What is the standard protocol for a comprehensive neurology examination?

Standard Neurological Examination Protocol

A comprehensive neurological examination should systematically assess mental status, cranial nerves, motor function, sensory function, reflexes, coordination, and gait, with documentation using validated scales such as the NIH Stroke Scale (NIHSS) for standardization. 1

Core Components of the Examination

Mental Status Assessment

• Evaluate level of consciousness using validated tools including the Glasgow Coma Scale (GCS), AVPU (Alert, Voice, Pain, Unresponsive), or ABC scale 2, 1
• Perform cognitive screening focused on memory, attention, executive function, and language 2
• Include behavioral assessment using standardized instruments such as the Neuropsychiatric Inventory-Q 2
• Screen for depression with validated scales (Center for Epidemiological Studies-Depression or Geriatric Depression Scale) 2

Cranial Nerve Examination

• Systematically evaluate all 12 cranial nerves including visual fields, pupillary responses, extraocular movements, facial sensation and strength, hearing, palatal elevation, tongue movement, and shoulder shrug 1

Motor System Evaluation

• Assess muscle tone, bulk, and strength in all extremities using standardized grading 1
• Document motor movements and any abnormal movements 2
• Test for pronator drift and coordination 2

Sensory System Assessment

• Test multiple sensory modalities including light touch, pinprick, temperature, vibration, and proprioception 1
• Compare symmetry between sides and proximal versus distal distribution 1

Reflexes and Pathological Signs

• Evaluate deep tendon reflexes in all extremities 2
• Test for Babinski sign bilaterally 2
• Assess for clonus if hyperreflexia is present 2

Gait and Coordination

• Perform timed gait assessment 2
• Observe for balance difficulties, ataxia, or asymmetry 2
• Test coordination with finger-to-nose and heel-to-shin maneuvers 2

Vital Signs and Physical Measurements

• Document height, weight, blood pressure (including orthostatic measurements), heart rate, waist circumference, temperature 2
• Measure ankle-brachial index when vascular disease is suspected 2
• Assess vision and hearing 2

Standardized Scoring Systems

NIH Stroke Scale (NIHSS)

• The NIHSS is the gold standard for quantifying neurological deficits in acute stroke settings, providing a 42-point scale with higher scores indicating more severe deficits 2
• Should be performed by certified examiners trained via standardized methods 2
• Repeat at defined intervals: immediately post-intervention, 24 hours, 72 hours, 7-10 days, 30 days, and 90 days 2
• Obtain additional NIHSS when neurological deterioration occurs (defined as 4-point increase) 2

Functional Assessment

• Use modified Rankin Scale Score (mRSS) for disability outcomes 2
• Assess activities of daily living with Barthel Index or Pfeffer Functional Assessment Questionnaire 2

Documentation Requirements

Essential History Elements

• Obtain detailed cerebrovascular and cardiovascular history including prior stroke, TIA, myocardial infarction, atrial fibrillation, peripheral artery disease 2
• Document all medications including over-the-counter preparations within 48 hours 2
• Record vascular risk factors: hypertension, hyperlipidemia, diabetes, smoking, alcohol use 2
• Family history of stroke, vascular disease, or dementia in first-degree relatives 2

Subjective Symptoms

• Record onset and progression of symptoms including cognitive changes, behavioral changes, gait problems, tremor, balance difficulties, swallowing problems, incontinence, and pseudobulbar affect 2

Special Populations and Contexts

Critical Care Settings

• Daily assessment by a neurologist/neurointensivist is recommended for hospitalized patients with neurological concerns 1
• For high-risk patients (e.g., ECMO), perform bedside nursing assessments every 1-4 hours 1

Serial Monitoring

• Document baseline neurological status and track changes over time using standardized forms 1
• In acute settings, perform serial examinations at 6,24, and 72 hours after admission 2

Common Pitfalls to Avoid

• Do not rely solely on history when examination findings are inconsistent - restart the assessment if information is contradictory 3
• The NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 2
• Avoid labeling findings as "non-organic" without thorough evaluation, as conditions like stiff-person syndrome can present with unusual gaits 4
• Ensure proper certification and training for administering standardized scales to reduce interobserver variability 2

Laboratory and Imaging Correlation

When indicated by examination findings:

• Obtain hematology (CBC), coagulation parameters (PT/INR, aPTT), chemistry panel (glucose, renal function, liver function) 2
• Perform 12-lead ECG at baseline and when clinically indicated 2
• Neuroimaging (CT or MRI) should be performed emergently when serious structural lesions are suspected based on examination findings 2