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How to master the neuro exam

As a medical student, neurology can be one of the most intimidating rotations. The brain is so complex and the neuro exam so difficult to master that many of us find ourselves dreading the month in which we are expected to be young neurologists.

During orientation on my first day of neurology, our clerkship director, Jeffrey Dunn, MD, addressed this directly. He admitted that the brain is often called the final frontier of medicine because we understand more about outer space than we do about this one organ. Was it any wonder we felt as though we were approaching a black box?

Then Dr. Dunn told us something I hope I'll remember for the rest of my career: He told us that "the greatest disease you will ever treat is solitude." Our very presence with the patient could be healing. And as medical students, he didn't expect us to come into the rotation knowing much about neurology -- but he expected us to want to be a little bit better each day.

Now that he had sufficiently inspired us, Dr. Dunn broke down the neuro exam into an easy skeleton figure. He explained that the physical exam for neurology was key to accurately diagnosing patients and that if done properly, we could even localize where the lesion was in our patients' nervous system.

Dr. Dunn wrote out a simple diagram on the white board, a basic map of our patient's bodies from the perspective of a neurologist. Then he explained how each of the six components of the neuro exam mapped onto the nervous system.

The neuro exam begins, as any other physical exam in medicine, by noting the general appearance and vital signs of the patient. After that, Dr. Dunn explained, there are six components to remember. They begin with the mental status exam, which is a way of measuring cortical function (the brain itself).

Next comes evaluating the cranial nerves, which is a way of testing the brainstem because cranial nerves originate and return to the brainstem. In fact, in a trauma setting where your exam has to be precise and incredibly efficient, you can evaluate the midbrain by pupillary reflexes; the pons by checking corneal reflexes; and the medulla by checking the gag reflex. This can be done on a comatose patient in less than five seconds.

The cerebellar function, deep tendon reflexes, sensory input, and motor function are the last four components. With these six components tested, you can write out in a table which parts of the exam were normal and abnormal. The highest point of abnormality is where the lesion occurred.

As Dr. Dunn wrote out his diagram and talked us through case examples, I realized that even a first-day medical student could easily follow his method. No matter how nervous I may get in a clinical setting, I can fall back on his exam schema and be able to contribute to my patient's care.

Ultimately, I left orientation feeling reassured and relatively prepared to care for the enigmatic organ that gives my patients their life and their personality. And I wanted to share Dr. Dunn's teaching in case there are other clerkship students out there wondering how to master the neuro exam.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

Natalia Birgisson is a fourth-year medical student at Stanford. She is in her second year off and writing her first novel, which is described on her site

Illustration by Natalia Birgisson

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