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Lecture - Master Clinician Series: The Symptom-Specific Rapid Neuro Examination

 
So one of the things I'm not that proud about is that for the first three years in my medical training, I was in neurosurgery. So I learned a lot of stuff in neurosurgery, and most of it was bad habits, and I learned how to do a lot of neuro exams relatively quickly. But what I do think I took away, I always try to frame it in my mind I did not waste three years, I just picked up three years of experience that lots of other people haven't had the pleasure of.

But I did learn how to do an effective neuro exam that would tell me what was going on with most patients, that would find the life threat. And we definitely did not do the neurologist neuro exam, nor do I think anybody needs to do the neurologist neuro exam. But I did learn how to do an exam that would help me figure out what specifically was wrong with this patient, and do I need to do something about it right now? So we're gonna cover first general thoughts in the neuro exam, and then we're gonna look at three things.

Back pain we already kinda covered, but I'll just hit the highlights. So first of all in the neurologic exam, we all know this stuff, but sometimes it's nice to review, and specifically it's nice to review what is the high yield stuff versus the I do not need to waste a neuron on this stuff.

I can reassure you that no one is pouring, no industry is pouring money into redoing the neurologic exam, so what you learn still applies, what Osler learned probably still applies to the neurologic exam. It's not changing, it's just focusing on the things that are most important.

So, the neurologic exam. Just like none of us drive like we did when we took our drivers test, none of us do our neurologic exam like we did when we were on a neurology rotation, and I don't always address my mirrors and all that stuff that I'm supposed to do when I get into a car, I sometimes just go. With a neurologic exam, it's not a lot in the same way, sometimes I just go cuz I gotta find the one thing I gotta know about and move on.

So we all learned how to do a complete neuro exam. I have probably never done a complete neurologic exam since the last time somebody was watching me do it for a grade. I don't think you need to do it, I don't think it's appropriate to do it, I don't have time to do it. In the ED, it's not one size fits all. There's a specific neuro exam I need to do for this complaint.

It doesn't exist in isolation of the general exam. I can do a lot of your neurologic exam when I do your general physical exam, and I think of it much more as a neurologic screening examination, and if I find something I'll go deeper, but if I don't I'm done. So I got two jobs in the ED. If somebody has a neurologic problem I have two jobs, and I need to do the most focused study that will tell me, that will answer the problem at hand, and is organized in a way that will give me a very strong sense of where I'm going.

Number one is, is there a neuro life threat here, or a neuro threat that needs me to intervene right now? And the second priority is find neurologic problems that don't need me to do anything right now, but need me to send you to a neurology specialist. So what is my most important tool when I'm doing, when I wanna know about a neurologic problem in the ED? And time and again study has said, it is so unlikely you are gonna uncover a neurologic problem that is not found in the history that the patient gives you. That usually anything you find, if they've given you nothing about neurologic, and you find some small neurologic problem, you probably have found something that's incidental. So rarely, rarely will there be a finding that I do anything about that was not in the history.

The things I'm gonna find out about in the history when you give me neurologic problem, I need to know the onset. How long has this been going? Is this a fast evolution, a slow evolution disease? What is the trajectory of this disease? What body part is involved? Did they make any sense anatomically? Are there triggers, or no triggers involved? Is this a sensory problem, a motor problem, or both? And are there associated non-neurologic symptoms that may in fact relate to a neurologic problem? This is not like I invented these, but these are the areas that you have to know about when you walk out of the room.

If somebody is giving you a neurologic complaint, and a history that pushes you towards neurology problem, I gotta know mental status /cognitive ability for global neurologic. Cranial nerves, motor exam, sensory exam, reflexes, and then coordination and balance. The first principle, and again I work with learners. I work with residents and medical students and off service residents, and they almost always will get stuck on some positive feature of a test.

So they will do an incredibly detailed neurologic exam, and they will decide that somebody's pinky has decreased sensation versus their other pinky. And my message for them is always never get stuck on one thing, neurology happens in a pattern. It does not happen in isolation, and so don't be looking for the one little thing that you're gonna find.

There will be a pattern, you don't have one shot to find the neurology problem. You have lots of shots to find the neurology problem, don't get stuck on one positive test. So here's my world's fastest screening neurologic examination. If I need to screen somebody for a neurologic problem, I'm gonna watch them walk, I'm gonna listen to them talk, and I'm gonna look at their eyes.

And if you think about what things it takes you to walk, to talk and have your eyes work, I've just assessed somebody's motor strength. They had the strength to walk across the room, and they didn't just walk, they had to have coordination. It's not easy to balance and walk and not fall down, and they know where their feet are and the space.

They didn't walk into anything, so I know their vision is working. They were able to talk to me, so I've tested speech content. Did what they tell me make sense, or was it gibberish? And fluency, do they have a normal speech pattern? They have cognition. I say, can you get up and walk across the room, and walk back to me? They were both paying attention to what I said, so I've tested their ability to pay attention, and their ability to translate that into action.

So I've tested their cognition.
And when I look at their eyes, I can find out just about everything important I need to know about the midbrain. So just by saying get up, walk across the room, walk back, listen to them tell their story, look at their eyes, I have screened almost all the neurologic system that will be a problem in the ED.

So if I'm looking at cognitive, so going down my list of things I gotta know, mental status / cognitive ability. If they can give me a coherent story, they tell me what happened, then I know their mental status is essentially normal. As long as the story makes sense, and it always helps if there's someone there who can verify it.

But if they tell a lucid story, it has details. I was in the parking lot of the grocery store, and this happened and then that happened, and I noticed this. They have to have normal orientation, they have to know what just happened. They have to pay attention, they heard my question, and they answered me.

They have memory and recall because they're telling me the story, and by telling me, I've check their speech. So mental status /cognitive ability, just in that ability to give me a history, I'm pretty sure they have a normal mental status / cognitive ability. If they can't, then I have to start doing things like the mini-mental status, or the quick confusion scale, I'm not gonna go into those today, but there are things that I can do to try to sort out what degree of confusion you have.

Now here's the problem, is that, if someone's attention is impaired, I stop. If they can't focus on me enough to listen to my question, no matter what they say, I don't know if they're saying something wrong because it's they don't have the cognition, or they don't have the attention to hear my questions.

So if they cannot pay attention, I start talking to them and they're wandering off and they're looking around like that, I'm done with mental status / cognitive ability. I can't get any further cuz I won't know how to interpret that result, so I stop trying to figure that out any further.

I avoid the phrase, cranial nerves 2 through 12 were normal, and the residents always think it's great sport when a student will come up to me and say that. And like, their cranials were all intact, and I'll say, how do you check the vagus nerve? What was their spinal accessory test? And the student will always say, I have no idea, I have no idea. I was just taught to say 2 through 12 are intact.

What I do is I say, just tell me what you checked, and if you tell me what you checked, I can interpret what things are working and what things are not working. So if you tell me the face is symmetric, I know cranial nerve VII is intact. If you do go through the H of the extraocular movements, I know III, IV and VI are working fine. If the pupils are equally reactive, I know II and III is working fine. If they stick out their tongue and it's midline, I know XII is intact.

Just tell me what you did, and I'll interpret which things are working, and I think that works really well for a chart. So I only ever chart, this is what I tested and I say, the face was symmetric, the extraocular movements were intact, I don't say 2 through 12 were intact. Here's something that is not infrequent in our shop.

They will rush somebody back to our resuscitation room and they'll say, well they came in and they said this and this, but I noticed their pupils were asymmetric, so I got them in here. And I always tell the triage nurses, an asymmetric pupil in somebody sitting there talking to you, they're walking to the ED, they're talking to you, they're not herniating in their brain, that's an end-stage. So when your pupils become asymmetric, that's an end-stage of brain herniation.

It's not the first thing that happens, it's one of the last things that happen. So I tell them, I'm not super excited about a brain herniation syndrome in somebody who's walking and talking. We know 20% of the population, 1 in 5 has asymmetric pupils of 1 to 2 millimeters, so I don't get super excited about that one finding.

If they're both dilated, the things I think about is anoxia, and in Portland, Maine, I think about drugs a lot. If they're both constricted, you can have that with Pontine hemorrhage or in Portland, Maine, I think about opiates a lot. We have a problem, a lot problem with drugs in our town as I assume everybody has in their towns also. Extraocular motions, anybody ever do this and say I don't really know what I'm testing, but I just know I'm supposed to do this? I would say most of my residents say, I know I'm supposed to do this, but I don't know what I'm testing. If you ever care then to know which are the ones you're testing, and I tell residents, don't memorize which one is tested by each one.

If you have a problem, go figure out which one it is. But if they have normal extraocular movements, you already know that you've got to test at III, IV and VI and they're all okay. [COUGH] Nystagmus. It's okay on lateral gaze for you to have a little bit of nystagmus, a little lateral nystagmus, that's normal and that doesn't mean anything to me.

If you have long marked sustained nystagmus on lateral gaze, or any nystagmus on vertical gaze, that's abnormal and that get's my attention for doing more imaging. Now it can still be a peripheral problem, like vertical benign positional vertigo or something like that, but at least now there's a shot that it's a central problem.

Vertical nystagmus is pathologic, there's no good reason for you to have vertical nystagmus. And direction changing nystagmus, so sometimes it's beating to the right and sometimes it's beating to the left, that's usually a central brain problem also. Motor exam, they have to be cooperative.

Pain can cause limitations, I always tell the residents, that's your opportunity to coach them up. So if they say it hurts too much to do something, I say you gotta get them to give you a full strength, full effort just for a second, enough to know that they have it. I will say the minority of my residents and students ever remember what number is what, so they'll just blindly put a number on something saying, it kinda felt like 3. And I'll say, what does 3 mean? And they'll say, I don't really know what 3 is, but it's not 5 and it's not 0. So if you care about the numbering system, 5 is real easy, 5 is normal.

0 is real easy, there's nothing. 4 is probably the softest, it's just not quite as strong as I thought they would be. 3 is if they can go anti-gravity, so they can pick their arm up against gravity. 2 is if you take gravity out of the picture, can then now flex their arm without gravity fighting them? 1 is you can feel the muscle firing, but they can't move anything.

So again, with a neurologic exam I think you should know what you're testing, and just be real specific. We see a lot of people who hurt their neck, or who have neck problem or neck pain or whatever, and I think the neck exam, or the neuro exam related to neck problems is really easy and people tend to make it harder than it has to be.

So here's the way I check how your cervical spine is working, your brachial plexus all that, is I know I have to check C5, 6, 7, 8 and T1. I can check everything about your brachial plexus, and every root coming out of your cervical spine, I can check all of them at your wrist except C5.

I cannot check C5 at your wrist, so I have to do something other than your wrist. So for C5, I do shoulder abduction like this, and that's C5. We're gonna do this all as a group in a minute cuz it helps you stretch too. So C5, I can check motor with abduction. I can check your biceps for reflex, so I can know you have motor reflex, and then the dermatomes, you see them listed there.

They basically it's 5, 6, 7, 8, T1, it just goes from lowest to highest, that's I think the easiest one you can always look that up. So I gotta check 5 at the shoulders. Now I can do everything else at the wrist, 6 is wrist extension. Wrist extension. In my mind it kinda looks like a 6, but I don't know if that looks like a 6 to you, but it kind of in my mind if I can't remember like that's a 6.

7, kinda looks like a 7, it feels kinda like a 7 there, or you could say, well couldn't that be a 7? So it's 6, 7, okay? So 5, 6, 7 and you see the reflexes and the dermatomes there. 8 is finger flexion. I have them lock their fingers together, and I try to pull them apart. Does that kinda look like an 8? See, it kind of is like an 8, two little circles is kind of like an 8. So 8, and then T1 is hand intrinsics. I have them separate their fingers, don't let me push them together. But I've checked everything here except 5.

So I go 5, 6, 7, 8, 1. I know when I write that their cervical spine exam was normal for neurologic function, my dot phrase in Epic, if you guys use Epic, is I just say exactly what I did. I say, the C5 was shoulder abduction, 6 was wrist extension, 7 was wrist flexion, 8 was finger flexion, T1 was hand intrinsics. I can document exactly what I found, and how their exam was.

So 5, 6, 7, 8, 1. Lower extremity is not as elegant because you can't separate out the roots from each other the way you can in the upper extremity. So I can check 1, 2, 3 with hip flexion. I can do again, we talked about this with back pain, 4 is foot inversion, 5 is dorsiflexion, SI is foot eversion. I don't have an L5 reflex, I have an L4 reflex at the knee, and I have an SI reflex at the achilles.

Sensory exam is obviously the softest one. Diminished sensation is more helpful. Positive sensory phenomena are generally not super helpful, like I have a little tingling here. It's when I find a deficit, where they don't feel something. A negative symptom is more helpful in the neurologic exam than a positive symptom cuz a lot of different things can cause a positive symptom. A negative symptom is more likely to be a neurologic problem.

If I'm going to test and I screen, I break a Q-tip, which you have in every room, and I just use the sharp end, and I do a screening exam for upper extremity, lower extremity, down the body. If you're gonna screen, if you care enough to do a sensory exam just use something sharp.

Light touches is not very sensitive, and you can trigger light touch with purpose. People can perceive light touch, but it's actually proprioception. So if you care, if you're gonna do a sensory exam, just do it with something sharp. So in coordination, this is one of the areas I wanna know.

It's managed by the cerebellum, and it coordinates not just balance, but also fluidity of motion. The ability to move something fluid in space. To reach out and touch this is actually a pretty complicated thing, and the cerebellum is what keeps me from going out and then up and then out to try to get it, it lets me fluidly go up and just make one smooth motion.

In order to have coordination and balance, your cerebellum need three sources of input. Well it needs two, it gets three, and as long as it has any two it's gonna work okay. So you need vision, you need proprioception and you need vestibular system to be working. And as long as two systems are intact, you will not be able to detect usually a coordination problem. Once you get rid of two, then you will start having a problem, and that's why when we do the Romberg, and you have them stand and close their eyes, you've taken away one of them. So if there's a problem with proprioception or vestibular system, that's when I'm gonna pick it up because I've taken away one of the systems, and I'm down to two and I need both to have a solid Romberg.

So if they close their eyes and they start swaying, their vision is making up for one of the two, proprioception or the vestibular system. If they can walk and perform motor functions smoothly. Again that smoothness, that is what the cerebellum controls, and if they're doing it smoothly the cerebellum is working.

So that's our whirlwind 28-minute through the neuro exam, let's look at it in context in a few different complaints. Again we talked about back pain a little bit, so I'll spend the least amount of time on that. So a headache, lots of people get them. Just like back pain, most are gonna be fine. The rule of thumb in ED, if you look at ED population studies, about 1 in 100 people who show up in an ED with the chief complaint of headache have something bad, and 99 in 100 don't have something bad. And the something bad can be subarachnoid or intracerebral hemorrhage, or subdural, or epidural, or a tumor, or hydrocephalus, all the things that we think about. Almost everybody doesn't have something, 1 in 100 has something.

I can't image everybody, so I need to use my history and physical to try to figure out who needs more and who doesn't need more. So their history is important, and this has been looked at and they actually have done a little bit of research on this lately. Each one of these risk factors is additive. So worst ever headache, worst headache of your life, throw that out.

That's been proven to be not useful.
Most everyone will say yes because they wanna say why I'm here today. The reason I'm here today, is this is the worst one I've ever had, but they wanna validate why they're there. So ask the question differently. Say, what exactly were you doing when this headache started? If they can tell you the thing they were doing at that moment, that's important.

If they say, it's sometime this morning, I don't know. It was there a little bit and then later in the day it was a little, that's much less worrisome. If they can say, I was reaching up to the cupboard to get a cup, and all of a sudden I had a horrible headache, that ups the ante for me.

And rapid onset. Maximal intensity within 15 minutes is a predictor for having something going on in your CNS, that's someone who is probably gonna get some imaging for me. But the phrase, is this the worst headache of your life? Is so fraught with peril that most literature narratives just don't ask the question cuz they're always gonna say yes, and then that makes you do stuff you don't really wanna do.

History of Marfan's, history of connective tissue disorders, these are all upping the ante for aneurysms. Polycystic kidney ups the ante, first degree relatives. So not great granddad might have died of a brain stroke or something like that. I don't know what to do with that cuz I don't know what great granddad really died from, but if you have a first degree relative, mum, dad, brother, sister, child who's had a ruptured aneurysm. An aneurysm in their brain, it doesn't have to rupture.

But has an aneurysm in their brain, it has been identified, they're at increased risk. Trauma obviously, anticoagulation. Maine is the oldest state in the Union not based on an average age, and when you move to Maine, the first thing they do is they randomize you to Coumadin, Pradaxa, or Apixaban. So everyone is on anticoagulation, we just don't know which arm of study you're in when you walk in.

But anticoagulation obviously ups the ante, and we're seeing more spontaneous hemorrhages than I think we used to. Changing consciousness with a headache is something that worries me. A different headache than usual pattern, with a caveat that again people often wanna have a reason why they're there today.

And then older people have more features, are more worrisome than younger people. Physical stuff, it's kinda no duh! Confounders, alcohol is always a confounder, dementia is always a confounder. It's harder to figure out who does and does not need imaging in those groups. But altered mentation, if you have a headache and you have altered mentation, that's a pretty specific finding, and those people all should get some imaging, same with focal deficits. If you have a focal deficit and a headache that's new or different.

The finding is new and different, plus a headache, you're gonna get imaging at least from me. Any focality to exam, any neurologic focality to the exam makes me nervous and do more. I always like to just review clinical policies as they relate to the specific thing I'm talking about. So does ACEP have a headache policy? Yes, it does.

What do they talk about? So the first question that they set out to answer was, if I give somebody some medicine and it makes their headache better, does that mean it was not a bad problem? And there is no Level A or B data, which means there is no data really that covers it.

Level C data though says, that pain response to treatment should not be used to decide who has a headache. So if you give them some medicine and they get better, therefore it was a benign cause of headache. That's not true. You can make someone with subarachnoid hemorrhage feel better with some pain medicine, you can make someone with tension headache feel better with pain medicine. I would never say document that the reason why I'm not doing more is because they got better with some pain medicine.

Next question ACEP looked to answer was, who requires neuro imaging? So no Level A, and Level A is good data. So randomized, double blind, placebo controlled trials are none of those. Level B, if you have a headache and new neurologic findings, those people get a non-con CT. Sudden onset severe headache, and that's at maximal intensity within 15 minutes, and specific onset and it's not just vague over days or weeks. It's a specific onset maximal intensity, they got a non-con CT. HIV positive and a new type of headache also, you should consider. They don't say you have to, but they say consider emergent testing. And then Level C, if you are old, which is greater than 50 and you have a new type of headache, but even with a normal neurologic exam they should be considered, which is kind of wimpy. It don't really tell you to do it or not do it, it just says consider it, so you can say you considered. And they say consider for urgent, which doesn't mean you have to do in the ED.

If you can arrange it as an outpatient, that would be under their policy of considered urgent neuroimaging. Dizziness, does anybody ever get frustrated with a dizzy patient because you can't figure out what they mean? So dizziness is not a medical term, it's a lay term. It's a patient term, there is no disease called dizziness.

First job is to pin them down on what they mean when they say, I'm dizzy. Do they mean they're vertiginous? Is there a sensation of movement, spinning? They're spinning, the room is spinning. And if it's a vertiginous complaint, my job becomes really, really easy. I need to figure out, is this a central problem? So brain. Or is this a peripheral problem? Like BPV inner ear whatever, that's all I gotta do in the vertiginous patient, as long as it's not like they're in a dysrhythmia, or some reason that's why they're having vertigo. If it's just I have a vertigo, I feel like the room is spinning, I gotta know is this a central or a peripheral process? And the other thing they may mean is, I'm having presyncope.

I'm getting lightheaded, I'm losing consciousness or semi-conscious, but I pin them down. First of all, if it's vertigo, I'm gonna figure out central or peripheral. If it's syncope, I'm gonna figure out why they're having syncope. Make them describe what they're feeling without using the word dizzy.

So my screen if they say vertiginous symptoms. If it's a peripheral problem, except for maybe a little horizontal or rotatory nystagmus and maybe some auditory symptoms like rushing in the ear. There shouldn't be another abnormal neurologic finding on my cranial nerve, or neurologic exam.

So I'm looking for bare bones. You give me vertigo, you may be having a little nystagmus, the rest of your neuro exam is normal, I'm pretty comfortable this is gonna be a peripheral problem. If you give me vertigo and nystagmus, but I start finding other positive neuro findings, you're in the central till proven other group. You're getting imaging from me, you're getting more stuff done.

So in peripheral vertigo in general for that nystagmus, it's gonna be delayed. So you change their position,they're not gonna to get nystagmus right away, it will come on after a time. If you do it a bunch of times, it will fatigue and they can suppress it if they look hard at something.

If you have central nystagmus, it doesn't matter how hard you stare at one thing, you're still gonna have the nystagmus going on. Other ways to sort out that central peripheral. There is nothing about BPV that should give you a headache. So if I have a headache and new vertigo, that makes me a little bit more nervous. Peripheral symptoms should be worse in the morning and get better as the day goes on due to that fatigue-ability. The system kinda resets overnight, so you have a brand new opportunity everyday to have more vertigo the next morning than you had the night before, but it does tend to fatigue over time. So if someone has had it for a week and they can say, yeah it's bad in the morning it get's better by evening, that's a strong predictor. It's a peripheral problem, and don't worry about it problem.

Hearing loss is uncommon with a central lesion. It's not that common with a peripheral lesion either, but if they give me a hearing, atinnitus that's more likely to be a peripheral. And then nystagmus at rest is uncommon with a peripheral, that makes it more likely to be central.

With central vertigo, symptoms are gonna be there at rest, if they're moving, if their eyes are open, or if their eyes are closed, it doesn't fatigue, and I'm gonna probably find another brain problem with it. So in my mind I break vertigo down very simply. If they have vertigo plus, I'm looking harder.

If they have just vertigo and I don't have any plus I know, except for maybe that little bit of nystagmus, nothing else feature wise that makes me nervous, nothing else on their exam, I'm done. I say, this is a peripheral problem. Take some Ativan, take some whatever you wanna treat your peripheral vertigo with, it doesn't matter.

Syncope or near-syncope, treat them as the same. Don't try to sort those things out. In a young person, it's almost never gonna be bad unless they have WPW, which I can answer with an EKG. In older people, it is concerning. Infinite drugs and diseases, and just a little talk about there of sudden cardiac death.

So cardiac and neuro examination should be carefully done, but are frequently normal on the syncope, presyncope person. Orthostatics may point the way, especially in older folks. Volume depletion, drugs, a combination of those. The EKG, anyone who has a syncope or presyncope should obviously get an EKG.

Labs almost never help in the diagnosis of syncope and presyncope, if you find positives track them down. And then I only have about a minute left, but we've covered back pain. I'll hit the highlights. Look for the red flags. Check motor, sensory, reflexes and all. We know about that. We know about that. So our Frank Netter, outdid himself with this picture with the guy getting them dollar signs laid over his aching lower back. However you wanna look at it, that we lose a lot of time and money to back pain. Just to review, if they can walk on their heels, they can walk on their toes, they can do a squat to rise, you've tested the distal part of the neurologic system and it is intact. If you can't, you test them as is with the inversion, dorsiflexion, eversion. Sensory exam, we've already covered.

The reflexes, again for back pain I gotta know, do you have normal DTRs? Knee jerk at the knee is L4 and the Achilles is SI. Bowel and bladder, we've covered. Just a little bit about the straight leg raise. The straight leg raise, again working with learners, they always come out and say either positive or negative straight leg raise, and they have absolutely no idea what that actually means. So just so we're all on the same page.

A positive straight leg raise is you lift someone's leg up more than 20 degrees, if it hurts in their back that is not a positive straight leg raise. It has to radiate pain down the leg, below the knee and that's a positive. So you get them above 20, and if they get pain down the leg that's a positive.

If it just is back pain, or if it doesn't radiate below the knee, or if you get them one inch off the bed and they say it's radiating down, you haven't stretched their sciatic nerve yet, that's not a positive straight leg raise. Straight raise leg sensitivity for nerve root irritation.

So if you give me that, I get you above 20 and you get the symptom radiation. It's got a positive sensitivity for that nerve root irritation of about 80%, which is pretty good, but a pretty low specificity. There's other things that can cause it. Crossed straight leg raise. So you're telling me, I have terrible sciatica down the right, and I do a straight leg raise with your left leg and it gives you the pain down your right leg, that's a pretty specific test for having root irritation probably caused by a disc.

Back to our first talk this morning, just cuz you have nerve root irritation caused by a disc does not mean you need surgery. So the bottom line, we've covered these. Look for red flags, find them. So the neuro exam bottom line is keep it simple. Get a good history, cuz it's unlikely you're gonna find something that's on the history. Don't feel like you gotta do a complete neuro exam, do an adequate. Telling yourself, I'm gonna do an adequate neuro exam.

I'm not gonna do a complete neuro exam, I don't have time for that. My strategy to charting is in this world is say what I do and do what I say. So I just tell you exactly what I tested, so that you know what I tested and what I saw. And just remember how many things it takes to be going right if somebody can walk, talk and their eyes work.

You've assessed a whole lot of the neurologic system, just by looking at those three things. I think that brings us to, I got 10:01 so I think we're on time, we're at the break. Do we just take the break now? Break now. Thank you. >> [APPLAUSE]  
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