psych7711

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Feb 7, 2008
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Anyone have a neuro exam template including an example of a patient with normal neurological findings?
 

typhoonegator

Neurointensivist
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Here's a basic emergency room screening neuro exam that many of our juniors use at my program. Don't flame me for leaving stuff out -- it's just a template. You should tailor it to the patient you're seeing (i.e. dementia exam with a longer mental status evaluation)

MS: AA&Ox3, appropriately interactive, normal affect
Attention: WORLD backwards, MOY backwards, digit span 4 forwards, 3 back
Speech: fluent w/o paraphasic error, repetition, naming, reading, writing intact
Memory: x/3 at 5 minutes, x/3 with prompting
Calculations: 9 quarters = $2.25
L/R confusion: No L/R confusion
Praxis: Able to mimic brushing teeth and blowing out match with either hand.
CN: I--not tested; II,III--PERRLA, VFF by confrontation, optic discs sharp; III,IV,VI—EOMI w/o nystagmus, no ptosis; V--sensation intact to LT, masseters strong symmetrically; VII--face symmetric without weakness; VIII—hearing grossly intact; IX,X--voice normal, palate elevates symmetrically, gag intact; XI--SCM/trapezii 5/5; XII--tongue protrudes midline, no atrophy or fasciculation.
Motor: normal bulk and tone, no tremor, rigidity or bradykinesia, no pronator drift. No orbital movement.
Strength:

|Delt|Bic|Tri |WE|FiE |FgSp | IP |Quad|Ham |TibA|EHL |Gast|
| C5|C6 | C7| C6| C7 |C8/T1|L1-2|L3-4|L5/S1| L4 | L5 | S1 |
L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
R | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |

Coord: rapid alternating and point-to-point (FNF, HTS, TTF) movements intact.
Refl:
| Bi |Bra | Tri | Pat |Ank |Toe |
|C5-6| C6 | C7 |L2-4| S1 |
L | 2 | 2 | 2 | 2 | 2 | dn |
R | 2 | 2 | 2 | 2 | 2 | dn |

Sens: LT, PP, temperature, vibration and joint position intact. No evidence of extinction to DSS.
Gait: posture, stance, stride and arm-swing normal. Tandem gait intact. Able to walk on heels and toes. Romberg absent.
 

neurologist

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"Neuro exam WNL"

(at least if a neurologist writes it, you know it must be true . . . ) :D