NEUROLOGICAL

EXAMINATION
INTRODUCTION
The nervous system consists of the central nervous system (CNS), the peripheral
nervous system, and the autonomic nervous system. The CNS includes the brain and
spinal cord the neurologic examination begins with careful observation of the patient
entering the examination area and continues during history taking. The patient
should be assisted as little as possible, so that difficulties in function can become
apparent. The patients speed, symmetry, and coordination while moving to the
examining table are noted, as are posture and gait. The patient’s demeanor, dress,
and responses provide information about mood and social adaptation. abnormal or
unusual speech, use of language, or praxis; neglect of space; unusual posturing; and
other disorders of movement may be apparent before formal testing.

As information is obtained, a skilled examiner may include certain components of

the examination and exclude others based on a preliminary hypothesis about the
anatomy and pathophysiology of the problem. If the examiner is less skilled,
complete neurologic screening is done.
The neurologic examination includes the following:
- Mental status
- Cranial nerves
- Motor system
- Sensation
- Reflexes
- Autonomic nervous system

NEUROLOGIC ASSESSMENT

❖ CEREBRAL FUNCTION
❖ CRANIAL NERVES
❖ MOTOR SYSTEM
❖ REFLEXE
EQUIPMENT NEEDED

- BIG TRAY CONTAINING

- SHEET FOR COVER PATIENT
- GLOVES
- REFLEX HAMMER
- 128 AND 512 (OR 1024) hz TUNNING FORKS
- A SNELLEN EYE CHART OR POCKET VISION CARD
- PEN LIGHT OR OTOSCOPE
- COTTON SWABS
- STETHESCOPE
- SPHYGMOMANOMETER
- WATCH
- COMMON PIN OR NEEDLE
- COFFEE POWDER, SUGAR, SALT
- PEN/ COIN

DEFINITION:
A neurological examination (also called a neuro- exam) is a systemic process that
includes a variety of tests and observations. it may be performed with instruments,
such as lights and reflex hammers, and usually does not cause any pain to the patient.

IDENTIFY THE PURPOSE OF PERFORMING NEUROLOGICAL

EXAMINATION:

During a routine physical assessment

• Following any type of trauma
• To follow the progression of a disease
• If the person has any of the following complaints
• Head aches
• Blurry vision
• Change in behavior
• Fatigue
• Change in balance or coordination
• Numbness or tingling in the arms or legs
• Decrease in movement of the arms or legs
• Injury to the head, neck, or back
• Slurred speech
• Weakness
• Tremors

OUTLINE WHAT TO ASSESS IN MENTAL STATUS EXAMINATION

General appearances and movements
1. Appearance
2. Dress
3. Personal hygiene
4. Posture and gestures
5. Movements, facial expressions
6. Motor activity
7. Manner of speech
8. Level of consciousness (GCS) Appearances and general behavior

ii
The MSE begins when the physician first encounters and observes the patient. How
the patient interacts with the physician and the environment may reveal underlying
psychiatric disturbances or clues signifying he patients emotional and mental state.
Collaborative observations from office staff may also be useful. If the physician has
known the patient for some time, it may be helpful to acknowledge and document
any changes that have occurred over time that may correlate with changes in mental
health. Important observations f appearances may include the disheveled
appearances of a patient with schizophrenia, the self-neglect of a patient with
depression, or the provocative style of a patient with mania.

MOTOR ACTIVITY
Observations of motor activity include body posture; general body movement; facial
expressions; gait; level of psychomotor activity; gestures; and the presence of
dyskinesias. Such as tics or tremors. psychomotor retardation (a general slowing of
physical and emotional reactions) may signify depression or negative symptoms of
schizophrenia. psychomotor agitation may occur with anxiety or mania. Changes in
motor activity over time may correlate with progression of the patient’s illness, such
as increasing bradykinesia with worsening parkinsonism. In addition, changes in
motor activity may be related to treatment response (e.g., parkinsonism secondary
to an antipsychotic medication).

SPEECH:
Observations of speech may include rate, volume, spontaneity, and coherence.
Incoherent speech may be caused by dysarthria, poor articulation, or inaudibility.
The form of speech is more important than the content of speech in this portion of
the examination, and may provide clues to associated disorders. for example,
patients with mania may speak quickly, where as patients with depression often
speak slowly.

MOOD AND AFFECT

Mood is the patients internal, subjective emotional state. of note, this is one of the
new elements of the MSE that relay on patient’s self-report in addition to physician
observation. It is helpful to ask the patient to report his or her mood over the past
few weeks, as opposed to merely asking about the moment. It may also be helpful
to determine if mood remains constant over time or varies from visit to visit.
physician may perform a more objective assessment by asking the patient at each
visit to rate mood from 1 to 10 (with 1 being sad, and 10 being happy).
Affect is the physician’s objective observation of the patients expressed emotional
state. often, the patients affect changes with his or her emotional state and can be
determined by facial expressions, as well as interactions. descriptions of affect may
address emotional range (broad or restricted), intensity (blunted, flat, or normal), and
iii
stability. affect may or may not be congruent with mood, such as when a patient
laughs when talking about the recent death of a family member. Additionally, affect
may not be appropriate for a given situation. For example, a patient with delusions
of persecution may not seem frightened, as expected. inappropriateness of affect
occurs in some patents with schizophrenia.

THOUGHT PROCESS
Thought process can be used to describe a patients form of thinking and to
characterize how a patents ideas are expressed during an office visit. Physician may
note the rate of thought (extremely rapid thinking is called flight of ideas) and flow
of thought (whether thought s goal directed or disorganized). Additional descriptors
include whether thoughts are logical, tangential, circumstantial, and closely or
loosely associated. Often, a patients thought process can be described in relation to
a continuum between goal directed and disconnected thoughts. incoherence of
thought process is the lack of coherent connections between thoughts.

THOUGHT CONTENT
Thought content describes what the patient is thinking and includes the presence or
absence of delusional or obsessional thinking and suicidal or homicidal ideas. If any
of these thoughts are present, details regarding intensity and specificity should be
obtained,
More specifically, delusions are fixed, false beliefs that are not in accordance with
external reality. Delusions can be distinguished from obsessions because persons
who experience the latter recognize that the intrusiveness of their thoughts is not
normal. Bizarre delusions that occur over a period of time often suggest
schizophrenia and schizoaffective disorders, whereas acute delusions are more
consistent with alcohol or drug intoxication.

PERCEPTUAL DISTURBANCES
Hallucinations are perceptual disturbances that occur in the absence of a sensory
stimulus. Hallucinations can occur in different sensory systems, including auditory,
visual, olfactory, gustatory, tactile or visceral. the content of the hallucination and
the sensory system involved should be noted. Hallucinations are symptoms of a
schizophrenia disorder. bipolar disorder, severe unipolar depression, acute
intoxication, withdrawal from alcohol or illicit drug dose, delirium, and dementia.
perceptual disturbances may be difficult to elicit during an office visit because
patients may deny having hallucinations. The physician may conclude that
hallucinations are present if the patient is responding to internal stimuli as if the
patient is hearing somebody speaking to him or her.
Sensorium and cognition

iv
 The evaluation of a patient’s cognitive function is an essential component of the
MSE, the assessment of sensorium includes the patient’s level and stability of
consciousness. a disturbances or fluctuation of consciousness may indicate delirium.
descriptors of a patient’s level of consciousness include alert, clouded, somnolent,
lethargic, and comatose.

LEVEL OF CONSCIOUSNESS
There are a variety of medical conditions and drugs that contribute to the level of a
person’s consciousness. sometimes impaired consciousness is reversible, while
others times it is not.

Normal level of consciousness

According to medical definitions, a normal level of consciousness means that a
person is either awake or can be readily awakened from normal sleep. consciousness
identifies a state in which a patient is awake, aware, alert, and responsive to stimuli.

Unconsciousness identifies a state in which a patient has a deficit in awareness and

responsiveness to stimuli (touch, light, sound). A person who is sleeping would not
be considered unconscious, however, if waking up would result in normal
consciousness.
Between these two extremes, there are several altered levels of consciousness,
ranging from confusion to coma, each with its own definition.

Altered level of consciousness (ALOC)

Altered or abnormal levels of consciousness describe states in which a person either
has decreased cognitive function or cannot be easily aroused. Most medical
conditions affect the brain and impair consciousness when they become serous or
life threatening, and an altered state of consciousness usually signals a serious
medical problem.
Often, an altered level of consciousness can deteriorate rapidly from one stage to the
next, so it requires timely diagnosis and prompt treatment.

Confusion describes disorientation that makes it difficult to reason, to provide a

medical history, or to participate in the medical examination. Causes include sleep
deprivation, fever, medications, alcohol intoxication, recreational drug dose, and
postictal state (recovering from a seizure).

Delirium is term used to describe an acute confusional state, characterized by

impaired cognition, in particular, attention, alteration of the sleep wake cycle,
hyperactivity (agitation), or hypoactivity (apathy), perceptual disturbances such as
hallucinations (seeing things that are not there) or delusions (false beliefs). As well
v
as by instability of heart rate and blood pressure. Causes can include alcohol
withdrawal, recreational drugs, medications, illness, organ failure, and severe
infections.

Lethargy and somnolence describe sever drowsiness, listlessness, and apathy

accompanied by reduced alertness, A lethargic patient often needs a gentle touch or
verbal stimulation to initiate a response. Causes can include sever illness or
infections, recreational drugs, and organ failure.

Obtundation is reduction in alertness with slow responses to stimuli, requiring

repeated stimulation to maintain attention, as well as having prolonged periods of
sleep, and drowsiness between these periods. causes can include poisoning, stroke,
brain edema. Sepsis, and advanced organ failure.

Stupor is a level of impaired consciousness in which a person only minimally

responds to vigorous stimulation, such as pinching the toe or shining a light in the
eyes. cause can include stroke, drug over dose, lack of oxygen, brain edema, and
myocardial infraction (heart attack).

Coma is a state of unresponsiveness, even to stimuli. a person in a coma may lack a

gag reflex (gagging in response to a tongue depressor placed at the back of the throat)
r a pupillary response (pupils normally constrict in response to light). It is caused by
severely diminished brain function, usually due to extreme blood loss, organ failure
or brain damage. the causes of these altered states of consciousness may overlap.
For example, the early stages of brain edema or organ failure can cause confusion
but can advance rapidly through the stages of lethargy, Obtundation, stupor, and
coma.

vi
CLASSIFICATIONS OF COMA
The most commonly sed classifications systems are the Grady coma scale and the
Glasgow coma scale

• GRADY COMA SCALE

• GLASGOW COMA SCALE

The Glasgow coma scale was first published in 1974 at the university of Glasgow
by neurosurgery professor’s graham Teasdale and Bryan jennett. The Glasgow coma
scale is used to objectively describe the extent of impaired consciousness in all types
of acute medical and trauma patients. The scale assesses patients according to three
aspects of responsiveness: eye opening, motor, and verbal responses. reporting each
of these separately provides a clear, communicable picture of a patient’s state.
The score expression is the sum of the scores as well as the individual elements. For
example, a score of 10 might be expressed as GCS10= E3VM3.
vii
viii
 • APPLICATION OF THE GLASGOW COMA SCALE IN PEDAITRICS:

THE FOLLOWING FACTORS MAY INTERFERE WITH THE

GLASGOW COMA SCALE

- preexisting factors
- Language barriers
- Intellectual or neurological deficit
- Hearing loss or speech impairment
- Effects of current treatment
ix
- Physical (e.g., intubation): if patient is intubated and unable to speak, they are
evaluated only on the motor and eye-opening response and the suffix T is added to
their score to indicate intubation.

- Pharmacological (e.g., sedation) or paralysis: if possible, the clinician should

obtain the score before sedating the patient. effects of other injuries or lesions.

- Orbital / cranial fracture

- Spinal cord damage

- Hypoxic -ischemic encephalopathy after cold exposure

There are instances when the Glasgow coma scale is unobtainable despite efforts to
overcome the issues listed above. It is essential that the total score is not reported
without testing and including all of the components because the score will be low
and could cause confusion.
GLASGOW COMA SCALE PUPILS SCORE

The Glasgow coma scale pupils score (GCS- P) as described by Paul Brennan,
Gordon Murray, and graham Teasdale in 2018 as a strategy to combine the two key
indicators of the severity of traumatic brain injury into a single simple index.

Calculation of the GCS-P is by subtracting the pupil reactivity score (PRS) from the
Glasgow coma scale (GCS) total score:

GCS-P = GCS – PRS

The GCS-P score can range from 1 and 15 and extends the range over which early
severity can be shown to relate to outcomes of either mortality or independent
recovery.

x
CLASSIFICATION OF SEVERITY OF TBI

The realtionship between the GCS score and outcome is the basis for a common
classification of acute traumatic brain injury:
With the GCS-P score values between one and 8 denote a severe injury.

DESCRIBE HOW TO ASSESS THE CRANIAL NERVE

xi
xii
 IDENTIFY MOTOR SYSTEM ASSESSMENT
Assessment of the motor system includes evaluation of:
• Evaluation of bilateral muscle strength
• Coordination and balance
• Sensory system assessment
Be sure to compare assess bilaterally and findings

MUSCLE STREGTH
➢ Examine the arm and leg muscles looking for atrophy and abnormal movements such
as tremors
➢ Perform passive range of motion exercises and note any resistance
➢ Instruct the patient to bend the forearm up at the elbow (flexion) while you hold the
patient’s wrist exerting a slight downward pressure
➢ Test the triceps by having the patient extend his arm while you push against his wrist
➢ Ensure that the patient follows instructions to release the hand when assessing grip
strength.
COORDINATION AND BALANCE TEST
➢ Coordination can be checked by having the patient close the yes and touch the
finger to the nose
➢ Coordination can also be assessed by having the patient perform rapid
alternating movements (rams)
FINGER TO NOSE TEST
➢ Ask the client to extend both arms from the sides of the body
➢ Ask the client to keep both eyes open
➢ Ask the client to touch the tip of the nose with right index finger, and then
return right arm toa n extended position
➢ Ask the client to touch the tip of the nose with left index finger, and then return
the left arm to an extended position.
➢ Repeat the procedure several times
➢ Ask the client to close both eyes and repeat the alternating movements
➢ Coordination can be checked by having the patient close the eyes and touch the
finger to the nose
➢ Coordination can also be assessed by having the patient perform rapid
alternating movements (RAMs)
SENSORY SYSTEM ASSESSMENT
➢ Instruct the patient to keep his eyes closed during all the tests. Compare one
side with the other, noting whether sensory perception is bilateral.
REFLEXES TO CHECK:
1. BICEPS
Flex patients arm at the elbow and rest his forearm on his thigh with the palm up.
Place your thumb firmly on the biceps tendon in the antecubital fossa. Strike your
thumb with the hammer. the elbow and forearm should flex, and the biceps
muscle should contract.
2. TRICEPS
The triceps tendon is tested with the patient’s arm flexed at a 90 angle. Supporting
the arm with your hand, strike the triceps tendon on the posterior arm just above
the elbow. The tendon should contract and the elbow extend.
3. BRACHIORADIALIS
Have the patient rest his slightly flexed arm on his lap with the palm facing
downward. Strike the posterior arm about two inches above the wrist on the
thumb side, the forearm should rotate laterally and the palm turn upward.
4. PATELLAR
Dangle the patients’ legs over the side of the bed. Place your hand on the patient’s
thigh and strike the distal patellar tendon just below the kneecap. The normal;
response is contraction of the quadriceps muscle with extension of the knee.
5. ACHILLES
Have the patient dorsiflex (point downward) his foot slightly and lightly lap the
Achilles’s tendon on the posterior ankle area. A slightly jerking of the foot
should be seen.
6. ABDOMINAL REFLEX
- Use a blunt object such as a key or tongue blade.
- Stroke the abdomen lightly on each side in an inward and downward direction

2
- Note the contraction of the abdominal muscles and deviation of the umbilicus
towards the stimulus.
7. PLANTAR REFLEX (BABINSKI)
- Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer
or key.
- Observe for planter flexion of the foot.

GRADING REFLEXES
Reflexes are usually graded on a 0 to 4+ scale

*Clonus (rhythmic oscillations between flexion and extension)

SUMMARY:
Much of the patient’s neurological function is assessed during the history and during
early parts of physical examination. Much can be learned from the speech patterns,
mental status, gait, stance, motor power, and coordination during the nurse –
patients’ interaction.

3
4