What components should be included in a comprehensive neurological examination and how should the assessment be documented?

Neurological Examination in Clinical Practice

Documentation Framework

Document the neurological examination using a standardized approach that includes six core domains: mental status, cranial nerves, motor function, sensory function, cerebellar function, and reflexes, with specific attention to using validated scoring systems like the NIH Stroke Scale when applicable. 1, 2, 3

Essential Components to Examine and Document

Mental Status Assessment

• Level of consciousness using the Glasgow Coma Scale (alert, drowsy, obtunded, coma/unresponsive) 1, 2
• Orientation to person, place, and time (ask two orientation questions and document correct responses) 1
• Command following (test with two simple commands) 1
• Cognitive screening focusing on memory, attention, executive function, and language 2
• Behavioral assessment using standardized instruments when indicated 2
• Depression screening with validated scales (Center for Epidemiological Studies-Depression or Geriatric Depression Scale) 2

Cranial Nerve Examination

• CN II-III: Visual fields, pupillary reactivity, red reflexes (should be detectable and symmetric) 1
• CN III, IV, VI: Gaze (document normal horizontal movements, partial or complete gaze palsy) 1
• CN V, VII: Facial movement and expression including smile, cry, eye opening/closure (grade as normal, minor weakness, partial weakness, or complete unilateral palsy) 1
• CN IX, X: Oromotor movement, palate and tongue movement, swallowing ability 1
• CN XI: Shoulder shrug quality 1
• CN XII: Tongue movement, observe for fasciculations 1

Motor System Evaluation

• Strength assessment through functional observation of antigravity movement, posture, and quality of movement 1, 2
• Arm drift testing (document as no drift, drift before 5 seconds, falls before 10 seconds, no effort against gravity, or no movement for each side) 1
• Leg drift testing using the same grading scale 1
• Gower maneuver observation (inability to rise from floor without pushing up with arms suggests proximal weakness) 1
• Muscle bulk and texture assessment 1
• Coordination testing including limb ataxia (document as no ataxia, ataxia in 1 limb, or ataxia in 2 limbs) 1, 2
• Abnormal movements including involuntary movements, tremor, rigidity, bradykinesia 1, 2

Sensory System Assessment

• Sensory testing for any deficits (grade as no sensory loss, mild sensory loss, or severe sensory loss) 1
• Visual attention and visual field testing 1
• Extinction or inattention testing (grade as absent, mild loss in 1 sensory modality, or severe loss in 2 modalities) 1

Language and Speech

• Language function (document as normal, mild aphasia, severe aphasia, or mute/global aphasia) 1
• Articulation (document as normal, mild dysarthria, or severe dysarthria) 1

Additional Physical Findings

• Vital signs: Blood pressure, heart rate, oxygen saturation, temperature 1, 2
• Growth parameters in children: Head circumference, weight, length/height with percentile interpretation 1
• Parkinsonian signs when relevant: Bradykinesia, rigidity, gait abnormalities, tremor 1
• Vision and hearing screening 1, 2

Standardized Scoring Systems for Documentation

NIH Stroke Scale (NIHSS)

Use the NIH Stroke Scale as the gold standard for quantifying neurological deficits in acute stroke settings, with scores ranging from 0-42 points across 11 domains. 1, 2

• Perform 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
• Ensure proper certification and training to reduce interobserver variability 2
• Note that NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 2

Functional Outcome Measures

• Modified Rankin Scale for disability outcomes 2
• Barthel Index or Pfeffer Functional Assessment Questionnaire for activities of daily living 2

Documentation Structure for Assessment

History Documentation

• Symptom onset and progression: Document timing, quality, and evolution of neurological symptoms 1, 2
• Risk factors: Hypertension, hyperlipidemia, diabetes, smoking, alcohol use 2
• Past medical history: Prior stroke, TIA, myocardial infarction, atrial fibrillation, peripheral artery disease 2
• Medications: All medications including over-the-counter preparations within 48 hours 2
• Family history: Stroke, vascular disease, or dementia in first-degree relatives 2

Pediatric-Specific Considerations

• Motor milestone history: Ask "Is there anything your child is not doing that you think he or she should be able to do?" 1
• Regression: "Is there anything your child used to be able to do that he or she can no longer do?" 1
• Aberrant milestones: Rolling supine to prone before prone to supine, asymmetric propping, development of handedness before 18 months, standing before sitting 1
• Observation during play: Watch posture, play, and spontaneous motor function without stressful demands of formal testing 1

Common Pitfalls to Avoid

• Incomplete cranial nerve examination: Ensure all 12 cranial nerves are systematically evaluated, not just a subset 1, 4
• Relying solely on patient cooperation: When toddlers or uncooperative patients cannot perform formal testing, gain diagnostic information through observation of quality and quantity of spontaneous movement 1
• Missing subtle motor signs: Document drooling (suggests facial/oral motor weakness), ptosis, asymmetric movements, and use of compensatory strategies 1
• Inadequate serial examinations: In acute settings, perform serial examinations at 6,24, and 72 hours after admission 2
• Inconsistent documentation: Use standardized forms and scoring systems to ensure uniform assessment across time and providers 2, 5

Writing the Assessment

Structure your documentation to include:

1. Presenting complaint with onset time and witness information 1
2. Quantified deficits using standardized scales (NIHSS score with breakdown by domain) 1, 2
3. Specific examination findings organized by neurological domain 3
4. Functional implications of deficits identified 1, 2
5. Comparison to prior examinations when available, noting any deterioration or improvement 2, 5
6. Clinical impression with localization of lesion when applicable 1