Neurological Examination
Mental Status

Cranial Nerves

Motor & Sensory

Here, we offer multimedia presentations of examinations that you may find useful in assessing a person for neurological function. Each part is concise. You can assemble as many components as you need to meet your patient's particular need. For a  text summary of the screening neuro exam click here.

Neurological examination can take several forms, depending on the problem suspected and the patient's situation. Some examinations need to stress the central nervous system, others the spinal nerves or peripheral nerves. Some are done for diagnostic purposes, others to assess disabilities, responses to treatment, or other changes from  baseline. Some examination techniques are gathered into standardized scales or scores, such as the GCS or the DRS or the Folstein Mini- Mental Status.

 
Links Univ of Fla      Loyola University Chicago     Interactive online Guide

University of Toronto Neuro Exam     Temple University

Neuro Exam

Instruments needed:

Ophthalmoscope, otoscope
Stethoscope
Reflex hammer
Pocket screening card for visual activity
Pocket flashlight
Tuning fork
Tape measure
Disposables - safety pins, tongue blade

Review of Neurologic Symptoms

Ask about handedness.

Head, Neck

Headaches, Head Injury.

Cranial Nerves
I. Sensation of smell, abnormal smells
II. Loss or blurring of vision, difficulty reading, bumping into things on either side, inability to identify colours
III.IV.VI. Diplopia, squint
V. Numbness of face, tingling over the face, difficulty chewing
VII. Slurring of speech, drooping of one angle of mouth, drooling, stasis of food on one side.
VIII. Difficulty hearing, tinnitus, vertigo, dizziness
IX, X. Dysarthria

Motor System

  1. Power
    1. Upper limbs
      1. Proximal - lifting the arm above the head, eating, combining.
      2. Distal - writing, buttoning shirt.
    2. Lower limbs
      1. Proximal - climbing up or down the stairs, squatting, getting up from squatting position.
      2. Distal - inability to hold slippers onto feet.
  2. Nutrition - atrophy of muscles.
  3. Coordination - difficulty reaching the target, unsteadiness.
  4. Involuntary movements - tremor, twitching, spasms.

Sensory System

Tingling, numbness (pins and needles).
Inability to feel hot or cold water.
Burning or hurting body parts without realizing it, unexplained sores or bruises.
Inability to feel the ground or wall.

Other

Difficulty with micturition or bowel movements, sexual dysfunction.

Higher Function

In addition to doing a mental status examination, ask about speech disturbances; difficulty speaking, repeating, and comprehending commands; symptoms of raised intracranial pressure, such as headache, vomiting, and seizures; fainting, passing out, tonic-clonic convulsions, and associated symptoms (tongue bite, incontinence); aura; postictal drowsiness; and history of unconciousness.

Neurologic Examination

Always remember to compare both sides and compare the patient's function with respect to your function.

Cranial Nerve Examination

I. Test for smell in each nostril (coffee, peppermint, oil, etc); avoid strong smells or odours (as they stimulate the fifth nerve).
II. Test for activity of vision, colour vision, field of vision; fundus examination; examine pupils - size, shape, reaction to light and accommodation.
III.IV.VI. Test for external ocular movements; examine pupils - size, shape, reaction to light and accommodation.
V. Test
A. Sensations over face (light touch, pin prick).
B. Masseter, pterygoid, temporal muscles.
C. Corneal, conjunction reflex.
D. Jaw jerk.
VI. Look for facial asymmetry (ask patients to show their teeth, smile), flattening of nasolabial fold, difficulty in closing eyes, loss of forehead wrinkles,; test eye closure, frowning, raising eyebrows, platysma muscle.
VII. Test for hearing by running fingers next to the ear; Rinne test (air versus bone conduction); Weber's test (lateralization).
IX. X. Test
A. Uvula - centralized, deviated.
B. Gag reflex.
X. Test sternocleidomastoid, trapezius muscles
XII. Look for dysarthria, fibrillations of the tongue, wasting of the tongue muscles, deviation of the tongue to one side; test tongue muscles.

Motor System

  1. Nutrition - look for wasting, hypertrophy.
  2. Tone - normal, hypotonia, hypertonia (amount of resistance offered to passive movements).
  3. Power - Grade 0 to 5
    0 No power
    1 Flicker of contraction only
    2 Active movement with gravity eliminated
    3 Movement against gravity
    4 Movement against gravity and some resistance
    5 Normal strength
    Allow some difference for handedness.
  4. Coordination

Sensory System

  1. Superficial sensations
    1. Touch - cotton, wool, head of a pin.
    2. Pain - pin prick.
    3. Temperature - test tubes containing hot or cold water.
  2. Deep sensations
    1. Joint position - patient is asked to comment on the position of a limb or a part of a limb or asked to place the corresponding part of the other limb in the same position.
    2. Vibration - 128 Hz tuning fork placed over bony projections.
    3. Deep pressure - press calves, Achilles tendons.
    4. Romberg's test
  3. Cortical sensations
    1. Tactile localization.
    2. Tactile discrimination.
    3. Tactile extinction.
    4. Stereognosis.

Reflexes - Graded as:

Absent (-)
Diminished (+)
Normal (++)
Brisk (+++)
Brisk with clonus (++++)
  1. Superficial reflexes
    Abdominal (T6 - T12) `
    Cremasteric (L1)
    Plantar (S1)
    Bulbocavernous (S2 - S4)
    Anal (S4 - S5)
  2. Deep tendon
    Biceps (C5 - C6)
    Supinator (brachioradialis) (C5 - C6)
    Triceps (C7 - C8)
    Knee (L2 - L4)
    Ankle (S1 - S2)

Miscellaneous

I.Signs of meningeal irritation, stiff neck, Brudzinski's sign.
II.Straight leg raise, test to evaluate irritation of lower lumbosacral root Lasegue's sign for sciatica.
III.Peripheral pulses of head and neck (0 to 4 +).
IV.Bruits over carotids or eyeballs.
V.Heart sounds, murmur
VI.Examination of skull, spine.
VII.Gait.
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