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The Neuro Exam
Yes, you really do have to wake them up and do this
Last Updated by Lindsay PaganoSummer 2013
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What are the components and how do I document them?
Neuro:
•Mental Status
•Language, Speech
•Cranial Nerves
•Motor
•Reflexes
•Sensory
•Cerebellar
•Gait
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What are we checking and how?
Mental Status•What?
– Level of alertness, awareness
– Degree of interaction
– Orientation
– Following commands
– Older children: naming objects, simple calculations, extinction, neglect, fund of knowledge
– Difference from baseline
•How?
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Language, Speech
• Language– comprehension
– spontaneous, fluent
– appropriate content
– other things you can check: repetition, naming objects, reading, writing
• Speech– prosody
– volume
– rate
– dysarthria
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Cranial Nerves• CN 1: Olfactory…yeah, we don’t check that either
• CN 2: Optic
– Visual acuity
– Visual fields
– Fundus
• CN 3: Oculomotor
– Pupil reactivity to light (direct and consensual) and accomadation
– Extraocular eye movements (superior, medial and inferior recti; inferior oblique)
• CN 4: Trochlear
– Extraocular eye movements (superior oblique)
• CN 5: Trigeminal
– Muscles of mastication
– Facial sensation (V1, 2, 3 divisions)
• CN 6: Abducens
– Extraocular eye movements (lateral rectus)
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Cranial Nerves, continued• CN 7: Facial
– Facial muscles
– Taste (anterior 2/3)
• CN 8: Vestibulocochlear
– Hearing
– Vestibular function
• CN 9: Glossopharyngeal
– Taste (posterior 1/3)
– Uvula
• CN 10: Vagus
– Phonation
– Palate elevation
• CN 11: Spinal accessory
– Head turn
– Shoulder shrug
• CN 12: Hypoglossal
– Tongue protrusion
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Motor
• Tone
• Muscle bulk
• Strength: check agonist/antagonist pairs– Grading system
• 0: no movement
• 1: can see muscle contraction but no movement
• 2: can move with gravity eliminated
• 3: can move against gravity
• 4: can resist opposition to some extent, but not full (+, - also)
• 5: full strength
– Pronator drift: correct position!
– Orbiting
• Abnormal movements
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Reflexes• Grading system
– 0: absent
– 1+: hyporeflexic
– 2+: normal
– 3+: brisk, without clonus
– 4+: brisk, with clonus
• More pathologic descriptors: crossed, spreading
• Where to check
• Clonus– Sustained
– Unsustained
• Other reflexes: pectoral, grasp, suck, moro, jaw jerk
• Plantar response
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Sensory
• How and what part of the nervous system are we checking?– Light touch
– Pinprick
– Temperature
– Vibration
– Joint position sense
• Checking a level
• Romberg- correct positioning!
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Cerebellar
• Ataxia– Axial
– Appendicular
• Finger-nose-finger
• Heel-knee-shin
• Rapid alternating movements
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• Casual
• Toe
• Heel
• Tandem
• What are those last 3 testing?
Gait
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Other Neuro Rotation Tips
• Neuro exam on all patients
• Report all AEDs in per dose and mg/kg/day
• Know the patients primary neurologist
• When applicable know the last head imaging and EEG done and the results
• Make sure after their inpatient stay they have follow up and a breakthrough seizures plan/medication
• In clinic, be sure to ask birth history, developmental history (gross motor, fine motor, language, social), about school performance, therapies