What are the key components to include when writing a neurological examination note?

Key Components of a Neurological Examination Note

A comprehensive neurological examination note should include standardized assessment of mental status, cranial nerves, motor function, sensory function, coordination, reflexes, and gait, using validated tools like the NIH Stroke Scale when appropriate.

Mental Status Assessment

• Level of Consciousness: Document using specific descriptors 1:

  • Alert (0)
  • Drowsy/arousable to minor stimulation (1)
  • Obtunded/arousable only to painful stimulation (2)
  • Coma/unresponsive (3)

• Orientation: Assess and document orientation to 1, 2:

  • Person (name, identity)
  • Place (current location)
  • Time (date, month, year)
  • Situation (why they're being examined)

• Attention: Document ability to maintain focus during examination 2

  • Serial 7s (subtract 7 repeatedly from 100)
  • Digit span forward and backward
  • Reciting months backward

• Language: Assess and document 1, 2:

  • Fluency of spontaneous speech
  • Comprehension of commands
  • Naming objects
  • Repetition of phrases
  • Reading and writing abilities

Cranial Nerve Examination

• CN I (Olfactory): Smell identification (if clinically indicated)

• CN II (Optic): Document 1:

  • Visual acuity
  • Visual fields by confrontation
  • Record deficits as:
    • No visual loss (0)
    • Partial hemianopia/quadrantanopia (1)
    • Complete hemianopia (2)
    • Bilateral hemianopia/blindness (3)

• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Document 1:

  • Pupillary size, symmetry, and reactivity
  • Eye movements and gaze:
    • Normal (0)
    • Partial gaze palsy (1)
    • Forced deviation/total gaze paresis (2)

• CN V (Trigeminal): Document:

  • Facial sensation in all three divisions
  • Jaw strength and movement

• CN VII (Facial): Document facial movement 1:

  • Normal (0)
  • Minor paralysis/flat nasolabial fold (1)
  • Partial paralysis (lower face) (2)
  • Complete paralysis (upper and lower face) (3)

• CN VIII (Vestibulocochlear): Document:

  • Hearing assessment (finger rub or whisper test)
  • Balance testing if indicated

• CN IX, X (Glossopharyngeal, Vagus): Document:

  • Palatal movement
  • Gag reflex if indicated
  • Voice quality and dysarthria 1:
    • Normal (0)
    • Mild-moderate slurring but intelligible (1)
    • Severe/unintelligible/mute (2)

• CN XI (Spinal Accessory): Document:

  • Shoulder shrug strength
  • Head turning strength

• CN XII (Hypoglossal): Document:

  • Tongue protrusion and movement
  • Presence of atrophy or fasciculations

Motor Examination

• Bulk: Document any muscle atrophy

• Tone: Document as normal, increased (spasticity, rigidity), or decreased (flaccidity)

• Strength: Document using the 5-point MRC scale for key muscle groups 1:

  • Upper extremities: Document drift or weakness

    • No drift for 10 seconds (0)
    • Drift but doesn't hit bed (1)
    • Some effort against gravity but cannot sustain (2)
    • No effort against gravity (3)
    • No movement (4)

  • Lower extremities: Document for both sides

    • No drift for 5 seconds (0)
    • Drift but doesn't hit bed (1)
    • Some effort against gravity but cannot sustain (2)
    • No effort against gravity (3)
    • No movement (4)

• Pronator drift: Document presence or absence

Sensory Examination

• Primary sensory modalities: Document for each limb 1:

  • Light touch
  • Pain (pinprick)
  • Temperature (if indicated)
  • Vibration
  • Proprioception
  • Score as:
    • Normal (0)
    • Mild-moderate unilateral loss (1)
    • Total loss/unaware of touch (2)

• Cortical sensory function (if indicated):

  • Stereognosis
  • Graphesthesia
  • Two-point discrimination

Coordination and Cerebellar Function

• Coordination: Document 1:
  • Finger-to-nose testing
  • Heel-to-shin testing
  • Rapid alternating movements
  • Score as:
    • No ataxia (0)
    • Ataxia in 1 limb (1)
    • Ataxia in 2 limbs (2)

Reflexes

• Deep tendon reflexes: Document for each location using 0-4+ scale:

  • Biceps
  • Triceps
  • Brachioradialis
  • Patellar
  • Achilles

• Pathological reflexes: Document presence or absence:

  • Babinski sign
  • Hoffman sign
  • Clonus
  • Snout reflex
  • Grasp reflex

Gait and Station

• Stance: Document ability to stand with feet together, eyes open and closed (Romberg)

• Gait: Document 1, 3:

  • Base width
  • Step length and height
  • Arm swing
  • Turning
  • Tandem walking
  • Specify if cerebellar, sensory, or vestibular ataxia pattern

Special Assessments

• NIHSS: When evaluating stroke patients, include the complete NIH Stroke Scale score 1

• Cognitive screening: When cognitive impairment is suspected, include results of validated screening tools such as MMSE, MoCA, or Mini-Cog 2, 4

• Extinction/Inattention: Document 1:

  • Response to bilateral simultaneous stimulation
  • Score as:
    • Normal (0)
    • Neglects/extinguishes to double simultaneous stimulation (1)
    • Profound neglect in multiple modalities (2)

Documentation Tips

• Organize findings systematically following the structure above
• Document both positive and pertinent negative findings
• Use precise, objective language rather than vague terms
• Include quantitative measures when possible (e.g., "5/5 strength" rather than "normal strength")
• Clearly document asymmetries or abnormalities
• For follow-up examinations, note changes from previous assessments
• Conclude with a brief interpretation of findings and their clinical significance

By following this structured approach, you'll create a comprehensive neurological examination note that facilitates accurate diagnosis, treatment planning, and monitoring of neurological conditions.