The Neuro Exam Revisited - Neuro E2 L7

HPI Questions to Ask (Neuro Related)

1. Numbness or tingling

2. HA

3. Vision changes

4. Gait/balance changes

5. Hearing

6. Recent illness

7. Memory changes

8. Sleep disturbances

Pertinent Fam Hx

1. Dementia

2. DM

3. CVA

Pertinent Social Hx

1. Tobacco

2. EtOH

3. Drugs

Pertinent Surgical hx

1. Total joints

2. CABG

3. Stents

4. Endarterectomy

Medications of Importance

1. Benzos

2. Opioids

3. Antipsyhcoitics

4. Steroids

5. Anti-HTN

6. DM meds

7. Anticoags

Components of Neuro Exam

1. General

2. Inspection

3. Palpation

4. CN

5. Coordination

6. Spine (M, S, Reflexes, ROM)

7. Gait

8. special tests

General Assessment

1. AO x3

2. Appearance (dress/hygiene)

3. Behavior (cooperative, agitated, communication)

4. Glasgow Coma Scale

Alert on GCS

1. 15

2. Fully conscious, oriented, follows commands

Lethargic on GCS

1. 13-14

2. Drowsy but arousable, responds appropriately to voice

Obtunded on GCS

1. 11-13

2. Responds slowly, confused, needs repeated stimuli

Stuporous on GCS

1. 8-10

2. Only responds to vigorous or painful stimuli, minimal verbal response

Comatose on GCS

1. <8

2. No meaning response to any stimuli. Often requires airway protection

Inspection Portion of the Exam

1. Posture

2. Head tilt

3. Nystagmus

4. Atrophy

5. Tremors/Tics

6. Wounds/drainage

7. Deformity

8. Skin changes

Palpitation Portion of the Exam

1. Area of CC

2. Head to Toe if deformity, spasticity, masses, temp

3. Spinous from C to L spine

4. Sacrum

CN I

1. Olfactory (smell)

2. Sensory only

CN II

Optic (sensory only)

Testing of CN II

1. Visual acuity

2. Visual fields

3. Direct and consensual response to light

4. Fundoscopic exam

5. Color perception

CN III

1. Oculomotor (motor only)

2. Superior rectus

3. Inferior rectus

4. Medial rectus

Testing of CN III

1. Swinging flashlight test

2. Accommodation testing

3. Extra ocular movements

4. Eye lid inspection

CN IV

1, Trochlear nerve (motor only

2. Superior oblique

Testing of CN IV

EOM tracking down and out

What is important to remember with CN IV?

Crossover; left brain stem injury can cause right sided symptoms

CN V

Trigeminal nerve (sensory and motor)

Sensory Branches of CN V

1. Ophthalmic

2. Maxillary

3. Mandibular

Motor Branches of CN V

Mandibular for muscles of mastication

Testing CN V

1. Sensory to all 3 branches

2. Motor - clench jaw

3. Reflex - corneal reflex afferent pathway and jaw jerk

Corneal Reflex Testing

1. CN V - afferent signal

2. If CN V lesion, both eyes will not blink

3. CN VII - efferent signal

4. If CN VII lesion then affected eye won't blink, but other will

CN VI

1. Abducens nerve (motor only)

2. Lateral rectus

Testing CN VI

EOM

CN VII

1. Facial nerve

2. Sensory and motor function

Sensory of CN VII

1. Somatic - pinna of ear to EAM

2. Visceral - taste anterior 2/3 of the tongue

Motor of CN VII

1. Somatic - muscles of expression

2. Visceral - vasodilation and secretion of lacrimal glands and salivation

Testing CN VII

1. Look for asymmetry

2. Test muscles of expression

3. Corneal reflex testing

4. Taste

CN VIII

1. Vestibulocochlear (sensory only)

2. Hearing and balance

Testing CN VIII

1. Weber and Rinne

2. Whispered Word

3. Caloric Stimulation

4. Dix-Hall Pike

CN IX

Glossopharyngeal (sensory and motor)

Sensory of CN IX

1. Somatic - taste posterior 1/3 tongue and external ear

2. Visceral - pharynx and carotid sinus and body

Motor of CN IX

1. Somatic - swallowing (stylopharyngeus)

2. Visceral - parotid gland (salivary production)

Testing CN IX

1. Gag reflex (afferent pathway)

2. Say AH

3. Swallow

CN X

1. Vagus nerve

2. Sensory and motor

Sensory of CN X

1. Somatic - external ear

2. Visceral - epiglottis, pharynx, larynx, trachea, esophagus, thoracic/abdominal viscera

Motor of CN X

1. Somatic - swallowing (levator veli palatini)

2. Visceral - thoracic and abdominal viscera

Testing CN X

1. Check for symmetry of soft palate and uvula position

2. Gag reflex - efferent pathway

3. Say ah

4. Check ability to swallow

5. Speech

6. Cough

How does CN X lesion present?

1. Soft palate fails to rise on AFFECTED side

2. Uvula will deviate to UNAFFECTED side

CN XI

Accessory nerve (motor)

What muscles does CN XI innervate?

1. Trapezius

2. Sternocleidomastoid

Testing of CN XI

1. Turn chin to left and right against hand

2. Shrug shoulder

CN XII

Hypoglossal (motor for tongue movement)

Testing CN XII

1. Inspect

2. Stick out tongue

3. Push tongue against both sides

If there is a left CN XII lesion, the tongue will point in what direction?

Left

Pupillary Reflex

CN II and III

Corneal Reflex

CN V and VII

Gag Reflex

CN IX and X

Jaw Jerk

CN V - UMN; hyperactive reflex

Scoliosis

abnormal lateral curvature of the spine

Kyphosis

excessive posterior curvature of the spine, causing hunching of the back.

Lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition)

Flat Back

decreased anterior lumbar curve

Neck ROM

1. Flexion/extension

2. Lateral rotation/bending

Spine ROM

1. Flexion/extension

2. Rotation

3. Lateral bending

Motor Exam

1. Determine handedness

2. UE - Brachial Plexus

3. LE - lumbar and sacral plexus

Brachial Plexus

C5-T1

Nerve Root C5

1. Axillary nerve

2. Shoulder abduction

3. Lateral shoulder

4. Biceps reflex (C5-6)

Nerve Root C6

1. Musculocutaneous nerve

2. Wrist extension

3. Elbow flexion

4. Lateral forearm

5. Brachioradialis reflex (C5-C6)

Nerve Root C7

1. Radial nerve

2. Wrist flexion

3. Elbow extension

4. Dorsum of hand, middle finger

5. Triceps reflex (C7)

Nerve Root C8

1. Median nerve

2. Finger flexion (FDP digits 2-3)

3. Ulnar side of the hand

Nerve Root T1

1. Ulnar nerve

2. Finger abduction/adduction

3. Medial forearm

Axillary Nerve (C5-C6)

1. Deltoid and teres minor (motor)

2. lateral shoulder (Sensory)

Injury Pattern to Axillary Nerve

1. Surgical neck humerus fracture

2. Shoulder dislocation

Musculocutaneous Nerve (C5-C7)

1. Biceps, brachialis, coracobrachialis (elbow flex,supinate)

2. Lateral forearm (sensory)

Injury Pattern to Musculocutaneous Nerve

Upper trunk injury (Erb Palsy)

Long Thoracic Nerve (C5-C7)

1. Serratus anterior (scapula protraction, arm elevation)

2. No cutaneous sensory branch

3. Injury via axillar dissection or trauma causing winged scapula

Suprascapular Nerve (C5-C6)

1. Supraspinatus (abd.) and infraspinatus (Er)

2. No sensory loss

3. Compression at suprascapular notch

Dorsal Scapular Nerve (C5)

1. Rhomboids, levatro scapulae

2. No sensory loss

3. Scapular instability

Thoracodorsal Nerve (C6-C8)

1. Latissimus dorsi (add, ext, IR)

2. No sensory loss

3. Axillary surgery risk

Lumbar Plexus

L1-L5

L1 Nerve Root

1. Iliohypogastric

2. Test via minor hip flexion

3. Suprapubic skin (sensory)

4. Present with weak hip flexion

Ilioinguinal Nerve (L1)

1. Also L1

2. Minor hip flexion

3. Medial groin/scrotum/labia sensory

4. Present with groin numbness

L2 Nerve Root

1. Femoral

2. Hip flexion via iliopsoas

3. Anterior thigh (sensory)

4. Present with difficulty lifting thigh

L3 Nerve Root

1. Femoral

2. Knee extension

3. Medial knee sensory

4. Patellar reflex

5. Present with weak quads

L4 Nerve Root

1. Femoral (saphenous branch)

2. Knee extension

3. Medial lower leg

4. Patella reflex

5. Knee buckling

L5 Nerve Root

1. Deep peroneal nerve

2. Great toe dorsiflexion

3. 1st dorsal web space (sensory)

4. Foot drop

Femoral (L2-L4) Motor Function

1. Quadriceps (knee extension)

2. Iliopsoas (hip flexion)

Femoral (L2-L4) Sensory Function

Anterior thigh, medial leg (via saphenous nerve)

Femoral (L2-L4) Injury Pattern

Pelvic fracture, psoas hematoma

Obturator (L2-L4) Motor Function

1. Adductors (adductor longus/brevis/magnus)

2. Gracilis

Obturator (L2-L4) Sensory Function

Medial thigh

Obturator (L2-L4) Injury Pattern

Pelvic surgery, obturator canal compression

Sciatic (L4-S3) Motor Function

1. Hamstrings (knee flexion)

2. All muscles below knee via tibial and common fibular branches

Sciatic (L4-S3) Sensory Function

Posterior thigh

Sciatic (L4-S3) Injury Pattern

Hip dislocation, piriformis compression

Tibial (L4-S3) Motor Function

1. Plantarflexion (gastroc/soleus)

2. Toe flexion

3. Inversion (tibialis posterior)

Tibial (L4-S3) Sensory Function

Sole of foot (plantar surface)

Tibial (L4-S3) Common Injury Pattern

Tarsal tunnel syndrome, knee trauma

Common Fibular (peroneal, L4-S2) Motor Function

1. Dorsiflexion

2. Eversion (via branches)

Common Fibular (peroneal, L4-S2) Sensory Function

Lateral leg + dorsum of foot

Common Fibular (peroneal, L4-S2) Injury Mattern

Fibular head fracture -> foot drop

Superifical Fibular (peroneal, L4-S1) Motor Function

Foot eversion (peroneus longus/brevis)

Superficial Fibular (peroneal, L4-S1) Sensory Function

Dorsum of foot (except 1st web space)

Superficial Fibular (peroneal, L4-S1) Injury Pattern

Ankle sprain compression