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Our program has a stellar neuro rotation so I feel super comfortable doing the neuro exam with patients. Per hospital policy we have to do physical exams on every single person we admit as a resident, so fortunately/unfortunately we end up doing neuro exams on almost everyone.
 
I end up doing a lot more neuro exams on patient than some of my co-residents but I have caught some things to date as a result. I can think of at least one patient whom my attending was going to discharge rather precipitously for her total lack of cooperation with treatment and frequent behavioral outbursts who, as a result of my neuro exam (and the cascade of testing it triggered) ended up being discharged to a SNF.

Also at least on our inpatient side we do a lot of call and we get at least a couple of falls per night. Need to do at least an abbreviated neuro exam on someone who has fallen, especially when we have several dozen geriatric patients at any given time.
 
If you're doing consult or geriatric psychiatry, it's pretty relevant. You may not be doing the definitive exam and diagnosis, but you're still a lot more savvy about the CNS than the PCP or surgeon is likely to be.
 
I perform an abbreviated one fairly regularly. I rarely test for strength (something about arm wrestling with the patient seems counter therapeutic), but will look for asymmetry with forearm rolling or pronator drift. Otherwise, I'm mostly interested in coordination, tremor/astrexis/clonus (both evoked and spontaneous) and frontal release signs. I don't spend a lot of time with gait, but that's probably the most important to look at considering what it could yield and how badly we screw it up with our meds. I'll check extraocular muscles and ophthalmoplegia, but otherwise don't worry about cranial nerves.

The question is, would I actually do anything different based on my exam. The answer is usually no. If I have any inkling there's a neurological deficit, I'll either consult a neurologist or just order the imaging. I think I like to do an exam because I'm hoping it will convey to the patient that I take their complaints "seriously."
 
Tone is the most relevant thing to the psychiatrist. The rest of the neuro exam is as part of a screening admission physical exam, usually. Other stuff only if you have good reason. I have yet to find good reason, personally, although coresidents have had patients who ended up being transferred from inpatient psych to inpatient neuro.
 
chajjohnson said:
Hey Everyone,

So I'm at the start of my 4th year of med school and still torn between psych and neuro. I'm leaning more towards psych at this point but I still find the neuro exam and medicine aspects of neuro attractive. As a psychiatrist how often do you perform neuro exams, or any physical exam for that matter? I'd imagine it's useful for evaluating conversion disorders and EPS of anti-psychotics, but can't think of many more examples.
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on my unit the medicine team does and documents all that stuff. medicine is consulted on every pt and follows every pt daily.
 
FlowRate said:
Tone is the most relevant thing to the psychiatrist. The rest of the neuro exam is as part of a screening admission physical exam, usually. Other stuff only if you have good reason. I have yet to find good reason, personally, although coresidents have had patients who ended up being transferred from inpatient psych to inpatient neuro.
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I got yelled at by a senior resident for admitting someone early on in intern year because he seemed excessively sedated and the resident in question blamed the Zyprexa PRN I had ordered. Two days and an EEG later at it turned out he was in nonconvulsive status and spent two months in a pentobarb coma. Granted, there were reasons in the history to be a bit suspicious of something intracranial, but you're not going to find anything if you don't look. Interictal EEGs are waaaay overused and we need to be proper Bayesians about them, but you can be very efficient about a screening neuro exam and the marginal cost is next to nothing, so I don't think you need much suspicion at all.
 
I have the skill set (thanks to extra neuro rotations in med school and amazing months on neuro during residency) but hardly do it in outpatient clinic- unless I need to. We do admission physicals on our inpatient unit that include neuro exams, but most of these are routine. They are actually useful on consults sometimes.

Just doing a routine exam if you have next to no suspicion of "organic" pathology is a waste of time. Most outpatient neurologists don't do a full exam.

Also, most internists don't know how to do competent neuro exams.
 
As a PGY-1 you'll have a neuro rotation (2 months of neuro consults in my program) which is pretty neat, but if you enjoy the neuro exam, why not consider neurology?

As someone finishing up PGY-1 psychiatry, we do a physical exam whenever we admit someone and I like to do a 2-minute neuro exam as well. You'll also do physical exams while on the medicine rotations. To be honest, while I try to be thorough, I think most colleagues consider it a perfunctory exam done just to fill in the appropriate spot in the admission write-up. After a patient is admitted, unless there is a specific concern, you will not do a physical or neuro exam on them again.
 
one of the most useful exams is to examine cogwheeling. great way to titrate your antipsychotic dose.
 
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