THE 5-MINUTE SCREENING

NEUROLOGIC EXAMINATION

David Lee Gordon, M.D., FAAN, FANA, FAHA

Professor and Chair
Department of Neurology
The University of Oklahoma Health Sciences Center

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5-MINUTE NEUROLOGIC EXAM
DAVID LEE GORDON – DISCLOSURES

I have no financial relationships or

affiliations to disclose.

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5-MINUTE NEUROLOGIC EXAM
LEARNING OBJECTIVES

■ Describe the indications for performing a

screening neurologic examination
■ List the components of a screening
neurologic examination
■ Perform an accurate screening
examination of a patient’s visual fields

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 NEUROLOGIC EXAM:
TAILOR EXAM TO PATIENT & SITUATION

ESSENTIAL EXAM FOCUSED EXAMS SCREENING EXAM

 Pt WITH suspected  Pt WITH suspected  Pt WITHOUT suspected
neurologic disease neurologic disease neurologic disease
 Core neurologic  Sx- or condition-  Quick neurologic exam
examination specific neuro exam  Especially for non-
items neurologist:
 no need for tools
 part of general
physical exam
 If abnormal findings,
perform essential and
focused exams

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 • 46 items
• 6 tools
ESSENTIAL NEUROLOGIC EXAM • 6-10 min

TOOLS
 Penlight
 Ophthalmoscope
 Rosenbaum card
 Safety pin (1 per pt)
 Tuning fork (large/128 Hz)
 Reflex hammer (w/ weight)

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 • 16 items
SCREENING NEUROLOGIC EXAM: • 0 tools
HEAD-TO-TOE DOCUMENTATION • 2 min

MENTAL STATUS MOTOR SENSATION

 Level of consciousness  Arm drift  Light touch
 Language (naming)  Finger tap COORDINATION
 Orientation  Hip flexors  Finger to nose
CRANIAL NERVES  Ankle dorsiflexors  Heel to shin
 Visual fields GAIT & STATION
 Extraocular movements  Regular gait
 Facial sensation  Romberg
 Facial strength

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 • 16 items
SCREENING NEUROLOGIC EXAM: • 0 tools
TIME-EFFICIENT PERFORMANCE • 2 min

MENTAL STATUS MOTOR/COORDINATION—UPPER

 Level of consciousness  Facial strength
 Language (naming)  Arm drift
 Orientation  Finger tap
EYES  Finger to nose*
 Visual fields MOTOR/COORDINATION—LOWER
 Extraocular movements  Hip flexors
SENSATION  Ankle dorsiflexors
 Light touch (face)  Heel to shin
 Light touch (body)* GAIT & STATION
 Regular gait
 Romberg

*Move these two items to improve time efficiency

OU Neurology
 SCREENING NEUROLOGIC EXAM:
MENTAL STATUS

 Level of DON’T FORGET!

consciousness Start the neurologic exam
 Language with mental status
(naming) assessment—ironically,
 Orientation this component of the
exam is often forgotten

OU Neurology
 SCREENING NEUROLOGIC EXAM:
MENTAL STATUS

 Level of DON’T FORGET!

consciousness Perform language testing
 Language BEFORE orientation and
(naming) the rest of mental status:
 Orientation Incorrect responses on
mental status testing may
be due to language
difficulty, not true
“confusion”
If naming is abnormal,
complete language
testing:
• Comprehension
• Repetition
• Fluency

OU Neurology
 SCREENING NEUROLOGIC EXAM:
MENTAL STATUS

 Level of DON’T FORGET!

consciousness Recalling the exact date
 Language is even difficult for
(naming) patients with normal
 Orientation mental status:
Accept the year, month,
and “beginning,”
“middle,” or “end” of the
month
The inability to name
one’s self only occurs in
patients with aphasia or
profound dementia

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 SCREENING NEUROLOGIC EXAM:
CRANIAL NERVES

 Visual fields DON’T FORGET!

 Extraocular Do NOT cover your own
movements eye—it may confuse you
 Facial sensation and is not necessary
 Facial strength Keep the four quadrants
in tight, close to the
midline
Use only 1, 2, and 5
fingers when assessing
finger counting

OU Neurology
 SCREENING NEUROLOGIC EXAM:
CRANIAL NERVES

 Visual fields DON’T FORGET!

 Extraocular For patients who do NOT
movements complain of double vision,
 Facial sensation check the four main
directions of gaze (up,
 Facial strength down, left, right), not the
cardinal positions
Only check the cardinal
positions of gaze (the “H”)
if a patient complains of
double vision
Bury the sclerae in all
directions (i.e., make sure
the eyes move completely
in all directions of gaze)

OU Neurology
 SCREENING NEUROLOGIC EXAM:
CRANIAL NERVES

 Visual fields DON’T FORGET!

 Extraocular Test light touch in all three
movements trigeminal-nerve
 Facial dermatomes, just a few
sensation centimeters from the
midline (trigeminal-nerve
 Facial strength dermatomes are medial,
cervical dermatomes are
lateral)
Ask two questions:
“Where do you feel it?”
“Is it same on both sides?”
Must ask pt to compare
areas, e.g., R vs. L

OU Neurology
 SCREENING NEUROLOGIC EXAM:
CRANIAL NERVES

 Visual fields DON’T FORGET!

 Extraocular First observe palpebral
movements fissures and nasolabial
 Facial sensation folds for asymmetry at
rest and during
 Facial strength conversation
Then ask patient to raise
eyebrows, close eyes,
and smile or grimace

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 SCREENING NEUROLOGIC EXAM:
MOTOR

 Arm drift DON’T FORGET!

 Finger tap Test arm drift with the
 Hip flexors patient’s eyes closed and
palms up
 Ankle
dorsiflexors Look for pronation or
downward drift of an arm
as a sign of weakness
If the patient is supine,
realize that gravity may
cause a weak arm to drift
toward the patient’s head

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 SCREENING NEUROLOGIC EXAM:
MOTOR

 Arm drift DON’T FORGET!

 Finger tap Have the patient tap the
 Hip flexors index fingers on the
thumbs of both hands
 Ankle
simultaneously and look
dorsiflexors for differences
Small or slow excursions
suggest weakness in the
limb

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 SCREENING NEUROLOGIC EXAM:
MOTOR

 Arm drift DON’T FORGET!

 Finger tap Ask the supine patient to
 Hip flexors lift one “leg”
 Ankle Ask the seated patient to
dorsiflexors stabilize himself and lift
one “knee”

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 SCREENING NEUROLOGIC EXAM:
MOTOR

 Arm drift DON’T FORGET!

 Finger tap Stabilize the joint
 Hip flexors (hold the ankle)
 Ankle
dorsiflexors
Test side to side

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 SCREENING NEUROLOGIC EXAM:
SENSATION

 Light touch DON’T FORGET!

Lightly stroke backs of the
hands and feet
Ask two questions:
“Where do you feel it?”
“Is it same on both sides?”
Must ask pt to compare
areas, e.g., R vs. L
Don’t waste time with
superfluous testing
Keep patient’s limbs
uncrossed, eyes closed
Don’t touch patient
elsewhere when testing
sensation

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 SCREENING NEUROLOGIC EXAM:
COORDINATION

 Finger to nose DON’T FORGET!

 Heel to shin Observe both dysmetria
and dystaxia
Detect subtle ataxia by
fully extending the
patient’s arm

OU Neurology
 SCREENING NEUROLOGIC EXAM:
COORDINATION

 Finger to nose DON’T FORGET!

 Heel to shin Observe both dysmetria
and dystaxia
Don’t let the leg dangle
when testing a seated
patient: Lift the leg you
are not testing so that it is
parallel to the ground—
this will prevent the
tested leg from simply
falling due to gravity

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 SCREENING NEUROLOGIC EXAM:
GAIT & STATION

 Regular gait DON’T FORGET!

 Romberg Do not test gait in socks
on hard floor (socks are
too slippery—shoes or
bare feet preferred)
Observe:
- Posture
- Base width
- Step size
- Arm swing

OU Neurology
 SCREENING NEUROLOGIC EXAM:
GAIT & STATION

 Regular gait DON’T FORGET!

 Romberg Stay near the patient in
case he or she falls
If patient falls with eyes
open, Romberg is not
testable
Romberg sign is a test for
proprioception—patient
must have eyes closed
Do not push or pull
patient when testing for
Romberg

OU Neurology
 SCREENING NEUROLOGIC EXAM:
HEAD-TO-TOE DOCUMENTATION

MENTAL STATUS MOTOR SENSATION

 Level of consciousness  Arm drift  Light touch
 Language (naming)  Finger tap COORDINATION
 Orientation  Hip flexors  Finger to nose
CRANIAL NERVES  Ankle dorsiflexors  Heel to shin
 Visual fields GAIT & STATION
 Extraocular movements  Regular gait
 Facial sensation  Romberg
 Facial strength

OU Neurology
SCREENING NEUROLOGIC EXAM:
TIME-EFFICIENT PERFORMANCE

Move two items to improve time efficiency

OU Neurology
5-MINUTE NEUROLOGIC EXAM
LEARNING OBJECTIVES

■ Describe the indications for performing a

screening neurologic examination
■ List the components of a screening
neurologic examination
■ Perform an accurate screening
examination of a patient’s visual fields

OU Neurology
THE END

OU Neurology