What is the proper procedure for conducting a neuro examination?

Neurological Examination Protocol

The proper procedure for conducting a neurological examination includes systematic assessment of level of consciousness, cranial nerves, motor function, sensory function, coordination, and reflexes, following standardized protocols to ensure comprehensive evaluation of neurological status. 1, 2

Level of Consciousness Assessment

• Assess alertness using the Glasgow Coma Scale (GCS) components: eye opening, verbal response, and motor response 3
• Evaluate orientation by asking patients about person, place, and time 2
• Test ability to follow commands by asking patients to open/close eyes and grip/release hand 2
• Document the ICE (Immune Effector Cell-Associated Encephalopathy) score in patients receiving immunotherapy to track neurological status 3

Cranial Nerve Assessment

• Test all 12 cranial nerves systematically: 1, 2
  • CN I: Assess smell (optional in routine examination)
  • CN II: Check visual acuity and visual fields using confrontation testing
  • CN III, IV, VI: Evaluate pupillary size, reactivity, and eye movements
  • CN V: Test facial sensation in all three divisions and jaw strength
  • CN VII: Assess facial symmetry and movement
  • CN VIII: Evaluate hearing
  • CN IX, X: Check gag reflex, voice quality, and swallowing
  • CN XI: Test shoulder shrug and head turning strength
  • CN XII: Observe tongue movement and symmetry

Motor Function Assessment

• Have patients extend arms at 90° (seated) or 45° (supine) for 10 seconds to detect drift 2
• Ask patients to raise legs 30° and hold for 5 seconds 2
• Assess strength in major muscle groups using the 0-5 scale 2
• Evaluate muscle tone through passive range of motion 2
• Check for abnormal movements such as tremor, myoclonus, or asterixis 3

Sensory Function Assessment

• Test various sensory modalities including: 1, 2
  • Light touch
  • Pain/temperature sensation using pinprick
  • Vibration using a tuning fork
  • Proprioception (joint position sense)
• Compare symmetry between sides 2

Coordination and Cerebellar Function

• Test finger-to-nose and heel-to-shin movements to detect ataxia 2
• Assess rapid alternating movements 1
• Evaluate gait and balance if patient is able to stand and walk 3

Reflex Testing

• Check deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles) 2
• Test for pathological reflexes including Babinski sign 2
• Assess for frontal release signs in patients with suspected cognitive impairment 4

Cognitive Assessment

• Evaluate language function through naming objects, repetition, and comprehension 2
• Test memory (immediate, recent, and remote) 4
• Assess attention and concentration 4
• Screen for neglect or inattention using simultaneous bilateral stimulation 2

Documentation and Standardized Scales

• Use the NIH Stroke Scale (NIHSS) for patients with suspected stroke 3
• Apply the Glasgow Coma Scale for trauma patients or altered consciousness 3
• Document baseline status and any changes over time 1
• Consider using standardized cognitive assessment tools like Mini-Mental State Examination or Montreal Cognitive Assessment when appropriate 5, 4

Special Considerations

• Perform more frequent assessments (every 1-4 hours) in critically ill patients 1
• Note medications that may affect the neurological assessment, such as sedatives 2
• Consider the timing of the examination, as early assessments after injury may be less reliable 3
• Ensure adequate training of examiners to achieve high interrater reliability 3

Common Pitfalls to Avoid

• Incomplete motor testing - always assess both sides for comparison 2
• Failure to account for systemic factors that may affect neurological status (hypotension, hypoxemia) 3
• Inaccurate initial examination due to patient factors (uncooperativeness, intoxication, cognitive impairment) 3
• Neglecting to repeat examinations to detect neurological deterioration 3

Following this systematic approach ensures a comprehensive neurological examination that can guide diagnosis and management decisions across various clinical scenarios.