This document provides an overview of performing a neurological examination in the emergency room setting. It describes examining six categories: mental status, cranial nerves, motor exam, reflexes, coordination/gait, and sensory exam. It details how to test each cranial nerve, as well as signs of upper and lower motor neuron lesions. Motor strength, deep tendon reflexes, plantar responses, and sensory exams are also outlined. Meningeal irritation signs and lumbar puncture for meningitis workup are also mentioned. The goal is to localize any neurological deficits and consider central vs. peripheral causes.

1. Neurological Examinationin the Emergency Room 急診神經學檢查 Tintinalli‘s Emergency Medicine: A Comprehensive Study Guide, 7E Chapter e158.1 The Neurologic Examination in the Emergency Setting

2. Neurological Examination急診神經學檢查 General Considerations Always consider left to right symmetry 比較左右對稱 Consider central vs. peripheral deficits 區分中樞或週邊缺損

3. Overview Organize your thinking into six categories: Mental Status 意識狀態 Cranial Nerves 顱神經檢查 Motor Exam 運動功能檢查 Reflexes 反射 Coordination and Gait 協調性及步態 Sensory Exam 感覺功能檢查

4. Awareness Patient Examine for Cortical Deficits Orientation: time, place, person and situation) Digital span: 7 numbers foreward and 5 numbers backward Confusion of right and left Calculation: 100－7－7…or 20－3－3… Recent memory: recall 3 objects after 5-minutes interval

8. Brainstem Anatomy

9. I –Olfactory 嗅神經 Not Normally Tested

10. II –Optic 視神經 Examine the Optic Fundi Test Visual Acuity Screen Visual Fields by Confrontation Test Pupillary Reactions to Light Test Pupillary Reactions to Accommodation

11. III –Oculomotor動眼神經IV –Trochlear滑車神經VI –Abducens外展神經 Observe for Ptosis (CN III) Test Extraocular Movements (EOM) Test Pupillary Reactions to Light (CN III) CN6 CN4

13. V –Trigeminal 三叉神經 Test Temporal and Masseter Muscle Strength Test the Three Divisions for Pain Sensation Test the Corneal Reflex

14. VII – Facial 顏面神經 Observe for Any Facial Droop or Asymmetry Test the Corneal Reflex

16. VIII –Acoustic 聽神經 Screen Hearing Test for Lateralization (Weber) Compare Air and Bone Conduction (Rinne)

17. IX –Glossopharyngeal舌咽神經X –Vagus迷走神經 Listen to the patient's voice, is it hoarse or nasal? Ask Patient to Swallow Ask Patient to Say "Ah" Test Gag Reflex (Unconscious/Uncooperative Patient)

18. XI – Accessory 副神經 From behind, look for atrophy or assymetry of the trapezius muscles. Ask patient to shrug shoulders against resistance. Ask patient to turn their head against resistance. Watch and palpate the sternomastoid muscle on the opposite side.

19. XII – Hypoglossal 舌下神經 Listen to the articulation of the patient's words. Observe the tongue as it lies in the mouth

20. Cranial Nerves Observation Ptosis (III) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III)

21. Cerebellar Test Coordination and Gait Rapid Alternating Movements 快速翻轉運動 Point-to-Point Movements 點對點運 finger-to-nose test heel-to-shin test Romberging test Gait 步態協調

22. Rapid Alternating Movements

23. Point-to-Point Movements

24. Motor Power Pronator Drift

25. Muscle System Strength Muscle Groups 0/5: no contraction 1/5: flicker 2/5: movement when gravity eliminated 3/5: movement against gravity 4/5: movement against resistance 5/5: normal strength

26. Reflexes 反射 Deep Tendon Reflexes 0: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustainedclonus (i.e., repetitive vibratory movements) 5+: sustained clonus Jendrassik's maneuver (locking the finger tips together and pulling) Anal reflex: rectal sphincter tone, spinal cord injury

28. Signs of Upper Motor Neuron (UMN) & Lower Motor Neuron (LMN) Lesions

29. C5, C6 C7, C8 L3, L4 S1, S2

30. Plantar Response (Babinski)

33. Sensory 感覺 General 一般感覺 Vibration 震動 Subjective Light Touch 輕觸 Position Sense 位置感

34. DermatomalTesting 皮層測驗 Pain 疼痛 Temperature 溫度 Light Touch 輕觸 Discrimination 兩點分辨

35. 加油，還剩六分鐘！ 好好學，護一生喔！ C7 C8 C6

36. Brudzinski’s and Kernig’s SignsBoth Signs of Meningeal Irritation Kernig’s sign: Resistance to extension of the leg while the hip is flexed Brudzinski’s sign: Flexion of the hips and knees in response to neck flexion

37. Lumbar Puncture (CSF Exam):Meningitis or Subarachnoid Hemorrhage (SAH)

38. Neurological Examination急診神經學檢查 General Considerations Always consider left to right symmetry 比較左右對稱 Consider central vs. peripheral deficits 區分中樞或週邊缺損