What is the recommended approach for reporting a complete neurophysical exam?

How to Report a Complete Neurophysical Exam

A complete neurophysiological examination report should document six core domains using standardized scoring systems: mental status (including level of consciousness via Glasgow Coma Scale), cranial nerves (all 12 systematically), motor function (strength, tone, coordination), sensory function (multiple modalities), cerebellar function, and reflexes, with specific attention to validated instruments like the NIH Stroke Scale when applicable. 1, 2

Essential Documentation Structure

Mental Status Assessment

• Document level of consciousness using the Glasgow Coma Scale with specific descriptors: alert, drowsy, obtunded, or coma/unresponsive 1, 2
• Record orientation to person, place, and time by asking two orientation questions and documenting correct responses 2
• Assess command following by testing with two simple commands 2
• Screen cognitive domains including memory, attention, executive function, and language using validated instruments 1, 2
• Document behavioral findings using standardized instruments when indicated 1, 2
• Screen for depression with validated scales such as the Center for Epidemiological Studies-Depression or Geriatric Depression Scale 1, 2

Cranial Nerve Examination

• CN II-III: Document visual fields, pupillary reactivity, and red reflexes (should be detectable and symmetric) 2
• CN III, IV, VI: Record gaze function as normal horizontal movements, partial gaze palsy, or complete gaze palsy 2
• CN V, VII: Grade facial movement and expression including smile, cry, and eye opening/closure as normal, minor weakness, partial weakness, or complete unilateral palsy 2
• CN IX, X: Document oromotor movement, palate and tongue movement, and swallowing ability 2
• CN XI: Record shoulder shrug quality 2
• CN XII: Document tongue movement and observe for fasciculations 2

Motor System Evaluation

• Assess strength through functional observation of antigravity movement, posture, and quality of movement 2
• Perform arm drift testing and document as: no drift, drift before 5 seconds, falls before 10 seconds, no effort against gravity, or no movement for each side 2
• Perform leg drift testing using the same grading scale 2
• Observe Gower maneuver (inability to rise from floor without pushing up with arms suggests proximal weakness) 2
• Document muscle bulk and texture 2
• Test coordination including limb ataxia, documented as no ataxia, ataxia in 1 limb, or ataxia in 2 limbs 2
• Record abnormal movements including involuntary movements, tremor, rigidity, and bradykinesia 1, 2

Sensory System Assessment

• Grade sensory testing as no sensory loss, mild sensory loss, or severe sensory loss 2
• Document visual attention and visual field testing results 2
• Test extinction or inattention and grade as absent, mild loss in 1 sensory modality, or severe loss in 2 modalities 2

Language and Speech

• Document language function as normal, mild aphasia, severe aphasia, or mute/global aphasia 2
• Record articulation as normal, mild dysarthria, or severe dysarthria 2

Additional Physical Findings

• Record vital signs: blood pressure, heart rate, oxygen saturation, and temperature 1, 2
• Document growth parameters in children: head circumference, weight, length/height with percentile interpretation 2
• Assess parkinsonian signs when relevant: bradykinesia, rigidity, gait abnormalities, and tremor 2
• Screen vision and hearing 1, 2

Standardized Scoring Systems for Quantification

NIH Stroke Scale (NIHSS)

The NIH Stroke Scale is the gold standard for quantifying neurological deficits in acute stroke settings, with scores ranging from 0-42 points across 11 domains 1, 2. This should be performed by certified examiners trained via standardized methods 1.

• Perform NIHSS at defined intervals: immediately post-intervention, 24 hours, 72 hours, 7-10 days, 30 days, and 90 days 1, 2
• Obtain additional NIHSS when neurological deterioration occurs, defined as a 4-point increase 1, 2
• Note the limitation: NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 1, 2

Functional Outcome Measures

• Use the Modified Rankin Scale for disability outcomes 1, 2
• Use the Barthel Index or Pfeffer Functional Assessment Questionnaire for activities of daily living 1, 2

Clinical Context Documentation

History Elements

• Document symptom onset and progression: timing, quality, and evolution of neurological symptoms 2
• Record risk factors: hypertension, hyperlipidemia, diabetes, smoking, and alcohol use 1, 2
• Document past medical history: prior stroke, TIA, myocardial infarction, atrial fibrillation, and peripheral artery disease 1, 2
• List all medications including over-the-counter preparations within 48 hours 1, 2
• Record family history: stroke, vascular disease, or dementia in first-degree relatives 1, 2

Special Considerations for Specific Populations

Acute Care Settings

• Perform serial examinations at 6,24, and 72 hours after admission 1
• Ensure proper certification and training for administering standardized scales to reduce interobserver variability 1, 2

Pediatric Patients

• Assess motor milestone history: ask "Is there anything your child is not doing that you think he or she should be able to do?" 2
• Assess regression: "Is there anything your child used to be able to do that he or she can no longer do?" 2

Patients with Atypical Presentations

When office-based cognitive assessment is not sufficiently informative, neuropsychological evaluation is recommended, particularly when patients or caregivers report concerning symptoms but the patient performs within normal limits on cognitive examination 3. The neuropsychological evaluation should minimally include normed testing of learning and memory (delayed free and cued recall/recognition), attention, executive function, visuospatial function, and language 3.

Critically Ill Patients

In ICU settings, the neurological examination should include assessment of consciousness and cognition, brainstem function, and motor function, with sedation managed to maximize clinical detection of neurological dysfunction except in patients with reduced intracranial compliance 4. The need for additional neurophysiological and neuroradiological investigations should be guided by the neurological examination findings 4.

Common Pitfalls to Avoid

• Do not rely solely on global cognitive screening test scores to distinguish between different neurological conditions 3
• Recognize that executive dysfunction may not be present on formal neuropsychological test results in early stages of some conditions, so consider qualitative evidence when examining task performance 3
• Be aware that standardized scales have limitations: ensure proper training and certification to reduce interobserver variability 1, 2
• Document baseline status and any changes over time using standardized evaluation forms 1