Pupils
mm, reactive
mm, reactive
EOM
intact, w/o diplopia/nystagmus
intact, w/o diplopia/nystagmus
Remember to test each eye separately!
Subjective vision
  • Denies blurry vision
  • Denies double vision at rest
  • Denies pain with extra-ocular movement
CSF Leak negative on chin-to-chest provocation for 30 seconds
Ask for positional headaches
1For acuity, use MDCalc Snellen chart, stand 4 feet away (measure how far this is on your own wingspan).

Cerebellar

  • dysdiadochokinesia
  • intention tremor (cerebellar tremor) = worsens as you get closer to target
  • Romberg test: close eyes and see if patient can maintain a standing posture
  • positive if start swaying, means they rely on vision to maintain balance

Rectal

Intact perianal sensation, intact rectal tone, intact deep anal sensation, intact voluntary anal contraction

Cervical (Trauma)

No cervical TTP, pain with passive ROM

Stroke

Names 3/3, Repeats 2/2

Subarachnoid Hemorrhage

check for neck pain

Cranial Oncology

Every exam needs to test visual fields

Bulbo-cavernous Reflex

Normal reflex:
What does it tell you if someone does NOT have the reflex:

Gait Patterns

Neurovascular Exam

  • Check puncture site (femoral vs. wrist)
  • Check to make sure no hematoma / pseudoaneurysm (hard to distinguish in reality on exam, just make sure soft tissue is compressible, has no lump or active signs of bleeding)
  • Check to make sure have distal pulses
Location of pulses
1720213957993-581.png

Pediatric Neuro Exams

Vocabulary:
Sutures can be "splayed"
Fontanelles can be "bulging"
1704049080682-147.png

Miscellaneous

Akinetic Mutism: unresponsiveness with superficial appearance of alertness
  • occurs 2/2 bilat lesions caudate w/ destruction of medial putamen, septum, medial frontal cortex, cingulate cortex