This post is designed so that you will never have to write “Neuro: Grossly intact” on your History & Physicals again! Writing “grossly intact” is pretty much saying that you didn’t examinate the system at all.
This post will address how to do a thorough peripheral nervous system physical examination for the purposes of a routine history and physical. I do not cover the complete neurological exam in this post, but just focus on the PNS including myotome, reflex, and dermatome evaluation. Of course to complete the neuro exam, cranial nerves and cerebellar testing must also be performed.
I have been on a neurosurgery rotation this past month, and have learned how they perform their physical exams. When examining the PNS, it is especially important to evaluate for radiculopathy and document which nerve root distribution the patient feels pain in.
I have created a chart, located below, to help provide a framework for the evaluation of each spinal nerve root (C1-S5). Examining the PNS should be done in three steps. First, evaluate the myotomes (motor), followed by the reflexes, then dermatomes (sensory) that each nerve root innervates. This information is provided in the chart.
*Click on the chart to enlarge it, then right click on it and select "view image," then right click on it to download.
*Alternatively, you may email me if you would like a bigger size.
*Alternatively, you may email me if you would like a bigger size.
For each myotome, the physical movement the muscle performs, the name of the muscle, and the peripheral nerve that innervates the muscle is given. Note that only the most clinically relevant muscles are listed as being innervated by the nerve root(s). Each reflex is only listed beside the main nerve root that innervates it, even though the one above or below may also contribute. For each dermatome, the cutaneous area and the peripheral nerve that innervates that area is given. All dermatome maps are slightly different, so care was taken to list only the most clinically relevant areas and the main peripheral nerves responsible for innervation.
The yellow highlighted areas in the table indicate the most important areas to test on a routine physical exam. The superscript numbers listed before the text in these boxes indicate the recommended sequence of exam. I have also listed on the left side of the table the plexus each nerve root contributes to. For the brachial, lumbar, and sacral plexuses I have listed the main components and what will happen if each of these nerves is lesioned.
In conclusion, do not write or dictate “grossly intact” for your neuro exam! Make sure to list out the nerve roots or muscles you tested, along with each reflex and dermatome. That way you are able to precisely determine where any deficit is located and are able to define it to a single nerve root.
Sources:
Bickley, Lynn S., Peter G. Szilagyi, and Barbara Bates. "The Nervous System." Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009. Print.
Goldberg, Stephen. Clinical Neuroanatomy: Made Ridiculously Simple. Miami: MedMaster, 1994. Print.
Gray, Henry, and Warren H. Lewis. Anatomy of the Human Body. 20th ed. Philadelphia: Lea and Febiger, 1918. Print.
Hoppenfeld, Stanley, and Richard Hutton. Orthopaedic Neurology: A Diagnostic Guide to Neurologic Levels. Philadelphia: Lippincott, 1977. Print.
Le, Tao, and Vikas Bhushan. "Musculoskeletal." First Aid for the USMLE Step 1. 2010 ed. New York: McGraw-Hill Medical, 2010. 368-72. Print.
Netter, Frank H., John T. Hansen, and David R. Lambert. Netter's Clinical Anatomy. Carlstadt, NJ: Icon Learning Systems, 2005. Print.
Nice article
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