fast, basic neurological exam
This page has two fast, basic neurological exams (also known as rapid, simple neurological exam).
The first is the standard if you suspect someone has had a stroke.
The second one could be quite useful if someone took a fall that you suspect might have caused a concussion, but they are unwilling to take their accident seriously. By having them lie still and do these tests, you might be able to prove to them that they need immediate help and need to stay still until help arrives.
It is also used for a scuba diver you suspect has the bends, (decompression sickness (DCS) or Caisson disease).
If you are giving first aid to a victim who realizes they are quite injured, getting the answers to the secondary survey questions you learned in a first aid class (signs and symptoms, allergies, medications, medical conditions, last oral intake, etc.) in case they pass out before the EMTs arrive, could literally help save their life. Trying some of the tests in the second exam on this page and having the results for the EMTs/Paramedics, could also assist them and help make the time waiting go faster.
(Even if someone ‘passes’ all these tests, if you have reason to suspect a concussion, consult a doctor. It is always better to be safe.)
Note to on-line users not in my classes: this is a study sheet. It is not complete instruction in first aid. In a formal class you will learn steps for recognizing emergencies, how and when to call 911, protecting yourself, (including how to obtain consent and prevent disease transmission), how to prioritize care and much more. You would always deal with life-threatening situations before you start a simple secondary survey / secondary assessment.
If at some point before or during a secondary survey (Simple secondary survey study sheet) you had reason to suspect a head injury, you could ask ‘levels of consciousness’ (LOC) questions.
A person who is oriented to their surroundings and situation should be able to tell you their name, where they are, what time it is (not to the exact hour but at least is it morning or evening, what month and year it is), and what happened to them.
Sometimes as people go in and out of consciousness they tend to lose ability to answer the levels of consciousness (LOC) questions in the order person, place, time and event, with their name being the last thing they remember. They can be fully awake, (as in, not asleep) but not fully conscious.
The Glasgow Trauma (or COMA) Scale, used by medical personnel, labels a person who can answer all these questions ‘oriented.’ If they can’t give accurate responses, but they can take part in a conversation of sorts the label is ‘confused.’ They are given a score for these and ‘inappropriate words,’ ‘incomprehensible sounds,’ or ‘no verbal response’ as well. A person who is not ‘oriented’ or has slurred speech needs professional help and should not be allowed to leave the scene until seen by an EMT. Remember, even if they are not oriented, and may not respond to you properly, they often can understand everything you are saying so be positive without lying.
If the victim passed the ‘oriented’ test, but you had reason to suspect a concussion/injury, you could also do part or all of a fast, basic neurological exam, such as the following.
Remember that you wouldn’t have them move any body part you suspected was injured and if you suspect a spinal injury you would be manually protecting the spine/neck from movement, would not let them move around and would not want them to tilt their head yes or no in the process of answering questions. You should be describing to the person what you are going to do before you touch them, get consent and continue to get consent as you go along.
If you suspect a stroke, don’t take the time to do all the tests further down this page. Start with the following tests covered in Red Cross first aid. Ask the person to smile. (Watch their face to see if both sides of their face move the same or if there is drooping or weakness on one side of their face.) Have them hold up both arms, extended out straight from their body. (Someone who had a stroke might be able to lift both arms up, but not be able to keep both arms at the same height or might not be able to lift both arms up to the same height or might have numbness in one arm.) Have the person try to repeat something you say. (Someone who had a stroke might have slurred or distorted speech or trouble speaking.) If they fail any of these, note the time, call 911 or the local emergency number and tell the dispatcher about the symptoms and what time the symptoms started.
To care for a victim of stroke, think FAST.
Face – weakness on one side of the face
Arm – weakness or numbness in one arm
Speech – slurred speech or trouble speaking
Time – Time to summon EMS personnel (call 911) if any of the above are seen and note the time the signs and symptoms began
The stroke tests above plus holding out two hands with your index fingers pointing out, and asking the person to squeeze one of your fingers with each hand at the same time, might be all you need. (Squeezing fingers is a way to test strength to see if it is equal in both hands and also a fairly standard test of someone’s ability to respond properly to your command.) If you have more time (or if the victim needs a bit more convincing that they should not try to stand up) you can try all the tests below.
These tests are not meant for you to think you have completely ruled out problems. Again, if you suspect a spinal injury you should not do most of these tests or let the victim move about.
Eyesight Ask them if they are having any blurry vision or double vision. Hold up fingers for the victim to count. (Check each eye separately and both eyes at once.) Also notice if they have any trouble fully closing either eye, are having any facial twitches/tremors.
Check pupils — are they equal? Cover each eye and shine shine a flashlight at the other .. do they both constrict at the same speed and the same amount?
Hold up your finger and ask them to follow its movement in an ‘H’ pattern with their eyes. Eyes should be able to follow the movement all the way without jerking.
Hearing Rub your fingers together near their ears (but some elderly people might be losing their hearing and not realize it and have not gotten hearing aids and therefor can’t ‘pass’ this test.
Face muscles If you did not do so before, ask them to smile.
Ask them whistle. Watch both sides of their face to see if lip/cheek movement is equal.
Ask them to stick out their tongue and then also move it from side to side.
Can they swallow without difficulty?
Muscular strength If they don’t have any sign of specific injuries to their hands/shoulders/arms/legs…
If you did not already do so, hold out your hands with your index fingers pointing out, and ask them to squeeze one of your fingers with each hand at the same time.
Again, you should be describing to the person what you are going to do before you touch them and continue to get consent as you go along.
You could put your hands on their shoulders, press down slightly and ask them to shrug their shoulders.
You could also have them straighten each leg, likewise their elbow and wrist against resistance you supply.
If you have a way to do it, you could also test each nostril for sense of smell.
Have them move their thumb to the tip of each finger on that hand. Try this with both hands.
Hold up your finger about a foot and a half from their face and have them move their index finger from their nose tip to your finger and back and forth. This test is best if they have to fully extend their arm each time.
While still lying on their back, have them slide the heel of one foot along the shin of the other leg from the knee to the ankle. Then try the other leg. You are looking for whether they can move their heel in a straight line on both legs as they do it.
Balance when standing, walking
If the victim fell or you have any reason to doubt their ability to perform these standing/walking tests you should have two people stand right next to them on either side as they stand up and as they try these, ready to catch them should they faint, stumble, etc.
Have the victim stand with feet together. If they sway or fall with their eyes open you should have them sit or lie down again and not proceed with any more standing tests.
Have the victim stand and close their eyes. They should be able to stand and stay completely still with their arms staying at their sides.
They should also be able to stand with eyes closed, arms straight out in front of them, palms up and keep both arms raised and straight. If palms rotate, one palm should not rotate differently from the other.
With their eyes open, ask the victim to clap one hand into the palm of the other as quickly as possible, or, if they know how, to snap their fingers.
Again, you should have two people stand right next to them as they try these walking tests:
The next test should be easy to remember to do if you picture a police officer testing for sobriety; have the victim walk putting the heel of one foot right in front of the other foot.
and then walk on tiptoes.
Have the victim recite the months of the year in reverse order. (Don’t start with December or January.)
.. (Some people may not have enough math background to pass the following math tests.)
Have the victim add 2 plus 2 equals___? plus two equals—?
Then make it a little more difficult, such as counting to 30 by threes (3,6,9,12,15,18,21,24,27,30).
Finally do a subtraction series (subtracting seven (or eight, just be consistent) from a hundred, and seven or eight from that number, etc.). This one is the best test of abstract reasoning, because it’s more difficult.
If the victim ‘passes’ the tests and they won’t wait for an EMT, you should warn them and anyone with them that should things change they need to seek professional help. Remind them that if they faint, get a headache, start vomiting, have any loss of function or numbness, go blind or get blurred/double vision, even for a split second, they need to get help.
Remember: you are not a doctor. ‘Passing’ this does not mean the victim will not need medical care. Symptoms can develop slowly. You should always advise a victim of injury to see their doctor or if at all possible, wait for an EMT to arrive and report to them what was found.
Signs and symptoms of a concussion:
(Symptoms of a concussion may be delayed. They can take several hours or even days to present themselves.)
(Many teams require that an athlete with concussion symptoms be evaluiated by a medical staff member with experience in the evaluation of concussions and prohibits them from returning to play on the day of the activity. Mild symptoms can resolve themselves in less than two days, but the victim still needs to seen by a doctor.)
Appears dazed or stunned
Answers questions slowly
Loses consciousness (even briefly)
Shows behavior or personality changes / mood changes like feeling sad, anxious or listless or becoming easily irritated or angry for little or no reason. Might resist treatment.
Mental status deteriorates – sometimes moving from disoriented, to irritable, to combatative to a coma.
another source says: feeling sluggish, feeling unusally irritable
Can’t recall events prior to hit or fall and/or after hit or fall
Headache or ‘pressure’ in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry/fuzzy vision
Sensitivity to light and/or noise
Hearing problems, ringing in ears
Feeling dinged or dazed, sluggish, hazy, foggy, or groggy
Concentration or memory problems
Does not ‘feel right’
In later stages pupils may become unequal
Athlete who is confused about assignment or position, forgets sports plays, is unsure of game, score, or opponent
An elderly person can have a concussion from a seemingly minor fall. Sometimes their symptoms are mistaken for a stroke. You might not witness the fall of an elderly person, for example, but after the fact would notice some of the symptoms above and/or:
low-grade headache that won’t go away
having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks or making decisions or solving problems
slowness in speaking, acting, thinking or reading
getting lost or easily confused
changes in sleep patterns, inability to wake up from sleep
sensitive to light or noise
doesn’t recognise people or places
seizures (arms and legs jerk uncontrollably)
weak arms or legs, unsteady on feet
Note that confusion in an elderly person that comes on suddenly could be caused by a head injury OR by a medication/taking a medication improperly, OR by pneumonia/infection (sometimes without a fever or coughing).
An infant can’t answer questions or tell you they have symptoms, but you might notice they cry persistantly and it is difficult to console them, are not interested in toys they usual are fond of (or might not even reach for a toy offered them), have changes in eating/drinking/nursing.
They might not interact normally with a parent/sibling, give eye contact.
They might not pay their usual attention the their surroundings. Their eyes might not follow a person/object near them, or they could even have a blank or trance-like stare.