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Focused Neurological Exam
Focused Neurological Exam (Questions and Answers)
10.1 Basic Concepts
What are the six components of a full neurological exam?
1. Level of consciousness/mental status
2. Cranial nerve exam (usually nerves II through XII)
3. Motor exam (Royal Medical Research Council of Great Britain grading scale)
4. Sensory exam (key sensory landmarks)
5. Reflexes (muscle stretch [“deep tendon”] reflexes and primitive reflexes)
6. Coordination and gait
What is a “focused neurological exam”?
It is a problem-oriented exam (based on the chief complaint and manifested symptoms)
that should be conducted in an efficient time frame with the purpose of localizing the
lesion.
What three deficits may a physician observe by careful observation alone?
(1) Obvious speech problems/aphasia (expressive or receptive), (2) general gross motor
problems, and (3) dysarthria
How long should a focused neurological exam last?
It should be patient-specific. Serving as a screening tool, it may be short if there are no
findings but extend to a lengthier examination if pertinent positives are found.
What are the four objectives of a focused neurological exam?
NEUROLOGICAL EXAM
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To determine (1) the etiology, (2) appropriate diagnostic testing, (3) the working
diagnosis, and (4) ultimately the proper treatment necessary to improve the patient’s
presenting symptoms.
Why is both a focused and rapid neurological exam especially important in a trauma patient
with multiple injuries?
Such an exam that is both focused and rapid allows the trauma surgeon and neurosurgeon
to collaborate and prioritize the patient’s injuries and institute diagnostic tests and
imaging before starting treatment.
When would extensive examination of higher cerebral functioning, cerebellar functioning,
and cranial nerve function be deemed unnecessary?
When a patient presents with isolated spinal pathology and does not present with
complaints or symptoms that are suggestive of intracranial pathology
10.2 Level of Consciousness/Mental Status
When should one use the Glasgow Coma Scale (GCS) or Full Outline of Unresponsiveness
(FOUR) scale?1
When approximating level of consciousness in a poorly responsive patient
What is the maximum number of points that one can receive in the GCS?
15:
4 for eye opening
5 for verbal
6 for motor
What is the minimum number?
3
What does “T” mean in GCS scoring?
Intubated (e.g., the patient may arrive 3T: unresponsive and intubated from the field)
NEUROLOGICAL EXAM
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How are points awarded for verbal responses?
1: no verbal response
2: incomprehensible sounds
3: inappropriate words
4: confused, disoriented 5: normal, appropriate speech
When applying the GCS, who receives a “best eye opening” score of 4?
Those whose eyes are opened spontaneously upon entering the room. Patients who
respond to speech only should not be confused with an awaking or a sleeping person;
such patients receive a score of 4, and not 3.
When applying the GCS, how is best eye opening to pain only (a score of 2) tested?
By applying pressure on the patient’s fingernail bed
When assessing the “best motor response” of the GCS, what is meant by “withdrawal to
pain” (a score of 4)?
Pulling part of the body away when pinched, exhibiting normal flexion to central pain
stimulation
When assessing the “best motor response” of the GCS, what is meant by “localization to
pain” (a score of 5)?
Purposeful movements toward changing painful stimuli (e.g., when the patient’s hand
crosses the midline with deep sternal rub or gets above the clavicle when supraorbital
pressure is applied)1
How would a physician recognize decorticate posturing (a score of 3) when estimating level
of consciousness?
Flexion at the arms and elbows, hyperextension of the legs (clue: decorticate = “hands
over heart” [or Corazon])1
NEUROLOGICAL EXAM
Focused Neurological Exam
Focused Neurological Exam (Questions and Answers)
10.1 Basic Concepts
What are the six components of a full neurological exam?
1. Level of consciousness/mental status
2. Cranial nerve exam (usually nerves II through XII)
3. Motor exam (Royal Medical Research Council of Great Britain grading scale)
4. Sensory exam (key sensory landmarks)
5. Reflexes (muscle stretch [“deep tendon”] reflexes and primitive reflexes)
6. Coordination and gait
What is a “focused neurological exam”?
It is a problem-oriented exam (based on the chief complaint and manifested symptoms)
that should be conducted in an efficient time frame with the purpose of localizing the
lesion.
What three deficits may a physician observe by careful observation alone?
(1) Obvious speech problems/aphasia (expressive or receptive), (2) general gross motor
problems, and (3) dysarthria
How long should a focused neurological exam last?
It should be patient-specific. Serving as a screening tool, it may be short if there are no
findings but extend to a lengthier examination if pertinent positives are found.
What are the four objectives of a focused neurological exam?
NEUROLOGICAL EXAM
,2
To determine (1) the etiology, (2) appropriate diagnostic testing, (3) the working
diagnosis, and (4) ultimately the proper treatment necessary to improve the patient’s
presenting symptoms.
Why is both a focused and rapid neurological exam especially important in a trauma patient
with multiple injuries?
Such an exam that is both focused and rapid allows the trauma surgeon and neurosurgeon
to collaborate and prioritize the patient’s injuries and institute diagnostic tests and
imaging before starting treatment.
When would extensive examination of higher cerebral functioning, cerebellar functioning,
and cranial nerve function be deemed unnecessary?
When a patient presents with isolated spinal pathology and does not present with
complaints or symptoms that are suggestive of intracranial pathology
10.2 Level of Consciousness/Mental Status
When should one use the Glasgow Coma Scale (GCS) or Full Outline of Unresponsiveness
(FOUR) scale?1
When approximating level of consciousness in a poorly responsive patient
What is the maximum number of points that one can receive in the GCS?
15:
4 for eye opening
5 for verbal
6 for motor
What is the minimum number?
3
What does “T” mean in GCS scoring?
Intubated (e.g., the patient may arrive 3T: unresponsive and intubated from the field)
NEUROLOGICAL EXAM
, 3
How are points awarded for verbal responses?
1: no verbal response
2: incomprehensible sounds
3: inappropriate words
4: confused, disoriented 5: normal, appropriate speech
When applying the GCS, who receives a “best eye opening” score of 4?
Those whose eyes are opened spontaneously upon entering the room. Patients who
respond to speech only should not be confused with an awaking or a sleeping person;
such patients receive a score of 4, and not 3.
When applying the GCS, how is best eye opening to pain only (a score of 2) tested?
By applying pressure on the patient’s fingernail bed
When assessing the “best motor response” of the GCS, what is meant by “withdrawal to
pain” (a score of 4)?
Pulling part of the body away when pinched, exhibiting normal flexion to central pain
stimulation
When assessing the “best motor response” of the GCS, what is meant by “localization to
pain” (a score of 5)?
Purposeful movements toward changing painful stimuli (e.g., when the patient’s hand
crosses the midline with deep sternal rub or gets above the clavicle when supraorbital
pressure is applied)1
How would a physician recognize decorticate posturing (a score of 3) when estimating level
of consciousness?
Flexion at the arms and elbows, hyperextension of the legs (clue: decorticate = “hands
over heart” [or Corazon])1
NEUROLOGICAL EXAM
