 Paper Clip

 Cotton
 Tuning Fork
 Penlight
 Ophthalmoscope
 Vision Screeners
 Reflex Hammer
 Orange
 Key
 PPE
As the patient enters the room, check the following:
 Posture and motor behavior
 Dress, grooming and personal hygiene
 Facial expression
 Speech manner, mood and relation to persons and
things around him

A simple means of gathering a great deal of information

about the patient’s neurological system is to observe the
patient walking, talking, seeing and hearing. Watching
the patient enter the room is also important in giving the
examiner information.
LEVEL OF CONSCIOUSNESS
The single most valuable indicator of neurological function is the
individual’s level of consciousness. You can legally describe the
patient's condition in the nurses’ notes by saying “appears to be” alert
or lethargic or so forth.

 Alert: the patient is awake, verbally and motorally responsive.

 Lethargic: the patient is sleepy or drowsy and will awaken and
respond appropriately to command.
 Stupor: the patient becomes unconscious spontaneously and is
very hard to awaken.
 Semi-coma: the patient is not awake but will respond to deep
pain purposefully .
 Coma: the patient is completely unresponsive.
BASIC CALCULATIONS
Ask the patient to do some simple arithmetic problems without using
paper and pencil. For example ask him to add 7 to subtract 3 from a
number. It should take the patient of average intelligence about one
minute to complete the calculations with few errors.

AFFECT AND MOOD

 During the physical part of the examination, note the patient’s mood
and emotional expressions which you can observe by his verbal and
nonverbal behavior.
 Notice if he has mood swings or behave as though he is anxious or
depressed. Notice whether the patient’s feelings are appropriate for
the situation.
 Disturbances in mood, affect and feelings may be indicated by a
patient who exhibits unresponsiveness, hopelessness, agitation,
euphoria, irritability or wide mood swings.
MEMORY (RECENT AND REMOTE)
Ask the patient his social security number, the city he is in, the building
number and state. Note if the patient is oriented by place, person and
time, or not.

KNOWLEDGE
Ask the patient to name five animals, colors, cities, etc. another way to
test this area is to ask the patient to tell you the meaning of proverb or
metaphor. For example, explain:
 Too many cooks spoil the soup.
 A penny saved is a penny earned.
 A stitch in time saves nine.
The Olfactory Nerve (CN I) is simply tested by offering something
familiar for the patient to smell and identify. For example, orange, coffee
or vinegar.
The Optic Nerve (CN II) is tested in five ways:

1. Acuity

2. Color

3. Fields

4. Reflexes

5. Fundoscopy
Visual Acuity
Visual acuity is tested using Snellen charts. If the patient
normally wears glasses or contact lenses, then this test
should be assessed both with and without their vision
aids.

Color
Color vision is tested using Ishihara charts which
identifies patients who are color blind.

Visual Field
Perform confrontational visual field testing by asking the
patient to look directly at you while you wiggle one of
your fingers in each of the four quadrants.
Visual Reflexes
Test corneal light reflex and
pupillary reaction to light to both
eyes.

Fundoscopy
Finally fundoscopy should be
performed on both eyes by
using ophthalmoscope.
The Oculomotor Nerve (CN III),
Trochlear Nerve (IV) and Abducens
Nerve (CN VI) are involved in the
movements of the eye.

Perform cardinal fields of gaze test and

test accommodation of pupils.

Note nystagmus and strabismus.

Assess pupillary response to light

(direct and indirect) and
accommodation in both eyes
The Trigeminal Nerve (CN V) is involved in sensory supply to the face
and motor supply to the muscles of mastification. There are three
sensory branches of the trigeminal nerve: ophthalmic, maxillary and
mandibulary.

Initially test the sensory branches by lightly touching the face with a
piece of cotton ball followed by a blunt paper clip in three places on
each side of the face:

1. Around the Jawline 2. On the Cheek 3. On the Forehead

MOTOR SUPPLY

To test the motor supply, ask the patient to clench their teeth together,
observing and feeling the bulk of the masseter and temporalis muscles.

Ask the patient to open their mouth against resistance.

The Facial Nerve (CN VII) supplies motor branches to the muscles of
facial expression.

This nerve is therefore tested by asking the patient to crease up their

forehead (raise their eyebrows), close their eyes and keep them closed
against resistance, puff out their cheeks and reveal their teeth.
The Vestibulocochlear Nerve (CN VIII) provides innervation to the
hearing apparatus of the ear and can be used to differentiate
conductive and sensorineural hearing loss using the Rinne and Weber
tests.

To carry out the Rinne’s test, place a sounding tuning fork on the
patient’s mastoid process and then next to their ear and ask which is
louder. To carry out the Weber’s test, place the tuning fork base down in
the center of the patient’s forehead and ask if it is louder in either ear.
Normally it should be heard equally in both ears.
The Glossopharyngeal Nerve (CN IX) provides sensory supply to the
palate. It can be tested with the gag reflex or by touching the arches of
the pharynx. The Vagus Nerve (CN X) provides motor supply to the
pharynx.
Asking the patient to speak gives a
good indication to the efficacy of
the muscles. The uvula should be
observed before and during the
patient saying “aah.” Check that it
lies centrally and does not deviate
on movement.
The Accessory Nerve (CN XI) gives motor supply to the trapezius and
sternocleidomastoid muscles. To test it, ask the patient to shrug their
shoulders and turn their head against resistance.
The Hypoglossal Nerve (CN XII) provides motor supply to the muscles
of the tongue.

Observe the tongue for any signs of wasting or fasciculation. Ask the
patient to stick their tongue out. If the tongue deviates to either side, it
suggests a weakening of the muscles on that side.
A. Assess bilateral muscle strength and muscle tone.
o Inspect the muscle group for size.
o Compare the right side with left side.
o Look for any asymmetry.
o See musculoskeletal assessment.

B. Posture and Gait; ask client to:

o Walk forward and backward in a straight line
o Walk heel to toe
o Walk on toes then on heels
o Hop in place on each foot.
C. Test for Coordination

o Finger to nose
o Rapid alternating movements
o Heel to shin test
o Fine motor test
o Romberg’s test
Perform the finger to nose test by placing your index finger about two feet from
the patient’s face. Ask them to touch the tip of their nose with their index finger
then the tip of your finger. Ask them to do this as fast as possible while you
slowly move your finger. Repeat the test with the other hand.

Dysmetria is the clinical term for the inability to perform point to point
movements due to over or under projecting ones fingers.
Ask the patient to place their hands on their thighs and then rapidly turn their
hands over and lift them off their thighs. Once the patient understands this
movement, tell them to repeat it rapidly for 10 seconds. Normally this is
possible without difficulty.

Dysdiadochokinesia is the clinical term for an inability to perform rapidly

alternating movements. It is usually caused by multiple sclerosis in adults and
cerebellar tumor in children.
With the patient lying supine, instruct ho
place their right heel on their left shin
just below the knee and then slide it
down their shin to the top of their foot.
Have them repeat this motion as quickly
as possible without making mistakes.
Have the patient repeat this movement
with the other foot. Inability to perform
this motion quickly is abnormal.

This may be abnormal if there is loss of

motor strength, proprioception or a
cerebellar lesion. If motor and sensory
systems are intact, an asymmetric heel
to shin test is highly suggestive of an
ipsilateral cerebellar lesion.
Patient rapidly touches thumb to each finger of same hand.

Abnormal with cortical lesions (tumor or stroke).

Instruct the patient to stand with his
feet together and his arms at his
side.

Have the patient do this with his

eyes open and then with his eyes
closed. Stand close to the patient to
keep him upright if he starts to sway.

Expect the patient to sway slightly

but not fall. This is a test of balance.
PAIN
Ask patient to close eyes and tell what they
feel and where they feel it. Scatter stimuli
over the body. To assess pain, use blunt and
sharp ends of a paper clip. Do not use
hypodermic needle.

TEMPERATURE
To test temperature sensation, use test tube
filled with hot and cold water. But the most
practical approach is to touch the patient with
a tuning fork as the metal feels cold.
TOUCH
To test touch sensation, use a wisp of cotton
ball to touch the client. DO not press down on
the skin or touch areas of the skin that have
hair. Instruct patient to point area being
touched.

Anesthesia: absence of touch sensation

Hypesthesia: decreased sensitivity to touch
Hyperesthesia: increased sensitivity to touch
Analgesia: absence of pain sensation
Hypalgesia: decreased sensitivity to pain
Hyperalgesia: increased sensitivity to pain
VIBRATION
Use a sounding tuning fork to assess
vibration. Place the fork on patient’s sternum
to show them how it feels. Then place it on
the bony prominence at the base of their
thumb and ask them if it feels the same.

PROPRIOCEPTION
Hold the distal phalanx of the thumb on either
side so that you can flex the interphalangeal
joint. Show the patient as you move the finger
up and down. Ask the patient to close eyes
and move the joint a few times and hold it in
a position and ask the patient if it is in up or
down position.
STEREOGNOSIS
With eyes closed, place a familiar object like
a paper clip or key in the patient’s hand and
ask the patient to identify it. Repeat with
another object in the other hand.

GRAPHESTHESIA
With eyes closed, use a blunt instrument like
pen to write a number on the palm of the
patient’s hand. Ask the patient to identify the
number. Repeat with another number on the
other hand.
CORNEAL REFLEX
Do this by lightly touching the cornea with the
cotton wool. This should cause the patient to
shut their eyelids.
Abnormal finding: No blinking

GAG AND SWALLOW REFLEX

Open client mouth and touch the tip of tongue
blade against his posterior pharynx and ask
the patient to say “aahhh.”
Absence of gag and swallow reflex are due to
impaired cranial nerve IX and X.
BABINSKI’S REFLEX
Stroke the lateral aspect of the sole of the
patient’s foot with a moderately sharp object
like a key. Normally, this elicits flexion of all
toes (Plantar reflex). With the Babinski’s
reflex, the great toe dorsiflexes and the other
toes fan out.

Babinski’s sign occur in paralyzed side in

CVA and bilateral spinal cord injury.
BICEPS REFLEX
Place your thumb on biceps
tendon and strike your thumb
with the reflex hammer.

BRACHIORADIALIS REFLEX
Strike tendon with flat side of
hammer.
 1. Triceps Reflex
2. Patellar Reflex
3. Achilles Reflex

1 2 3
https://www.youtube.com/watch?v=Sqb8icF6QhE