Thread by @MedinaRiojaMD

Neurological Examination in the unconscious patient: there is still plenty to do. 😴🧠
#Neuro #EndNeurophobia #Neurotwitter #Neuroexam

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Most of the time we are used to see fully conscious patients in the Neurology Service, nevertheless, there are plenty of situations (especially in the ER) where we need to assess patients with impaired consciousness.🏥

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You are not wrong if you think the neuro exam won't be as detailed as with a fully cooperative patient but there is still plenty that we can do to establish an initial diagnosis and hence, propose adequate treatment. 🤔

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1⃣ We need to check vital signs as with every other patient, but pay special attention to the breathing pattern, as some patterns help us localize lesions:

A: Cheyne-Stokes🎢
B: Central Neurogenic Hyperventilation🏃
C: Apneusis🏔️
D: Cluster🕺
E: Apnea🥿

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2⃣ Patient's wakefulness

Awake and aware? Reactive
Drowsy? Easy to wake up 😴
Stupor? Needs painful stimulation to wake up🤯
Coma? 😶

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3⃣ Cranial nerves: ophtalmoscopic exam + vision + brainstem reflexes:

Fundoscopy 👁‍🗨
Blink-to-threat 🥎
Pupils + eye movement 👀
Corneal reflex and facial symmetry 🫤
Gag reflex 😝

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3⃣ "The eyes Chico, they never lie." - Scarface

Pupils (Afferent signal CN II, efferent response CN III)
Oculocephalic maneuver "doll's eyes"

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4⃣ Motor and Sensory Exam

Can the patient localize to painful stimuli?

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4⃣ How are the reflexes and the plantar response (AKA Babinski)?
🔨
Remember: reflexes localize to different spinal cord levels.

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4⃣ Abdnormal posture?

Upper midbrain damage: decorticate posture 🧠
Lesions bellow the red nucleus: decerebrate posture 🔴

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5⃣ And finally: meningeal signs

Are they present?

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Never forget that neurological examination is a flexible technique that adapts to the needs of our patients, as every situation is different. A systematic approach is a must in clinical medicine. ✔️✅☑️🏁

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Sources:
1.- Campbell W. DeJong’s The Neurologic Examination. Eighth Edition,2019
2.- Plum J, et al. Plum and Posner’s Diagnosis of stupor and coma. Fourth edition, 2007
3.- Blumenfield H. Neuroanatomy Through Clinical Cases, 2010