Do you have a specific method for assessing these patients you could share in a "step by step" type of path?
Just a disclaimer here: this would NOT BE for a trauma patient!! Haha. Also, I take a VERY holistic approach, and focus on the obvious problem at hand, and then radiate outward to adjacent cranial nerves. But generally, I start at bundles of problem areas and then move to less common regions of deficit. We also use the NIH stroke scale, but if I don't have the time to do it, I can do this assessment in about 6 min flat:
Let's say we have a patient complaining of a moderate weakness/numbness in the right hand/arm. So I test for equal power/strength and
verify this. Next, I check sensory and motor in the legs, and while I am there I run a tongue depressor along the bottom of their foot and look for Babinski sign. This can tell us if there is a wider area of upper motor neuron damage. I generally start with extremity sensory/motor to see if there are deficits on BOTH SIDES, which would point to a very low lesion in the brain - eg midbrain/pons/medulla. If it is unilateral, I then move to the "cluster" areas of the midbrain and pons.
Cranial nerve I (Olfactory) - eh, unless you have perfume ect forget it
Cranial Nerves II (Optic), III (Occulomotor), IV (Trochlear), and VI (Abducens) can be tested together for vision, pupillary reflex, movement, and heminopsia.
This is probably the most important part of the assessment. In less than two minutes, you could potentially detect severely life-threatening blockages/bleeds. You can test occulomotor function as well as higher association areas, which if not intact, is warp 9 to the hospital.
Also, here we are checking not only vision, but the tempo-parietal junction for RECOGNITION of objects, as well as NAMING objects and possible aphasia.
We check the pupillary reflex in both eyes, and the size of the pupils. We swing the penlight between eyes and look for consensual constriction. We have the patient follow the tip of the penlight side to side, top to bottom, and in a
circle. We move the penlight away from the patient to test accommodation, and then toward them to test convergence. Here we are looking for saccades of the eye, and "freezing" of one eye on a lateral or convergent gaze. We also have the patient tilt their head and see if any double vision pops up. Basically, using this pattern will find most if not all occulomotor abnormalities.
Now at this point, we can also have the patient fixate on on object, and then we roll their head side to side and watch the "dolls eyes" phenomenon, and check for evidence of saccades or freezing of an eye midline.
If there is double vision, we have them close one eye to see if it goes away. If it does go away, then we can be fairly sure the double vision arises from an eye muscle overcompensating from another eye muscle weakness.
We are also testing here for spatial NEGLECT. We are seeing if they ignore fingers we hold up in each region of space. If they are, there are more advanced techniques you can use by turning their head or presenting an unusual stimulus (making a weird face) on the
side they are neglecting. Since crossing your eyes and making a weird mouth expression is out of the ordinary, their frontal association areas will turn their ATTENTION subconsciously to that side. But later on, they will deny ever having seen you do that! This is very rare, but can be very informative to the Doc in the ER.
So while we are testing vision/neglect, we also test for naming and recognizing objects. I hold up my notebook and ask them what it is. I have them close their eyes and hand them a stuffed toy we have in the back for kids and ask me to tell me what it is.
Also, we can have them repeat a sentence to examine for dysarthria and comprehension.
If there is evidence of neglect, one of the BEST possible methods to DOCUMENT this -
so the docs don't think you are crazy if it spontaneously resolves - is to have them draw a clock with the hands at 2:10!! Patients with neglect will invariable ignore whatever side, and presto, you have written incontrovertible proof of this for a physician.
Cranial Nerve VII (Facial) - Now there is some weirdness with the facial nerve. The LOWER face is innervated by CONTRALATERAL fibers, so any lower facial deficit from CORTICAL damage should be on the same side as the motor deficit.
We do the smile, wrinkle your nose, raise your eyebrows, and then bury/hide your eyelashes. I also have them wink at me with one eye, then the other, and then in rapid succession.
Cranial nerves VIII-XII - Here is gets a bit more tricky, but the tongue is a GREAT way to test lower in the brain lesions. Stick out your tongue, move to the right, left, and then try to touch their nose with it. Any fasiculations (ridges) on the tongue are a dead giveaway for a cranial nerve XII deficit.
Other techniques:
-Nose to finger
-Having them hit their palm with the top and then bottom of their other hand in rapid alternating succession - we are looking for evidence of dysdactokinesia
-Instruct them to fold a piece of paper in half, hand it to you, and then touch their hand to their chest - we are testing memory, praxis, following commands, and spatial awareness
So in short:
1) Focus on the obvious deficit, and then identify extremity deficits in sensory/motor
(
2 and 3 can be interchangeable depending on your patient)
2) Check occulomotor function, vision, object recognition, and evidence of aphasia
3) Check the face and see if facial deficits correlate to the side of the extremity deficit
4) Go lower in the brain and check the tongue, and then follow up with the cerebellum and dysdactokinesia
5) Come up higher and check praxis, higher commands, memory, and visuospatial awareness - take into account motor deficits that are existing
If you simply do 1-3 and even forget testing for neglect, you will nail most CVA patients, and get them the priority they deserve at the ER. 4-5 may identify a global problem superimposed on top of a CVA, and get a good CYA for the ER doc transferring immediately to Neuro.
You may also say, hey that is the NIH stroke scale minus fine motor skills and the cards! Well yes and no. It was how I was trained to do it that does not take the strict and regimented and quantifiable of the NIH. No one I know can do NIH in the time most of our jurisdiction is to the hospital. No one.
If I really have the time, I give the patient the Mini-cog. I ask them to remember "ball, tree, and flag" as words to recall, have them draw a clock at 2:10, and then ask them to recall the words. This is a GREAT test for dementia, delirium, as well as executive and memory deficits from cerebrovascular disease.
@Brandon Oto
See above for Babinski, and Hoffman's sign can be done right after checking their power to squeeze. Just flick their middle finder while you already have their hand in yours!
Serial 7s and words backwards can be done after 3) above if you feel there is evidence of an executive dysfunction.
