1. Focused Neuro Exam Loren Bellows Norwalk Hospital – Surgery Rotation

2. Comprehensive Neuro Exam Components General Appearance –Posture, motor activity, speech Mental Status exam Cranial Nerves Motor Function –Atrophy, tone, strength Sensory –Vibratory, Position, sharp/dull, temperature Reflexes Cerebellar –Coordination, gait, Romberg’s

3. Focused Neuro Exam Three Exam Classifications –The Comatose Patient Unresponsive, Profound state of unconsciousness Example: Trauma, Neurogenic Shock –The Patient with Central Neurologic Disorder Dysarthria, Aphasia, Partial Paralysis Example: Stroke, Intracranial Bleed –The Patient with Spinal Cord Disorder Dysaesthesia, Incontinence, Pain, Weakness Example: Disk Herniation, Spinal Cord Compression, Brown- Sequard Syndrome

4. Focused Exam: The Comatose Patient Glasgow Coma Scale 654321 EyesN/A Opens eyes spontaneously Opens eyes in response to voice Opens eyes to painful stimuli Does not open eyes VerbalN/AOriented, converse s normally Confused, disoriented Utters inappropriate words Incompre- hensible sounds Makes no sounds MotorObeys commands Localizes painful stimuli Withdraws from painful stimuli Decorticate posturing upon painful stimuli Decerebrate posturing upon painful stimuli Makes no movements Interpretation: GCS < 8 = Severe, GCS 9-12 = Moderate, GCS > 13 = Minor

5. Focused Exam: The Comatose Patient (con’t) Brain Reflexes –Oculocephalic Reflex (Doll’s eyes) –Babinski –Gag Reflex (CN 9, 10) –Corneal Reflex (CN 5) –Cold Calorics Pupillary Response Response to Pain DTRs Gaze (Ping-Pong Gaze)

6. Focused Exam: Central Neuro Disorder CNs Speech Coordination Pronator Drift Motor Sensation Proprioception Graphesthesia Stereognosis

7. Focused Exam: Spinal Cord Disorder Sensation Motor Hot/Cold Vibratory Sense Proprioception Gait DTRs Rectal Tone Hoffman’s Sign

8. Motor Function Testing Lack of Consistency: –Patient: 90 y/o female vs. 20 y/o male –Examiner Motor Weakness helps to pinpoint spinal cord lesion

9. Keys to the Motor Exam Have patient perform movement First! One side at a time; Compare R vs L Examiner: Use the same hand throughout exam Examiner: Don’t be a wimp! Use full and consistent strength (unless there is known injury). –Use single muscle group, i.e. don’t use your body weight to oppose. Important to assign a specific response to a set grade Test Certain Muscle Groups

10. Grading Strength 5/5: Examiner is unable to overcome patient 4/5: Examiner is able to overcome patient; patient demonstrates moderate resistance 3/5: Patient able to overcome gravity only 2/5: Patient unable to overcome gravity, but can move joint 1/5: Muscle “fires”, but no joint movement 0/5: No muscle response May use +/- to differentiate further

11. Strength Testing: The Muscle Groups Upper extremities: ActionNerve Root / Spinal Level Shoulder AbductionC5 Elbow FlexionC5/C6 Elbow ExtensionC6/C7/C8 Wrist ExtensionC6 Wrist FlexionC7 Grip Strength (Finger Flexion)C8 Interosseous (Finger Ab/Adduction) T1

12. Strength Testing: The Muscle Groups Lower Extremities: ActionNerve Root / Spinal Level Hip FlexionL1 Knee ExtensionL3 Ankle DorsiflexionL4 Great Toe ExtensionL5 Ankle PlantarflexionS1

13. Nerve Root Landmarks C3 – Front of Neck T 4 – Nipples T 10 – Umbilicus L3 – Knee L4 – Medial LE L5 – Lateral LE & Great Toe

14. Questions??