The Nonspecific Neurological Exam

This is a hot case where the candidate is led to a random patient, and asked to "examine their neurological system".

These tend to come in three discrete flavours. The patient will be either

a) Comatose

b) Awake, extubated and cooperative, with weird neuro signs

c) Profoundly weak a'la Guillaine Barre

Slightly different approaches are required for each.

Approach to the comatose patient

Some excellent resources exist to help the exam candidate with this topic.
The candidate with months to spare may drink deep of Plum and Posner's Diagnosis of Stupor and Coma (warning, 9Mb download)
The time-poor candidate should read Examination of the Unconscious Patient  by Chris Nickson from LITFL.
An approach suggested by an ex-examiner is as follows:

• Start by asking whether there is a language barrier.
• Expose the patient. It is important to see the arms and legs. It is also important not to perform any weird bed sheet origami. Cover the groin; doesn't matter how.
• Observe the respiratory pattern. In fact, observe the whole exposed patient. You know, myoclonus, fasciculations et cetera.
• Start with the GCS. In the completely unconscious patient, you should ask before inflicting pain.
• Look for signs of trauma.  You don't know whether there has been some sort of recent surgical procedure.Specifically:
  • Scars, stapled craniotomy wounds
  • "NO BONE" dressings over craniectomy holes
  • Battle's sign and raccoon eyes
  • EVD wounds or actual EVDs or other ICP monitors; subgaleal drains etc.
• Next check for neck stiffness. This is to rule out meningism. You should ask before violently moving the neck.
• Then, start with the cranial nerves.
  • CN II and III: pupillary reflex
    • Note: is there scleral icterus? could be important.
      Subconjunctival haemorrage? Hyphaema?
  • CN V and VI: corneal reflex
  • CN V:  painful stimulus over the orbit.
    • Observe the limbs. This may change your opinion of the GCS.
  • CN VII: oculocephalic or caloric reflex
    • The oculocephalic reflex will also tell you about CN III, IV and VI.
      Essentially, if the doll's eye is intact, then so is much of the brainstem.
      If it is abnormal, you have to think about the gaze palsies.
  • CN IX and X: gag reflex, cough reflex
    • Properly! get the tongue depressor in there and look with the neuro torch.
  • CN XII, tongue fasciculation (generally seen while looking for the gag reflex)
• Then, go on to examining the rest of the neurological system:
  • Tone
  • Power (may have to inflict pain again)
  • Reflexes: brachioradialis, biceps, triceps, knee jerk, ankle jerk, plantar.
  • Clonus (while you're down at the feet)
• Sensation may or may not be possible to test.
• Cerebellar features - apart from nystagmus - are not going to be easy to detect.

So; then they ask you questions. "Why is this patient unconscious?" A broad range of differentials can be developed.  To recall them all, one hazards a descent into the the madness of increasingly elaborate acronyms. In short, its a matter of discriminating the coma with focal signs from the coma without focal signs. The latter comes in a variety of flavours, whereas the former should be reasonably straightforward.

Approach to the irritating awake patient

This is the ICU for god's sake. Shouldn't this guy be discharged by now?
Anyway. The awake neurology hot case frequently kills candidates. The patient will likely have some sort of very classical pathology which you will need to find. In order to find it, you must be thorough.

So:

• Start by asking the patient some baseline orientation-establishing questions:
  • "What's your name?"
  • "Do you know where you are right now?"
  • "What year is this?"
  • Most of such patients in the exam will have been oriented enough to consent for participation.
• Having performed this quick "delirium check", ask the patient for their permission and expose the patient.
  It is still important to see the arms and legs. Pay extra attention to covering the groin; the patient is awake enough to be sensitive about their hugely oedematous scrotum (for example).
• Observe the respiratory pattern. In fact, observe the whole exposed patient. You know, myoclonus, fasciculations et cetera.
• Then, start with the cranial nerves.
  • CN I : block one nostril and ask the patient whether they can smell the opened alcohol swab.
  • CN II: get the patient to read something convenient to grossly assess acuity (with each eye individually)
  • Visual fields: its better to use the "count my fingers" technique
    • One should mention that without fundoscopy this stage of the cranial nerve examination is not complete. However, examiners may frown on somebody doing something that is not a part of routine ICU practice, so keep quiet about the fundoscopy.
  • CN II and III: pupillary reflex
  • CN II and III: accomodation
  • Eye movements: "follow my finger", draw a broad H about 1m away from the patients face.
  • CN V and VII: corneal reflex  (make sure the patient knows what is about to happen)
  • CN V: facial sensation; light touch over the face - three regions: forehead, cheeks, chin.
  • CN VII: facial movements: perform a few grimaces:
    • Raise eyebrows
    • Tightly close eyes; (try to force the eyelids open)
    • Puff out cheeks
    • Cheesy grin
    • Pout
  • CN VIII: oculocephalic and cold caloric test - In the context of a long whole-day exam, one should probably avoid performing a caloric test in the awake exam patient, but one should mention that one wishes to do it. Otherwise, its Rinne's and Webers' tests, and who has a tuning fork nowadays?
  • CN IX and X: gag reflex, cough reflex
    • Properly! get the tongue depressor in there and look with the neuro torch. Comment on the uvula. Ask them to say "Aaa" as this will cause the pharyngeal muscles to contract, dragging the uvula away from the lesion.
  • CN XII: tongue movements:  get them to stick their tongue out and wiggle it from side to side.
  • CN XI: get them to shrug their shoulders and turn their head left and right against your resistance.
• Then, go on to examining the rest of the neurological system:
  • Tone
  • Power (may have to inflict pain again)
    • If they are awake, this is a good time to check for "flap" of some sort (asterixis of hepatic encephalopathy, uraemia or hypercapnea)
  • Reflexes: brachioradialis, biceps, triceps, knee jerk, ankle jerk, plantar.
  • Clonus (while you're down at the feet)
  • Sensation
• Cerebellar exam: only if the power is adequate!
  • Trunkal ataxia: Sit the patient up and ask them to close their eyes, looking for
  • Drift: with eyes closed and outstretched arms
  • Arm rebound: Ask the patient to flex or extend against resistance, and rapidly release the tested arm. The patient will be unable to arrest the arm's movement on the affected side, and the arm will hit either one of you in the face.
  • Finger-nose pointing
  • Dysdiadochokinesis
  • Heel-shin test
  • Gait (if you and the patient are about to walk out of the exam, you are probably both doing well, but the examiners will probably stop you there.)