Comprehensive Neurological Examination Protocol
A systematic, standardized neurological examination should include assessment of mental status, cranial nerves, motor function, sensory function, coordination, reflexes, and gait to accurately identify neurological deficits and guide clinical decision-making. 1
Mental Status Examination
Level of Consciousness Assessment
- Assess alertness using the following scale 2:
- 0 = Alert and responsive
- 1 = Arousable to minor stimulation
- 2 = Arousable only to painful stimulation
- 3 = Reflex responses or unarousable
Orientation and Cognition
- Assess orientation by asking patient's age and current month 2
- Evaluate command following by asking patient to open/close eyes and grip/release hand 2
- Consider using standardized cognitive assessment tools:
- Montreal Cognitive Assessment (MoCA) for more comprehensive evaluation 2
- Mini-Mental State Examination (MMSE) for general screening
Cranial Nerve Examination
CN II (Optic)
- Visual fields testing using confrontation method 2
- Score as:
- 0 = No visual loss
- 1 = Partial hemianopia, quadrantanopia, extinction
- 2 = Complete hemianopia
- 3 = Bilateral hemianopia or blindness
CN III, IV, VI (Oculomotor, Trochlear, Abducens)
- Assess eye movements and gaze 2
- Score as:
- 0 = Normal
- 1 = Partial gaze palsy
- 2 = Forced eye deviation or total paresis
CN V (Trigeminal)
- Test facial sensation in all three divisions using pinprick 2
- Assess corneal reflex if indicated
CN VII (Facial)
- Evaluate facial symmetry at rest and with movement 2
- Score as:
- 0 = Normal
- 1 = Minor paralysis (flat nasolabial fold, asymmetric smile)
- 2 = Partial paralysis (lower face)
- 3 = Complete paralysis (upper and lower face)
CN VIII (Vestibulocochlear)
- Assess hearing with finger rub or whispered voice
- Test for nystagmus
CN IX, X (Glossopharyngeal, Vagus)
- Evaluate palate elevation and gag reflex
- Assess for dysarthria by having patient read standardized word list 2
CN XI (Spinal Accessory)
- Test shoulder shrug and head turning against resistance
CN XII (Hypoglossal)
- Observe tongue for atrophy or fasciculations
- Test tongue protrusion for midline deviation
Motor Examination
Muscle Tone
- Assess for spasticity, rigidity, or flaccidity in all extremities
Muscle Strength
- Test major muscle groups using the 0-5 scale:
- 0 = No movement
- 1 = Visible contraction without movement
- 2 = Movement with gravity eliminated
- 3 = Movement against gravity
- 4 = Movement against resistance, but weaker than normal
- 5 = Normal strength
Upper Extremity Testing 2
- Arms outstretched 90° (sitting) or 45° (supine) for 10 seconds
- Score as:
- 0 = No drift for 10 seconds
- 1 = Drift but does not hit bed
- 2 = Some antigravity effort but cannot sustain
- 3 = No antigravity effort, minimal movement
- 4 = No movement at all
Lower Extremity Testing 2
- Raise leg to 30° and hold for 5 seconds
- Score as:
- 0 = No drift for 5 seconds
- 1 = Drift but does not hit bed
- 2 = Some antigravity effort but cannot sustain
- 3 = No antigravity effort, minimal movement
- 4 = No movement at all
Sensory Examination
Pain Sensation
- Test with safety pin in key dermatomes 2
- Score as:
- 0 = Normal
- 1 = Mild to moderate unilateral loss
- 2 = Total loss or bilateral loss
Other Sensory Modalities
- Light touch: Test with cotton wisp
- Proprioception: Test joint position sense in fingers and toes
- Vibration: Test with 128 Hz tuning fork over bony prominences
- Temperature: Test if indicated (hot/cold discrimination)
Coordination Testing
Upper Extremity Coordination
- Finger-to-nose test
- Rapid alternating movements to assess for dysdiadochokinesia 1
Lower Extremity Coordination
- Heel-to-shin test
- Score limb ataxia as 2:
- 0 = No ataxia
- 1 = Ataxia in 1 limb
- 2 = Ataxia in 2 limbs
Reflex Testing
Deep Tendon Reflexes
- Test biceps, triceps, brachioradialis, patellar, and Achilles reflexes
- Score using the 0-4 scale:
- 0 = Absent
- 1 = Hypoactive
- 2 = Normal
- 3 = Hyperactive
- 4 = Clonus
Pathological Reflexes
- Babinski sign: Stroke lateral sole of foot and observe for toe response
- Hoffman reflex: Flick distal phalanx of middle finger and observe for thumb flexion
Gait and Station
Stance
- Observe posture and stability with feet together
- Romberg test: Observe stability with eyes closed
Gait Patterns 1
- Observe normal walking
- Tandem gait (heel-to-toe walking)
- Heel walking and toe walking
- Look for specific patterns:
- Cerebellar ataxia: unsteady, irregular stepping, wide-based stance
- Waddling gait: side-to-side swaying, exaggerated weight shifting
- Vestibular dysfunction: lurching gait triggered by head rotation
Special Tests for Cerebellar Function
Dysdiadochokinesia Testing 1
- Have patient rapidly pronate and supinate hands on thighs or lap
- Observe for rhythm, speed, and symmetry
Other Cerebellar Tests
- Finger-to-finger test
- Rebound phenomenon
- Check for intention tremor during targeted movements
Extinction/Inattention Assessment
- Simultaneously touch patient on both hands 2
- Show fingers in both visual fields
- Ask if patient recognizes own left hand
- Score as:
- 0 = Normal
- 1 = Neglects/extinguishes to double simultaneous stimulation
- 2 = Profound neglect in more than 1 modality
Documentation and Scoring
- Document findings systematically by region
- Consider using standardized scales when appropriate:
Common Pitfalls to Avoid
- Inaccurate initial examination due to 2:
- Uncooperative patient
- Cognitive impairment from head injury
- Language barriers
- Inexperienced examiner
- Misinterpreting findings due to:
- Systemic or neurogenic shock
- Poor interrater reliability (proper training is essential)
- Examiner bias (independent examiners recommended)
Remember that the neurological examination should be tailored to the clinical context while maintaining a systematic approach to ensure comprehensive assessment of all neurological domains.