Adult Neurological exam

Dear Physicians

The Corona virus has presented Neurologists with a true challenge , having to preform a full Neurological examination from afar, using digital tools.

Despite the difficulty, it is possible to preform a thorough Neurological examination, despite the hardshi, but certain elements must be taken into account that can't be done from afar, such as Ophthalmologic and Vestibular examinations, Sensory losses and slight weaknesses.

The AAN published guidelines for adults, which you can watch in the attached link. Here are the main points. 


There are a few important rules:

  • There is high emphasis on observation

  • It is important to demonstrate to the patient what you want them to do 

  • Adjust the camera throught the meeting in order to get an impression of body language 

  • If necessary , you can ask to repeat the assignment 

  • If another examiner is present , the NIH STROKE SCALE may be assessed 

  • Don't ask the patient to do anything they are uncomfortable with 

Neurological examination:

Cognitive assessment :

Cognition can be assessed fully by relevant questionnaires. 


Cranial nerves

CN 1 : Not examined 

CN 2 : Visual fields can be tested using the screen or by getting help by someone who is with the patient. Pupil size can be assessed if the camera has a high enough definition

CN 3,4,6 : Testing eye movements in all directions

CN 7 : Symmetry of the face

CN 9-12 : Shoulder movements up and down, and tongue movements. 


Motor system

Observ the patient for shaking and unwanted movements

Muscle strength:

Upper limb:

Pronator drift

Movement of fingers to thumb

Hand movements while walking 

Lower limb:

Walking on toes and heels

Standing on one foot 

Lower limb drift

In addition:

Sitting to standing 

Standing up from the sitting position without the use of hands 


Tone:

Movement of fingers to the thumb 

Openning and closing the fingers 

Pronation and supination of the hands 

Drumming movement with the fingers and toes 


Sensory :

Can only be assessed if there is another person present with the patient in the room. 

Ask to assess differences in senstation between the left and right , proximal and distal areas, and response to specific dermotomes if there is an experienced physician with the patient. You can ask to draw a line above the area with no sensation. 


Cerebellum:

Finger to nose test. 

Reflexes can't be tested. 


Format for documenting the Neurological exam for adults:

In a video meeting:

No blunt cognitive decline, 

pupils equal, normal eye movements without nistagmus, 

symmetric face, symmetric tongue. 

Motor exam:

No weakness, symmetric movements of the arms and legs, no pronator drift. 

Walking on toes and heels without clear asymmetry. 

Weight bearing on left and right feet - normal.

Cerebellum: No impression of ataxia or nistagmus, finger to nose test is normal. 

For the full AAN guidelines, click on the following link:


https://youtu.be/KGlFCWWZGCY


Good Luck!