What are the key components to include when documenting a neuro exam?

Documentation of Neurological Examination

A standardized neurological examination should document seven core domains: level of consciousness, cranial nerve function, motor function, sensory function, reflexes, coordination/cerebellar function, and gait, using validated scales like the NIH Stroke Scale (NIHSS) whenever applicable to ensure comprehensive, reproducible assessments.

Essential Components to Document

1. Level of Consciousness and Mental Status

• Document alertness using standardized scoring: Alert (0), drowsy (1), obtunded (2), or coma/unresponsive (3) 1
• Assess orientation: Ask two orientation questions (month, age) and score whether patient answers both, one, or neither correctly 1
• Test response to commands: Have patient perform two tasks (open/close eyes, make fist) and document performance 1
• Include cognitive assessment when evaluating for dementia or vascular cognitive impairment, documenting any behavioral changes, memory deficits, or functional decline 1

2. Cranial Nerve Examination

• Gaze and eye movements (CN III, IV, VI): Document normal horizontal movements, partial gaze palsy, or complete gaze palsy 1
• Visual fields (CN II): Test and record no defect, partial hemianopia, complete hemianopia, or bilateral hemianopia 1
• Facial movement (CN VII): Score as normal, minor weakness, partial weakness, or complete unilateral palsy 1
• Pupillary reactivity: Document size, symmetry, and response to light 1
• Additional cranial nerves: Observe quality of eye opening/closure, facial expression, smile, cry, palate and tongue movement, and shoulder shrug 1
• Look for tongue fasciculations in suspected lower motor neuron disorders 1

3. Motor Function Assessment

• Upper extremity motor testing: Test each arm separately for drift, documenting no drift (0), drift before 5 seconds (1), falls before 10 seconds (2), no effort against gravity (3), or no movement (4) 1
• Lower extremity motor testing: Use identical scoring system for each leg 1
• Functional observation in children: Document antigravity movement, quality of posture, sequential transitions from sitting to walking, running, climbing, hopping, and skipping 1
• Gower maneuver: Note if patient requires pushing up with arms to rise from floor, suggesting proximal muscle weakness 1
• Document muscle bulk, texture, joint flexibility, and presence/absence of atrophy 1

4. Coordination and Cerebellar Function

• Limb ataxia: Test finger-to-nose and heel-to-shin, documenting no ataxia (0), ataxia in one limb (1), or ataxia in two limbs (2) 1
• Gait assessment: Perform timed gait testing when feasible 1
• Observe for unsteady gait or tremor as signs of muscle weakness or cerebellar dysfunction 1

5. Sensory Examination

• Document sensory loss: Score as no sensory loss (0), mild sensory loss (1), or severe sensory loss (2) 1
• Test touch and pain sensation, particularly when neuromotor dysfunction is present 1
• Extinction or inattention: Document absent (0), mild with loss in one sensory modality (1), or severe with loss in two modalities (2) 1

6. Reflex Testing

• Deep tendon reflexes: Document presence, absence, or asymmetry 1
• Diminished or absent reflexes suggest lower motor neuron disorders 1
• Increased reflexes indicate upper motor neuron dysfunction 1
• Babinski sign: Test and document plantar reflex response 1
• An abnormal (upgoing) plantar reflex indicates upper motor neuron pathology 1

7. Language and Speech Function

• Language assessment: Score as normal (0), mild aphasia (1), severe aphasia (2), or mute/global aphasia (3) 1
• Articulation: Document normal (0), mild dysarthria (1), or severe dysarthria (2) 1
• Observe oromotor movement, drinking through a straw, or blowing kisses in children 1

Additional Critical Documentation Elements

Vital Signs and General Examination

• Record blood pressure (including orthostatic measurements), heart rate, oxygen saturation, temperature, height, weight, and waist circumference 1
• Document head circumference in children, interpreting percentiles according to CDC or WHO growth curves 1
• Examine head and face for signs of trauma or seizure activity (contusions, tongue lacerations) 1
• Auscultate neck for carotid bruits 1
• Perform cardiac examination for arrhythmias, murmurs, and signs of congestive heart failure 1
• Examine skin for stigmata of coagulopathies, platelet disorders, trauma, or embolic lesions 1

Pediatric-Specific Considerations

• Postural tone in infants: Assess by ventral suspension in younger infants and truncal positioning when sitting/standing in older infants 1
• Extremity tone: Document scarf sign in infants and popliteal angles after the first year 1
• Primitive reflexes: Note persistence of primitive reflexes and asymmetry or absence of protective reflexes 1
• Observe for drooling or poor weight gain suggesting facial and oral motor weakness 1

Common Pitfalls to Avoid

Research demonstrates significant variation in neurological examination documentation across different ICU settings and providers 2. To avoid incomplete assessments:

• Don't omit speech/language assessment—studies show this domain is documented less than 5% of the time in non-neuroscience ICUs, yet it's critical for detecting neurological dysfunction 2
• Avoid documenting only consciousness and cranial nerves while neglecting motor, sensory, and speech domains 2
• Use standardized scales (NIHSS) to ensure uniform documentation and facilitate communication between providers 1, 3
• Perform serial examinations to detect changes over time, not just a single baseline assessment 3
• In sedated patients, manage sedation to maximize clinical detection of neurological dysfunction, except when reduced intracranial compliance makes sedation withdrawal dangerous 3

Clinical Context Considerations

The depth and focus of neurological examination should be guided by clinical presentation:

• Acute stroke evaluation: Prioritize NIHSS components to quantify deficits, identify vessel occlusion location, provide prognosis, and determine intervention eligibility 1
• Cognitive impairment assessment: Include mental status examination, behavioral assessment (Neuropsychiatric Inventory-Q), depression screening (CES-D or Geriatric Depression Scale), and functional scales (Pfeffer Functional Assessment or Barthel Index) 1
• Pediatric motor delays: Focus on functional observation, quality of movement, developmental milestones, and differentiate between upper and lower motor neuron signs 1
• Critical care patients: Perform neurological examination on all ICU admissions, assessing consciousness, brainstem function, and motor function at minimum 3