Neurological Exam Overview

Neurological Exam

• The neurological exam is typically divided into six sections: mental status, cranial nerves, motor exam, reflexes, coordination and gait, and sensory exam.

Mental Status

• Level of alertness, attention, and cooperation: Assessing the patient's responsiveness and ability to follow instructions.
• Orientation: Determining the patient's awareness of person, place, and time.
• Memory: Assessing both recent and remote memory. Recent memory involves recall of recent events, while remote memory involves recall of events from the distant past.
• Language: Evaluating spontaneous speech, comprehension (understanding), naming (identifying objects), repetition (repeating phrases), reading, and writing.
• Calculations: Evaluating the ability to perform simple calculations.
• Right-left confusion: Testing for issues with distinguishing right and left sides.
• Finger agnosia: Assessing the patient's ability to recognize fingers.
• Agraphia: Assessing writing ability.
• Apraxia: Evaluating the ability to perform purposeful movements.
• Neglect and constructions: Assessing the patient's ability to attend to the whole of their surroundings, both visually and otherwise.
• Sequencing tasks and frontal release signs: Determining the patient's ability to perform complex tasks that require sequential execution (e.g., dressing or other series of actions).
• Logic and abstraction: Assessing reasoning skills.
• Delusions and hallucinations: Assessing for potentially abnormal beliefs and perceptions.
• Mood: Evaluating emotional state.

Alertness, Attention, Cooperation, and Orientation

• Allows clinicians to evaluate the reticular formation, thalamus, and cerebral hemispheres; they function simultaneously.
• Assessing alertness includes determining if the patient is awake and aware of surroundings.
• Reciting forward and backward sequences tests memory and attention.
• A simple test for orientation involves asking: "What is your name? Where are you?"
• "A&O x3" denotes alert and oriented to person, place, and time. This is only used if the patient's normal mental faculties are known.

Recent and Remote Memory

• Recent memory involves asking the patient to recall recent events or information.
• Remote memory involves asking the patient to recall events from the distant past. Verifiable information helps establish accuracy, e.g., a significant life event.

Language

• Spontaneous speech: Assessing the patient's natural and unprompted verbal fluency.
• Comprehension: Evaluating understanding of spoken instructions or concepts.
• Naming: Assessing the ability to identify objects verbally.
• Repetition: Assessing the ability to repeat words or phrases.
• Reading: Assessing comprehension of written text.
• Writing: Tests the ability of the patient to write words or descriptions.

Calculations, Apraxia, and Neglect

• Calculations, agraphia, right-left confusion, and finger agnosia assess parietal lobe function (Gerstmann's syndrome).
• Apraxia is the inability to perform purposeful motor acts, despite intact motor function.
• Neglect is the lack of awareness of one side of the body or space and may show up during drawing or other testing. It is typically assessed by bilateral (simultaneous to both sides) testing.

Sequencing, Logic, Delusions, and Mood

• Patients may have difficulty in performing tasks involving patterns or logical sequencing.
• Testing for logic and abstraction involves applying logic quizzes or similar tests.
• Clinicians assess for unusual perceptions (delusions) or perceptual abnormalities (hallucinations).
• An evaluation of mood disturbances (e.g., depression, mania) is made within the mental assessment.

Cranial Nerves

• Olfaction (CN I): Smell testing
• Ophthalmoscopic exam (CN II): Visual field & optic nerve examination.
• Vision (CN II): Evaluating visual acuity and visual fields.
• Pupillary responses (CN II, III): Assessing pupillary light reflex and accommodation reflex.
• Extraocular movements (CN III, IV, VI): Testing eye movements.
• Facial sensation and muscles of mastication (CN V): Assessing facial touch sensations and chewing movements.
• Facial muscles of expression and taste (CN VII): Facial expressions and taste sensations.
• Hearing and vestibular sense (CN VIII): Assessing hearing.
• Palate elevation and gag reflex (CN IX, X): Assessing palate movement and gag reflex.
• Muscles of articulation (CN V, VII, IX, X, XII): Assessing the muscles needed for speech.
• Sternocleidomastoid and trapezius muscles (CN XI): Neck muscle strength.
• Tongue muscles (CN XII): Assessing tongue movement and strength.

The Motor Exam

• Observation: Assessing spontaneous movements, tremors, and other unusual motor phenomena.
• Inspection: Visual examination for muscle wasting, fasciculations, or other signs.
• Palpation: Feeling the muscles for tenderness or fasciculations.
• Muscle tone: Assessing the resistance to movement (e.g., rigidity, spasticity).
• Functional testing: Assessing the ability to perform tasks that utilize muscle strength (e.g., drift, finger tap, heel-to-shin).
• Strength of individual muscle groups: Testing specific muscles for strength.

Reflexes

• Deep tendon reflexes: Evaluating reflexes using a reflex hammer on specific tendons.
• Plantar response: Assessing the reflex response to stimulation of the sole of the foot.
• Reflexes tested in special situations (e.g., suspected spinal cord damage, posturing): Testing for specific neurological deficits or signs associated with particular conditions.

Coordination and Gait

• Appendicular coordination: Rapid alternating movements such as finger-nose-finger and heel-to-shin testing assess coordination.
• Romberg test: Assessing balance and coordination while standing with feet together and eyes closed.
• Gait: Observing how a person walks (e.g., ordinary gait, tandem gait, forced gait) assesses posture, balance and motor skills.

Sensory Exam

• Primary sensation: Testing for pain (sharp vs. dull), temperature (cold vs. warm), vibration, position sense (proprioception), light touch, and two-point discrimination. Asymmetry in sensory responses may signal a lesion or neurological damage.
• Cortical sensation: Testing for graphesthesia & stereognosis (ability to identify objects by touch).