Neurological Assessment

Alice E. Davis, Ph.D., RN

A. History
1) chief complaint
2) history of present illness
3) past medical history
4) social history
5) review of systems

B. Mental/Emotional Status
1) observe mood, behavior, affect, posture, grooming and hygiene
2) personality changes -- may be reported by family
3) determine orientation
a) person
b) place
c) time-morning, afternoon, or evening, month or year
4) evaluate thought process
a) relevance
b) coherence
c) motor speech deficits
5) evaluate attention and concentration
a) serial 7’s (100-7, 93-7 etc.)
b) performance of tasks with multiple steps
c) digit span-repeat 7 numbers forward and 5 backward
6) test memory
a) recent information
b) remote information
c) antegrade and retrograde amnesias
7) determine ability for abstract thought
a) proverbs
b) ability to go from concrete to abstract thought
c) similarities and differences
8) test judgement
a) “what would you do” questions
b) observe behavior based on cognitive and motor deficits

C. Cranial Nerve Function

1) I Olfactory
a) test smell bilaterally
(1) 2 odors per nostril
(2) avoid strong or caustic odors

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2) II Optic
a) test vision of each eye separately
(1) Sneeling chart
(2) reading ability
b) visual fields, test each eye separately
(1) confrontation-test of peripheral vision
(2) identify scotomas
(c) ophthalmoscopic examination

3) III Oculomotor
a) ability of pupil to constrict to light
b) elevation of eye lid
c) extraocular movements (EOMs)
(1) medial
(2) upward and downward
(3) down and in
(4) lateral
(5) test with cranial nerves IV and VI
d) test pupil size
e) consensual response to light
f) Accommodation/convergence

4) IV Trochlear
a) EOMs test with III and VI
b) downward and inward eye movement

5) VI Abducens
a) EOMs test with III and IV
b) lateral movement

6) V Trigeminal
a) sensory response to pain and light touch
(1) ophthalmic branch
(2) maxillary branch
(3) mandibular branch
b) corneal reflex
(1) sensation V
(2) movement VII
c) motor response
(1) palpate masseter muscle
(2) palpate mandibular muscle

7) VII Facial
a) sensory response
(1) taste anterior 2/3 of tongue
b) motor response

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 (1) observe muscles of facial expression
(a) forehead
(b) eyes and mouth
(2) ask patient to
(a) smile
(b) whistle
(c) frown
(d) close eyes tightly (examiner attempts to open eyes)
(e) wrinkle forehead
(f) raise eyebrows
(g) bare teeth
(h) central VII th

8) VIII Acoustic or Vestibulatcholear

a) test gross hearing
(1) whisper simple question in one ear, wait for correct response, test
each ear separately
(2) Weber test (lateralization)
(3) Rinne test (bone vs air conduction)
b) test equilibrium
(1) Romberg test
c) episodes of vertigo
(1) describe spinning – room or person
d) nystagmus
(1) type – rotation, vertical, horizontal

9) IX Glossopharyngeal
a) test gag reflex bilaterally using a tongue blade
b) test taste posterior 1/3 of tongue
c) observe movement of soft palate
c) observe movement of uvula “Ahh”

10) X Vagus
a) sensory to pharynx and larynx
b) pain and paresthesias in pharynx and larynx
c) history of constant cough
d) history of dyspnea
e) motor to soft palate, pharynx and larynx
(1) quality of voice (hoarseness)
(2) ability to swallow (also test IX)
(3) history of nasal regurgitation of fluids
(4) presence of gag reflex bilaterally

11) XI Spinal Accessory or Assessory

a) test motor movement against resistance
(1) turning head-tests sterncleoidomastoid muscle, test bilaterally

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 (2) shrugging shoulders-tests trapezius muscle, test bilaterally
b) observe for atrophy of both muscles

12) XII Hypoglossal

a) test motor strength of tongue against resistance bilaterally (tongue in
cheek)
b) observe pushing strength of tongue
c) observe for deviation or protrusion
d) observe for atrophy
e) observe for fasiculations or tremors

D. Motor Status
1) Observe station and gait for sway or weakness
a) standing
b) tandem walking
c) walk on heels toward examiner
d) walk on heels away from examiner
e) hop on each leg
2) test muscle strength symmetrically against resistance
a) triceps
b) biceps
c) fingers (adduction and abduction)
d) quadriceps
e) hamstring
f) hip (adduction and abduction)
g) arms (adduction and abduction)
h) plantar flexion and dorsiflexion
3) assign grade to muscle strength using the following scale
a) 5 normal
b) 4 active movement, minimal weakness
c) 3 active movement, barely overcomes gravity
d) 2 active movement, does not overcome gravity
e) 1 slight trace of muscle contraction
f) 0 no muscle contraction (flaccid)
4) test gross motor strength of upper extremities
a) pronator sign, drift or “Barre”
5) determine if there is restriction of movement to passive range of motion
6) observe muscle tone bilaterally and document
a) normal
b) rigid
c) spastic
d) abnormal flexion (decorticate)
e) abnormal extension (decerebrate)
f) flaccid

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E. Coordination
1) finger to nose
2) rapid alternating movements include hands and feet
3) heel to shin
4) observe gait
5) abnormal involuntary movements (tics, ballismus, choreas, tremors)

F. Sensory Status
1) test various dermatome levels bilaterally for
a) pain (dull-sharp)
b) temperature
c) light touch (cotton)
d) pressure
2) test patient’s proprioception using
a) vibration
b) position sense
c) 2 point discrimination
d) number discrimination
e) stereognosis
f) extinction

G. Reflex Status
1) test each deep tendon reflex bilaterally and compare
a) triceps
b) biceps
c) brachioradialis
d) patellar
e) achilles
f) clonus
2) assign grade to reflex using the following scale
a) 0 areflexive
b) 1 hyporeflexive
c) 2-3 normoreflexive
d) 4-5 hyperreflexive
e) clonus
3) test or document physician’s test for presence or absence of the following reflexes
a) plantar response (Babinski)
b) occulocephalic reflex (Doll’s Eyes)
c) anal wink
d) Bulvocavernous reflex
e) occulovestibular reflex
f) upper abdominal superficial reflex
g) lower abdominal superficial reflex
h) cremasteric reflex

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 H. Glasgow Coma Score
1) Best eye opening
a) spontaneous 4
b) to speech 3
c) to pain 2
d) none 1
2) Best verbal response
a) oriented 5
b) confused 4
c) inappropriate 3
d) incomprehensible 2
e) none 1
3) Best motor response
a) obeys commands 6
b) localizes to pain 5
c) flexion/withdrawal 4
d) abnormal flexion 3
e) extension 2
f) flaccidity 1

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