Neuro Exams
How to perform and document an exam like a Pitt neurosurgeon
Universal Exams
Formats
Extubated/Floor
example
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/ICU
| 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
Components
Cranial Nerves
CN 1
generally not applicable
CN 2
CN 3, 4, 6
CN 5
facial sensorium (get a percentage if decreased)
CN 7
CN 8
CN 9-11
Check palatal elevation/intact gag and shoulder shrug for lesions involving the CPA angle or lower
CN 12
Check after every carotid
Motor Exam (ASIA standard)
|  |
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 |
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).
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
Bulbocavernous 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
Pediatric Neuro Exams
Vocabulary:
Sutures can be "splayed"
Fontanelles can be "bulging"
