What is the recommended approach for a neurological exam?

Recommended Approach for a Neurological Examination

A comprehensive neurological examination should include assessment of mental status, cranial nerve function, motor function, coordination, sensation, reflexes, and gait, using standardized tools whenever feasible. 1

Core Components of the Neurological Examination

1. Mental Status Assessment

• Use standardized scoring tools such as the Glasgow Coma Scale 2
• Assess cognitive domains including:
  • Learning and memory (particularly delayed free and cued recall/recognition)
  • Attention
  • Executive function
  • Visuospatial function
  • Language 2
• Consider using the Confusion Assessment Method for delirium screening 2

2. Cranial Nerve Examination

• Assess pupillary light response
• Evaluate eye movements (pursuit and saccades)
• Test facial strength
• Assess tongue movements
• Evaluate cough/gag reflexes 2

3. Motor Examination

• Assess muscle tone in arms and legs
• Evaluate muscle strength using the Medical Research Council scale
• Test for pronator drift or rapid arm movements in upper limbs
• Look for abnormal movements or tremors 3

4. Coordination Testing

• Finger-nose test
• Heel-shin test
• Rapid alternating movements
• Assess for dysmetria 1, 3

5. Sensory Examination

• Test light touch, pinprick, temperature, vibration, and proprioception
• Pay special attention to distal-to-proximal gradient in suspected peripheral neuropathies 4

6. Reflex Testing

• Assess deep tendon reflexes (biceps, triceps, brachioradialis, patellar, and Achilles)
• Test plantar responses (Babinski sign) 3

7. Gait and Station Assessment

• Observe natural walking pattern
• Test tandem gait
• Assess Romberg test
• Evaluate for specific gait patterns:
  • Wide-based cerebellar ataxia
  • Waddling gait
  • Vestibular dysfunction 1

Specialized Considerations

For Suspected Ataxia

• Focus on coordination tests
• Evaluate for truncal ataxia (difficulty sitting/standing without support)
• Distinguish between cerebellar and sensory ataxia (the latter worsens with eyes closed) 1

For Suspected Cognitive Impairment

• Perform more detailed cognitive assessment
• Consider neuropsychological evaluation when office-based cognitive assessment is not sufficiently informative 2
• Include assessment of behavioral symptoms using tools like the Neuropsychiatric Inventory-Q 2
• Evaluate functional abilities using scales like the Pfeffer Functional Assessment Questionnaire or Barthel Index 2

For Critically Ill Patients

• Manage sedation appropriately to maximize detection of neurological dysfunction
• Perform serial examinations to detect changes
• Consider additional neurophysiological and neuroradiological investigations based on examination findings 5

Documentation and Monitoring

• Establish a baseline neurological assessment
• Perform serial evaluations to monitor for changes
• Document findings using standardized formats
• Consider the frequency of reassessment based on clinical context and risk 2, 6

Common Pitfalls to Avoid

1. Failing to perform a complete examination due to time constraints
2. Not using standardized assessment tools
3. Misattributing neurological signs due to incomplete assessment 1
4. Overlooking subtle neurological deficits
5. Inadequate documentation of baseline status for future comparison 6

By following this structured approach to the neurological examination, clinicians can effectively detect neurological dysfunction, establish appropriate diagnoses, and monitor disease progression or treatment response.