4-Minute Neurological Examination Protocol
The most effective 4-minute neurological examination should focus on assessing level of consciousness, cranial nerves, motor function, sensory function, and coordination in a systematic approach to quickly identify neurological deficits that may impact morbidity and mortality.
Level of Consciousness Assessment (30 seconds)
- Assess alertness using the Glasgow Coma Scale components: eye opening, verbal response, and motor response 1
- Evaluate orientation by asking patient their age and the current month 1
- Test ability to follow commands by asking patient to open/close eyes and grip/release hand 1
Cranial Nerve Assessment (90 seconds)
- Pupillary response: Check size, symmetry, and light reactivity - abnormal findings may indicate structural brain lesions requiring urgent neurosurgical consultation 2
- Eye movements: Assess horizontal gaze for palsy or forced deviation 1
- Visual fields: Test using confrontation or visual threat to detect hemianopia 1
- Facial movement: Check for facial asymmetry, flat nasolabial fold, or weakness 1
- Bulbar function: Test gag reflex, cough response, and swallowing if indicated 1
Motor Function Assessment (60 seconds)
- Upper extremities: Have patient extend arms at 90° (seated) or 45° (supine) for 10 seconds to detect drift or weakness 1
- Lower extremities: Ask patient to raise legs 30° and hold for 5 seconds 1
- Tone assessment: Perform passive range of motion to detect abnormal resistance 1
- Strength grading: Assess strength in major muscle groups using the 0-5 scale 1
Sensory and Coordination Assessment (60 seconds)
- Sensory testing: Use safety pin to check sensation in extremities, noting any asymmetry or deficits 1
- Coordination: Test finger-to-nose and heel-to-shin movements to detect ataxia 1
- Gait assessment: If time permits and patient is able, observe patient standing and walking to assess dynamic balance 3
Pathological Reflexes and Higher Function (30 seconds)
- Reflexes: Check for Babinski sign by stroking lateral sole of foot 1
- Language: Assess for aphasia by asking patient to name objects or read simple sentences 1
- Neglect/Inattention: Test by simultaneous bilateral stimulation of hands or visual fields 1
Common Pitfalls to Avoid
- Don't skip pupillary assessment - reactive pupils usually indicate metabolic causes of altered mental status, while unreactive pupils often suggest structural lesions 2
- Avoid incomplete motor testing - always assess both sides for comparison 1
- Remember that sedation and analgesia can confound the neurological examination - note medications that may affect assessment 1
- Don't forget to document baseline findings for comparison with future examinations 4
- Avoid misinterpreting intubated patients' neurological status - consider using the Full Outline of Unresponsiveness (FOUR) score which better assesses intubated patients than GCS 5
This structured 4-minute examination provides a rapid but comprehensive assessment of neurological function that can guide immediate management decisions and help identify potentially life-threatening conditions requiring urgent intervention.