Podcast #70 – Neurological Exam Including HINTS and Documentation

​There have been recent requests for further discussion of the neurological exam.  Specifically, how to do a brief neurological exam in the emergency department, how to perform a HINTS exam, and documenting the exams performed. 
​Recently, we did a guest post with FOAMfrat regarding improving the neurological exam.  We made a video for that post which we are also sharing here.  Essentially, the neurological exam we recommend consists of assessing higher functions, cranial nerves, sensorimotor and peripheral, Glasgow Coma Score, and a cerebellar exam.  The exam, as demonstrated in the video, can be performed in approximately two minutes.

However, there is an additional portion of the exam that was not in the original video.  This is the HINTS exam which has been really well covered by sites such as EmCrit.  Although the HINTS exam offers some additional findings not present in the regular neurological exam we recommend, it is not something that can be easily performed with all patients.  There are also limitations to this exam and this was discussed well on FOAMcast.  In fact, caution should be advised in those with neck problems at a baseline.  When you watch the video on the HINTS exam, this will make more sense

When documenting, make sure to include all parts performed.  Below is a basic breakdown of what a normal exam is usually documented on our charts.

  • Higher Functions:
    • Alert and oriented x3, mood/affect normal (at baseline per parent/guardian/friend/etc), normal speech, normal cognition (again can list at baseline per person accompanying patient)
  • Cranial Nerves:
    • CN’s (II-XII) grossly intact, no sign of acute CVA, no facial palsy, no tongue deviation, no hearing deficit, EOMI, PERRLA
  • Sensorimotor/Peripheral:
    • No gross motor deficit, 5/5 throughout, no gross sensory loss, normal movement
  • Cerebellar:
    • Negative Romberg test, normal finger-nose-finger, no pronator drift, normal gait, normal heel-to-shin (and optionally “normal HINTS”)
  • Glasgow Coma Score:
    • Eyes 4, Speech 5, Motor 6

While describing the alert and oriented portion, if there is any portion abnormal specifically mention it and what is normal.  Since different places say x3 or x4, it is best to just specify what is normal versus what is not.  Speaking of this portion, if there is anything abnormal, elaborate in more detail.  Some will want to do reflexes and that is fine but it is worth learning maneuvers such as Jendrassik Maneuver.

This is a quick review but let us know if you have other questions or thoughts.  The key is to practice the exam and get into a routine.  Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on iTunes.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  ​Until then, continue to provide total care everywhere.

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