Neurologic Emergencies: How to Do a Fast, Focused Evaluation of Any Neurologic Complaint

© Springer International Publishing AG 2018

Latha Ganti and Joshua N. Goldstein (eds.)Neurologic Emergencieshttps://doi.org/10.1007/978-3-319-64523-0_1

1. The Fast and Focused Neurological Examination

Matthew S. Siket¹  

(1)

Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street 2nd Floor, Providence, 02903, RI, USA

Matthew S. Siket

Email: Matthew_Siket@brown.edu

Introduction

The neurological examination in the emergency department (ED) should be targeted and focused yet thorough and sensitive enough to detect subtle but meaningful abnormalities. Ideally, the components of the neurological exam for any given ED patient should be structured after an interview to gather historical information including the history of present illness, review of systems, as well as past medical, family, and social histories. Realistically, however, in today’s world of acute stroke metrics including door-to-CT and door-to-TPA times, with many institutions (including my own) embracing a direct-to-CT clinical pathway, the time that an ED provider spends with his/her hands on a patient with an acute neurologic complaint may be very limited before important and time-sensitive decisions must be made. This chapter will focus on structuring a proper encompassing yet efficient neurological exam to be used and relied on by the ED provider when minutes and seconds count for the patient with an acute and undifferentiated neurologic emergency.

Basic Principles

All ED providers should be comfortable performing a neurological examination, as invariably it will be performed several times each shift. According to the National Hospital Ambulatory Medical Care Survey, 9.4 million CT scans of the brain were obtained in US EDs in 2013, which is approximately 7% of all ED visits [1]. Moreover, there were 4 million ED visits each for headache and head/neck trauma, 1.3 million visits for vertebral/spinal trauma, and over 400,000 visits for dizziness in patients aged 65 and over. Despite the need for careful neurological assessment in these patients, a complete and encompassing neurological examination (as would be performed in a neurologist’s office) would be inefficient and practically impossible given competing time-sensitive demands in the ED setting. Therefore, it is best for the ED clinician to divide the emergent neurological exam into two components: the focused component, which is built around the patient’s complaint and historical data, and the screening component, which assesses for additional focal and localizing neurologic deficits in the remaining parts of the nervous system [2]. The focused component should be largely individualized and built on a foundation of basic understanding of neuroanatomy. The screening component can be more standardized but should be more comprehensive in patients with potentially neurological causes of acute illness than for those with clearly non-neurologic complaints. For example, one should not be expected to detect a homonymous quadrantopia in an otherwise healthy patient presenting with dysuria, whereas it would similarly be inappropriate to document the extent of a neurological exam as no gross abnormalities in a patient presenting with headache, dizziness, or weakness. A list of the most common neurologic complaints encountered in the ED is found in Table 1.1.

Table 1.1

Common chief complaints of neurological emergencies

Initial Assessment

In certain instances when time-critical decisions must be made, the initial neurological exam may consist of a brief screen to inform downstream processes, such as the activation of a stroke team, the acquisition of emergent neuroimaging, and of course in securing an airway in patients who have lost protective reflexes. In these cases, review of vital signs and a very brief assessment of neurological function are initiated prior to a comprehensive patient interview. For example, in patients with suspected head injury and/or decreased level of consciousness, the initial patient evaluation should assess the airway, breathing, and circulation (ABCs) followed by level of consciousness, typically using the Glasgow Coma Scale (Table 1.2). In patients suspected of experiencing an acute ischemic stroke, the Face, Arm, Speech, Time (FAST) assessment or severity scale such as the Los Angeles Motor Scale (LAMS) may be performed in the prehospital environment or upon initial contact with emergency personnel. A more encompassing list of prehospital stroke scales is listed in Table 1.3. The National Institutes of Health Stroke Scale (NIHSS) is a widely used tool for measuring neurologic deficits in a reproducible way, and in the United States, documentation of an NIHSS from the initial provider assessment in all ischemic stroke patients is expected in all certified stroke centers. This 11-item scale (Table 1.4) was designed to take 7 min to complete but in reality can be performed in a fraction of that time. Certification is encouraged but not mandated per The Joint Commission and is freely available online (https://​secure.​trainingcampus.​net/​uas/​modules/​trees/​windex.​aspx?​rx5nihss-english.​trainingcampus.​net). It is important to remember that the NIHSS is not a replacement for a complete neurological examination and is not encompassing. It is preferentially skewed toward the anterior circulation, and a NIHSS of 0 does not exclude serious and debilitating neurologic injury.

Table 1.2

The Glasgow Coma Scale [13]

Table 1.3

List of stroke recognition and severity assessment tools

Table 1.4

The National Institutes of Health Stroke Scale (NIHSS)

The History and Focused Neurological Examination

Under most circumstances, the components of a focused neurological examination in the ED should be individualized and constructed around relevant information gathered from the patient’s history. The experienced clinician formulates a differential diagnosis in real time during the patient interview and then caters the exam that follows to be hypothesis driven. The examiner should be looking to differentiate whether the patient has a neurologic or non-neurologic cause of illness and whether a neurologic cause can be traced to the central nervous system (brain and spinal cord) or peripheral nervous system. Simply put, the examiner should focus on addressing the following three questions: (1) Is there a lesion? (2) Where is the lesion? (3) What is the lesion?

Reported neurologic symptoms can generally be characterized as either positive or negative. Positive symptoms include the addition of clinical phenomena, such as certain visual aura preceding a migraine, tonic-clonic activity in a motor seizure, and pins and needles paresthesias such as in radicular back pain. Positive symptoms typically describe irritative phenomena, wherein there is an overabundance or abnormal neuronal discharge [3]. The examiner may note repetitive motor movements, such as automatisms or heightened sensation (aka hyperesthesia). Negative symptoms, on the other hand, describe ablative phenomena, where there is a loss of normal neurological function. Symptoms include motor weakness, sensory loss (numbness as opposed to tingling), and loss of normal coordination, vision, speech fluency, and articulation. Since motor, sensory, and visuospatial ablative phenomena are most often unilateral, it is best to directly compare the two sides of the body directly at each step of the examination [4].

Two other types of clinical phenomena are observed in patients with debilitating neurological disease: release and compensation syndromes, which typically follow ablative phenomena. Release syndromes include spasticity and hyperreflexia in upper motor neuron disease and motor rebound findings in patients with cerebellar dysfunction. Compensation syndromes occur as the brain adjusts for deficits, such as in patients with a notable head tilt to compensate for an ocular nerve palsy or a broad-based gait to compensate for imbalance and loss of coordination.

The pace and manner of onset of symptoms are important historical components that should be carefully elucidated during the encounter. For example, acute and sustained ablative-type symptoms should lead one to expect a vascular emergency such as stroke, whereas episodic, fluctuating, or triggered symptoms often point to a nonvascular cause (except in cases of transient ischemic attacks). Careful attention to the timing and triggers of the described symptoms is imperative, particularly in dizziness (which is discussed in depth in Chap. 6), as it serves as the foundation on which the remaining components of the exam, including provocative tests, are structured. Degenerative processes typically have a slow-to-variable course over months to years, whereas demyelinating diseases such as multiple sclerosis may have a variable course. Diffuse and non-localizing symptoms should clue the clinician into pursuing causes of encephalopathy, such as toxic/metabolic and infectious processes.

Once enough historical data has been collected to form a reasonable differential diagnosis with attention given to the most dangerous and treatable potential causes first, the focused examination that follows should confirm or refute those considerations and modify the list accordingly. The examiner should target the suspected affected portions of the nervous system first, compare to the contralateral side, and then expand to adjacent anatomical areas. For example, a patient with apparent right hemiparesis should have careful attention paid to speech and language function, knowing that Broca’s and Wernicke’s areas are generally located in the left hemisphere (approximately 95% of right-handed individuals and 60% of left-handed individuals). Similarly, if in the aforementioned example language is preserved but a right-homonymous hemianopia is noted, one can be nearly certain that the lesion is in the left cerebral hemisphere, not in the cervical spinal cord. When such deficits are present, they are described as focal localizing signs , which should always trigger further investigation, usually in the form of neuroimaging. False localizing signs describe phenomena such as limb weakness observed in hypoglycemia or cranial nerve deficits produced by mass effect from a space-occupying lesion. When formulating and narrowing the differential diagnosis, the ED provider should be mindful of the law of parsimony (Occam’s razor), which is the principle that most likely there is a single lesion and unifying diagnosis to explain a constellation of symptoms. Table 1.5 provides a list of general principles to aid in localization of CNS lesions.

Table 1.5

General principles regarding lesion localization

The Screening Neurological Examination

Following a focused exam, a screening exam should be performed to briefly interrogate the remaining parts of the nervous system. Though the history and physical examination are distinguished for purposes of organization, in reality, the objective assessment of neurological function begins at the commencement of the encounter. Is the patient fully alert and seemingly aware of his/her surroundings? Is there obvious hemispheric inattention or neglect? Does the patient exhibit a normal and fluent speech pattern? Is the patient able to recall historical events and appropriately communicate a history of present illness? Does he/she exhibit normal facial expressions? The interviewer inherently gains a sense of these functions in the first few moments of the interview. For purposes of convenience, the screening neurological exam can be divided into an organizational framework of six distinct components, (1) mental status and higher cortical function, (2) cranial nerves, (3) sensory function, (4) motor function, (5) gait and coordination, and (6) reflexes, which can be performed in any order.

Mental Status and Higher Cortical Function

Assessment of mental status includes both neurological and psychiatric components. Neurologic mental status includes level of consciousness (alertness), orientation (person, place, time, and situation), attention (ability to concentrate), and memory (immediate, short, and long term). Psychiatric components include mood, affect, thought process and content, judgment, and insight.

Interrogating language function is also an integral part of assessing a patient’s mental status. In order for language function to be intact, patients need to be able to hear and comprehend what was said, find the appropriate words to initiate a reply, and respond fluently with normal cadence and rhythm (prosody). Repetition, naming, reading, and writing are also components of a thorough assessment of language function. When speech comprehension, processing, or production is impaired, the patient is said to exhibit aphasia. Aphasia can be receptive (Wernicke’s aphasia), expressive (Broca’s aphasia), global, or limited to just repetitive (conductive aphasia) or naming dysfunction (nominal aphasia). Aphasia typically localizes to cortical or subcortical damage. The ED provider need not dwell on the specifics of aphasia subtype discrimination, but for purposes of identification and communication with consultants, one should describe whether the aphasia is fluent (receptive), nonfluent (expressive), or mixed [5]. Speech that is slurred or difficult to understand is considered dysarthric which suggests a mechanical disorder from facial muscle weakness or incoordination. This may be reflective of a motor hemispheric or cerebellar lesion or point to a problem in the brainstem, cranial nerves, or chemical effect, such as alcohol intoxication.

Other tests of higher cortical function include right-left discrimination, geographical orientation, recognition (gnosia), constructional ability, and carrying out learned tasks (praxis). A three-step command is a quick way to assess executive function in the ED. Though not encompassing, it does test multiple mental processes simultaneously when performed correctly. The key is to eliminate visual input and to ensure that the patient waits to perform the three-step task until after all the steps are described. An example is to ask the patient to close the eyes, make a fist with the right hand with the thumb out, and then use that thumb to touch the left ear while sticking out the tongue [3].

Cranial Nerves

A cranial nerve exam is fundamental when examining patients with neurologic complaints. Though the olfactory nerve (CN I) rarely needs emergent assessment, the remaining cranial nerves may be adequately interrogated in a matter of seconds and provide important clinical data. The ED provider should spend a minute or two assessing the patient’s eyes, preferably paying attention to pupillary response, presence of nystagmus, extraocular movements, visual fields, and fundoscopy in addition to assessing facial movements and sensation. This is particularly important in patients presenting with headache when the focus of the encounter is to exclude potentially dangerous causes such as aneurysmal subarachnoid hemorrhage, vasculitis, a space-occupying lesion, meningitis, encephalitis, and other causes of increased intracranial pressure. The remaining cranial nerves (II–XII) and how to test them are described below. Note, significant attention is paid to CN II, III, IV, and VI as the examination of the eyes is often one of the most valuable parts of the neurological exam.

Optic Nerve (CN II) : Assess visual acuity, visual fields, pupillary response, and fundoscopy. Not every patient needs formal Snellen chart testing unless visual disturbance is reported. However, a patient may be unaware of a hemianopia or quadrantopia unless specifically tested. Face the patient directly and cover the eye of the patient which is not being tested, and then have the patient focus on your corresponding eye (patient’s left eye looks at your right eye). Place your hand hallway between your eye and the patient’s eye and find your corresponding visual fields, and then hold up 1–5 fingers and ask the patient to tell you how many. Patients sometimes need to be reminded to not look at your fingers but rather to focus on your eye and see the fingers with their peripheral vision. Do this for each quadrant of each eye. Alternatively, you may combine visual field testing with accessing for visuospatial inattention and some executive function by holding up two fingers in one hand and one finger in the other hand held over the lateral visual fields of each eye and ask the patient to tell you how many fingers are seen in total. For the patient to say three requires bihemispheric awareness, intact visual fields where tested, and the ability to add 1 + 2 (absence of acalculia), typically a parietal lobe function.

The pupils should be near symmetric in size (~1 mm of anisocoria can be physiologic) and round in shape and constrict equally to light. Illumination of one eye should cause an equal pupillary response in both eyes. In the swinging flashlight test, a seemingly paradoxical dilation of one pupil suggests an afferent pupillary defect (Marcus Gunn pupil) suggestive of unilateral optic nerve dysfunction. Note that slow, subtle (~1 mm) pupillary oscillations may be seen in a normal pupillary light reflex, called a hippus.

A fundoscopic exam should be performed to assess for papilledema whenever increased intracranial pressure is considered on the differential diagnosis. While many trainees in emergency medicine may skip this part of the exam due to difficulty visualizing the optic disk without the aid of a mydriatic agent or a lack of confidence in interpreting the presence of optic disk abnormalities, the exam can provide valuable clinical information and should always be considered. Technological advances in ophthalmoscopy have made fundus visualization and photography easier than ever before, and several portable products exist that can be attached to the examiner’s smartphone. Measurement of optic nerve sheath diameter 3 mm behind the eye over closed eyelids on bedside ocular ultrasound may be a useful adjunct to ophthalmoscopy, as a diameter ≥ 5.7 mm achieved 100% sensitivity and specificity for intracranial pressure > 20 mmHg among patients with intracerebral hemorrhage [6–9].

Oculomotor (CN III) , Trochlear (CN IV) , and Abducens (CN VI) Nerves : Assess the eyelids, extraocular movements, and for the presence and type of nystagmus. The oculomotor nerve innervates all the extraocular muscles except the superior oblique (which is innervated by CN IV) and the lateral rectus (CN VI). A lesion to CN III will lead to the affected eye deviated down and out. Additionally, because CN III innervates parasympathetic pupilloconstrictors as well as the levator palpebrae muscle, a third nerve palsy produces a dilated pupil and ptosis as well. Fourth nerve palsy usually manifests as vertical diplopia and is compensated by a head tilt away from the affected side. A sixth nerve palsy produces an inability to abduct the ipsilateral eye. These syndromes along with other causes of diplopia are discussed in more depth in Chap. 7.

Rhythmic oscillation of the eyes is called nystagmus and can be both physiologic and pathologic. Typically, there is a jerking movement with both a fast phase and a slow phase. It is best to assess whether nystagmus is present with the eyes in a neutral position and then with looking to the left and right. At extremes of lateral gaze, some horizontal nystagmus is normal; thus, it is best to assess for pathological nystagmus in acutely dizzy patients when looking ~45 degrees laterally. Pathological nystagmus can be overcome by fixation, producing a false-negative finding, which can be prevented by placing a piece of white paper in the field of view. Frenzel goggles also help prevent this while magnifying the eyes and making nystagmus much easier to visualize. Peripheral causes of acute vestibular syndrome typically produce a horizontal, unidirectional nystagmus, whereas benign paroxysmal, positional vertigo (s) more classically causes a torsional, horizontal-rotatory nystagmus. Vertical nystagmus can be seen in phenytoin toxicity but should be considered a central pathological lesion until proven otherwise.

Most commonly, nystagmus will be observed to be horizontal and unidirectional and will be from a peripheral cause. The fast phase typically beats in the direction of the unaffected ear. In patients with acute-onset and sustained vertigo, testing of the oculocephalic reflex (aka head impulse test) and for vertical skew deviation on alternating cover test can reliably exclude a central lesion such as a brainstem stroke as the cause of vertigo. This battery of tests is called the HINTS exam and when performed correctly may be more sensitive than diffusion-weighted MRI in the detection of stroke among high-risk acutely dizzy patients [10]. The head impulse test is performed by rapidly rotating the head from either center to lateral or lateral to center approximately 10° and assessing whether the patient is able to maintain his/her gaze on a fixed object (such as the examiner’s nose) without catch-up saccade-like movements being observed. The presence of saccades in one direction and failure to maintain a fixed gaze are abnormal findings and suggest a peripheral lesion, such as vestibular neuronitis or labyrinthitis. The alternating cover test assesses whether the patient can maintain gaze on a fixed object while one eye is covered in an alternating fashion. Refixation up and down suggests hypertropia/hypotropia and is a rare but abnormal finding. Horizontal refixation, on the other hand, is most often a normal finding associated with amblyopia.

Trigeminal Nerve (CN V) : Assess for sensation on the face and strength in the muscles of mastication. The trigeminal nerve has ophthalmic, maxillary, and mandibular branches and controls touch and temperature sensation throughout the face. The corneal reflex can be tested when patients are unable to communicate sensory findings. Having the patient clench his/her teeth and open/close the mouth tests the muscles of mastication. The jaw jerk reflex tests both sensory afferents and motor efferents.

Facial Nerve (CN VII) : Assess the muscles of facial expression. While the facial nerve contains motor, autonomic, and sensory fibers, testing the sense of taste on the anterior two-thirds of the tongue is beyond the scope of most ED neurological exams. Instead, having the patient smile, grimace, wrinkle the forehead, close eyes tightly, show teeth, and wiggle the nose is sufficient. When facial muscles are weak, a flattening of the nasolabial fold may be the first sign. A peripheral lesion (such as Bell’s palsy) will typically involve the forehead, whereas a central lesion (such as stroke) spares the forehead and predominantly affects the lower face.

Acoustic Nerve (CN VIII) : Assess the hearing component briefly by making a soft sound in each ear individually. Examples include clicking a disposable otoscope specula with one’s fingernail or rubbing two fingers together. The use of a tuning fork in the ED is seldom necessary. The vestibular component can be interrogated in patients suspected of having positional vertigo with provocative testing followed by canalith repositioning techniques. Since most (85–90%) of BPPV involve the posterior semicircular canal, the Dix-Hallpike test should be performed first, leading into the Epley maneuver if posterior BPPV is confirmed. If unsuccessful, then assessing the horizontal semicircular canal with the spine roll test is reasonable, followed by the Lempert roll if horizontal BPPV is confirmed.

Glossopharyngeal (CN IX) and Vagus (CN X) Nerves : Simply ask the patient to open his/her mouth and say ah while looking for symmetry of the palate and midline position of the uvula. Weakness of the palate may lead to dysarthric speech and impairment of saying words with the letter k [11]. Swallowing function may be impaired in patients with lesions to CN IX and X. If swallowing is impaired or the patient has a decreased level of consciousness or suspected brainstem pathology, consider also assessing the gag reflex.

Accessory Nerve (CN XI) : Since this innervates the trapezius and sternocleidomastoid muscles, having the patient shrug the shoulders against resistance and turn the head from lateral to center against resistance should be sufficient.

Hypoglossal Nerve (CN XII) : Look for symmetric protruding of the tongue, or have the patient push his/her tongue against the wall of the mouth while the examiner pushes back against the cheek. Having the patient say La La La rapidly is also reasonable [12].

Sensory Function

Sensation is divided into light touch, pinprick, position, vibration, and temperature modalities. While it would be impractical to test each modality in every patient, those with acute abnormalities in touch sensation should prompt further interrogation of the additional sensation subtypes. Adequate position sense assesses the spinal posterior column, making vibration testing redundant. Hence, a tuning fork is seldom needed in the ED setting. Altered sensation may either be heightened (hyperesthesia), reduced (hypoesthesia), or absent (anesthesia). When a sensory level is identified, a skin marker can be used for labeling. The examiner should then decide whether the lesion follows a specific dermatome or is more indicative of a polyneuropathy, myelopathy, or central lesion. Cortical sensory modalities include two-point discrimination, graphesthesia (recognizing letters written on the skin), stereognosis (tactile recognition of an object), and tactile extinction during double simultaneous stimulation.

Motor Function

Pronator drift is assessed in each limb individually with the eyes closed. The arms are held outstretched with palms facing up for 10 s. Subtle weakness may initially manifest with abduction of the pinky finger followed by hand pronation and then arm drift downward. The legs are assessed in a supine patient by active hip flexion upward a few inches off the bed for 5 s. Muscle strength can be further assessed by testing both sides simultaneously. Interossei muscles, grip, wrist flexion and extension, elbow flexion and extension, shoulder flexion and extension, and abduction and adduction should all be assessed when upper extremity weakness is reported or when a cervical spinal lesion is suspected. Similarly, plantar and dorsiflexion, knee flexion and extension, hip flexion and extension, and abduction and adduction should be assessed when lower extremity weakness is reported or a lumbar lesion is suspected. Table 1.6 outlines the grading of muscle strength using the Oxford scale.

Table 1.6

The Oxford scale of muscle strength

The presence of abnormal motor movements should be assessed for tremor, fasciculations, and repetitive movements including automatisms. This is best done while the limb is at rest and during movement. Muscle tone can be assessed by passive movements of the patient’s joints. Note should be made of rigidity, spasticity, hypotonia, and flaccidity. Muscle groups can be assessed for asymmetric wasting and atrophy. In general, upper motor neuron lesions cause increased muscle tone and hyperreflexia, whereas lower motor neuron lesions cause decreased muscle tone, hypoactive reflexes, and atrophy.

Reflexes

Proprioceptive muscle stretch reflexes such as the biceps, triceps, brachioradialis, quadriceps, and Achilles are performed to confirm the integrity of a reflex arc. Though they are of little use in isolation, taken together with strength, tone, and sensation, reflexes are a helpful and often necessary component of the neurological exam. Deep tendon reflexes are graded on a scale from 0 to 4, with 0 denoting areflexia and 4 being significantly hyperreflexic with clonus. Polysynaptic nociceptive reflexes include the Babinski, cremasteric, bulbocavernosus, and anal wink, which are generally reserved for cases when acute spinal cord damage is suspected.

Coordination and Gait

The cerebellum is responsible for orchestrating oppositional muscle function to form fluid and smooth body movements. The central cerebellum (vermis) controls posture and truncal movements and is best tested by assessing for truncal and gait ataxia. The lateral cerebellum (cortex) oversees oppositional muscle coordination and is best tested with rapid alternating movements, dysmetria (finger to nose, heel to shin), and cerebellar rebound testing. Loss of smooth pursuit of eye movements across the visual fields and impaired articulation of speech can be signs of cerebellar dysfunction and will have likely been tested in other parts of the neurological exam.

Putting It All Together

In clinical practice, a thoughtful neurological examination in the ED should take far less time to perform than to read about. One strategy for purposes of efficiency is to incorporate multiple components of the exam simultaneously starting at the patient’s head and working toward the toes. The following sequence is one example that incorporates most of what has been discussed and should be sufficient for nearly any neurologic complaint.

1.

Start with mental status if not already elucidated during the patient interview. Is the patient awake and alert, easily arousable, drowsy, lethargic, obtunded, or comatose? Is he/she communicative, oriented, and aware of surroundings and situation? Is speech fluent and appropriate and thought content normal? Can the patient repeat words and appropriately identify and recall objects? Questions:What is your full name? Where were you born? Where are you right now? What month is it? Who is the current President of the United States? What is this in my hand that I might use to write my name? Please repeat after me: no ifs, ands, or butts….what was it I was holding in my hand?

2.

Next examine the eyes. Note pupillary response to light and perform the swinging flashlight test. Check extraocular movements, assess for presence and type of nystagmus, and check the visual fields. Perform a fundoscopic exam to exclude papilledema.

3.

Proceed to assess facial movements and symmetry. Have the patient smile, grimace, puff out the cheeks, and protrude the tongue and move it side to side. Have the patient close his/her eyes forcefully against resistance from opening by your hands. While touching the face, now assess for symmetry in facial sensation. Then have the patient shrug the shoulders against resistance and turn his/her head from lateral to center against resistance. Palpate the face and skull for abnormalities including for tenderness over the temporal arteries. Visualize the tympanic membranes and, in cases of trauma, exclude Battle sign, raccoon eyes, and hemotympanum. Use the otoscope speculum to assess CN VIII.

4.

Proceed caudally to the upper extremities. Assess for pronator drift, then grip strength, and then strength of the shoulders, elbows, wrists, hands, and fingers. With fingers apart, have the patient mimic playing the piano (a test for coordination) and then finger-to-nose test and rapid alternating movements. Place the arms at the side and test sensation in a spiraling fashion distally, so as to not follow a single dermatome. Perform double simultaneous tactile stimulation to assess for inattention, and then do the same in the lower extremities.

5.

Having moved on to the legs, test again for sensation, paying special attention to the saddle distribution in patients with back pain or leg weakness. Assess for pronator drift in the legs and then strength in the toes, feet, ankles, knees, and hips. Check heel-to-shin coordination and then patellar and Achilles reflexes.

6.

While holding your reflex hammer, move back to the biceps, triceps, and brachioradialis; then, while holding the patient’s arm, help him/her up if able to assess for ataxia and gait.

7.

Lastly, complete the neurological exam with visual acuity if needed or with the visual items of the NIHSS if one is being scored.

Special Circumstances

Patients who are unable to participate may make parts of the aforementioned exam more difficult to interpret. Pupillary and corneal reflexes, as well as deep tendon and superficial reflexes, should be preserved. Visual field testing can be performed by assessing visual response to threat, and sensation can be assessed by response to painful stimuli.

Pearls and Pitfalls

Many components of a neurological examination can be observed in the initial moments of a patient’s interview.

Some components of a neurological examination can be assessed simultaneously, and moving from head to toe is one way to streamline the exam in the emergency