What components should be included in a comprehensive neuro exam?

Components of a Comprehensive Neurological Examination

A comprehensive neurological examination should systematically assess six core domains: mental status/consciousness, cranial nerves, motor function, sensory function, coordination/cerebellar function, and reflexes, with documentation of vital signs and standardized scoring when appropriate. 1, 2, 3

Essential Vital Signs and Physical Measurements

Before beginning the neurological examination proper, document baseline measurements 1:

• Height, weight, blood pressure, heart rate, waist circumference, and temperature 1
• Head circumference in pediatric patients, comparing to growth curves to identify microcephaly or macrocephaly 4
• Vision and hearing assessment 1
• Ankle-brachial index when peripheral vascular disease is suspected 4, 1

1. Mental Status and Level of Consciousness

Begin with systematic assessment of cognitive and behavioral function 1, 2:

• Level of consciousness using the Glasgow Coma Scale (eye opening, verbal response, motor response) or FOUR score for more detailed brainstem assessment in unresponsive patients 1, 2
• Cognitive screening focusing on memory, attention, executive function, and language using validated tools like the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination (MMSE) 4, 1, 2
• Behavioral assessment using standardized instruments such as the Neuropsychiatric Inventory-Q 1
• Depression screening with validated scales like the Center for Epidemiological Studies-Depression or Geriatric Depression Scale 1
• Observation of the patient's appearance, social behavior, emotional state, and mood 5

Important caveat: The MMSE often shows normal-range scores in early frontotemporal dementia and is unsuccessful in discriminating between behavioral variant frontotemporal dementia and psychiatric disorders, making the MoCA superior with 88% classification accuracy 4.

2. Cranial Nerve Examination (All 12 Nerves Systematically)

Perform a complete cranial nerve assessment 4, 1, 6:

• CN I (Olfactory): Test smell if indicated by history
• CN II (Optic): Visual acuity, visual fields by confrontation, pupillary size and symmetry, red reflex (should be detectable and symmetric), fundoscopic examination when possible 4, 2
• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements, response to visual confrontation, pupillary reactivity to light, assess for vertical gaze palsy (downward more than upward), smooth pursuit, saccadic eye movements, and optokinetic nystagmus 4, 2
• CN V (Trigeminal): Facial sensation, corneal reflex by gently touching cornea with cotton swab and observing blink response 4, 2
• CN VII (Facial): Quality of eye opening and closure, facial expression including smile and cry, facial symmetry and strength 4
• CN VIII (Vestibulocochlear): Hearing assessment 1
• CN IX, X (Glossopharyngeal, Vagus): Oromotor movement, palate and tongue movement, swallowing ability, drinking through a straw or blowing kisses in older children 4
• CN XI (Accessory): Quality of shoulder shrug 4
• CN XII (Hypoglossal): Tongue movement, observe for fasciculations 4

Critical pitfall: Eye movement abnormalities had the poorest interobserver agreement in telemedicine examinations, so particular attention and potentially repeat testing is warranted 4.

3. Motor System Examination

Assess motor function through both observation and formal testing 4, 1:

• Observation of spontaneous motor function: Watch posture, play, and movement without stressful demands of deliberate performance 4
• Antigravity movement in infants; sequential transitions from tripod sitting to walking, running, climbing, hopping, and skipping in older children 4
• Document motor movements and any abnormal movements including involuntary movements or coordination impairments 4, 1
• Test for pronator drift 1
• Muscle bulk and texture assessment 4
• Muscle tone, strength in all extremities using functional observation when possible 4, 1
• Gower maneuver: Note if the patient cannot rise from the floor without pulling or pushing up with arms, suggesting proximal muscle weakness 4
• Assessment for parkinsonism: bradykinesia/akinesia, parkinsonian gait/posture, rigidity (tremor less common in frontotemporal dementia) 4
• Test for asymmetric rigidity, alien hand, apraxia (suggests corticobasal syndrome) 4
• Postural instability (suggests progressive supranuclear palsy) 4
• Motor neuron signs and primitive reflexes such as grasp reflex 4

In trauma patients: Perform forced duction and forced generation testing to distinguish restriction from paresis of extraocular muscles 4.

4. Sensory System Examination

Test multiple sensory modalities systematically 4, 1, 2:

• 10-g monofilament testing (most useful for loss of protective sensation) with at least one other assessment 4
• Pinprick sensation 4, 1, 2
• Temperature sensation 4, 1, 2
• Vibration perception using 128-Hz tuning fork 4, 1, 2
• Pressure sensation 1, 2
• Ankle reflexes 4

Interpretation for diabetic neuropathy: Absent monofilament sensation suggests loss of protective sensation, while at least two normal tests (and no abnormal test) rules it out 4.

5. Coordination and Cerebellar Function

Evaluate coordination through functional tasks 1, 3:

• Coordination testing (finger-to-nose, heel-to-shin, rapid alternating movements) 1
• Sitting balance 4
• Gait assessment including walking, tandem gait when appropriate 4
• Observation for ataxia 4

6. Reflexes

Document deep tendon reflexes systematically 4, 3:

• Deep tendon reflexes in all extremities 4
• Plantar responses (Babinski) 4
• Primitive reflexes when indicated 4

Standardized Scoring Systems (When Applicable)

Use validated scales for specific clinical contexts 1:

• NIH Stroke Scale (NIHSS) as the gold standard for quantifying neurological deficits in acute stroke, performed by certified examiners at defined intervals (immediately post-intervention, 24 hours, 72 hours, 7-10 days, 30 days, 90 days, and with any 4-point deterioration) 4, 1
• Modified Rankin Scale Score for disability outcomes 1
• Barthel Index or Pfeffer Functional Assessment Questionnaire for activities of daily living 1

Important limitation: The NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 1.

Documentation Requirements

Record comprehensive historical and examination findings 4, 1:

• Detailed cerebrovascular and cardiovascular history including prior stroke, TIA, myocardial infarction, atrial fibrillation, peripheral artery disease 1
• All medications including over-the-counter preparations within 48 hours 1
• Vascular risk factors: hypertension, hyperlipidemia, diabetes, smoking, alcohol use 1
• Family history of stroke, vascular disease, or dementia in first-degree relatives 1
• Symptom onset and progression including cognitive changes, behavioral changes, gait problems, tremor, balance difficulties, swallowing problems, incontinence, pseudobulbar affect 1
• Motor history: delayed skill acquisition, regression of skills, strength/coordination/endurance issues 4

Special Considerations by Clinical Context

Pediatric patients: Carefully watch posture, play, and spontaneous motor function during history-taking, as direct observation may not be possible when children are tired or stressed 4. Note aberrant milestone patterns such as rolling supine-to-prone before prone-to-supine, asymmetric propping, asymmetric grasp, or handedness before 18 months 4.

Acute stroke/critical care: Perform serial examinations at 6,24, and 72 hours after admission 1. Hourly neurological assessments or more frequently based on condition 2. Daily assessment by neurologist/neurointensivist for hospitalized patients with neurological concerns 1, 2.

Post-cardiac arrest: Assess pupillary light reflex, corneal reflex, and motor response at 72 hours; combined absence has very low false positive rate for predicting poor outcomes 2. Note that myoclonus within 72 hours has been associated with poor outcomes, though some patients with early-onset myoclonus have had good recovery 2.

Diabetic neuropathy: Annual comprehensive foot examination after initial diagnosis, with inspection at every visit for patients with sensory loss or prior ulceration 4.

Trauma patients: Check for oculocardiac reflex (bradycardia, heart block, dizziness, nausea, vomiting, loss of consciousness) which can be life-threatening and requires urgent intervention 4.