What is a concise step‑by‑step bedside neurological exam for an inpatient, covering mental status, cranial nerves, motor strength, tone, sensation, reflexes, coordination, and gait?

Bedside Neurological Examination for Inpatient

For an inpatient neurological examination, perform a focused assessment covering mental status, cranial nerves, motor function, sensation, reflexes, coordination, and gait using standardized approaches that can be completed efficiently at the bedside. 1

Mental Status Assessment

Start with a brief validated cognitive screening tool rather than relying solely on general observation 1:

• Use MoCA, ACE-III, or DCQ as your primary screening instrument 1
• Add executive function testing (Luria motor sequences, Go/No-Go tasks) if initial screening is normal but clinical suspicion remains 1
• Assess orientation, attention, memory, language, and executive function systematically 1
• Observe mood, behavior, and appropriateness throughout the encounter 2, 3

Common pitfall: Do not rely on global cognitive scores alone—executive dysfunction may be present despite normal screening scores 1

Cranial Nerve Examination

Test systematically from CN I through XII 1:

• CN II (Visual fields): Use confrontation testing, examining each eye separately and together; score 0 (no loss) to 3 (bilateral hemianopia) 4
• CN III, IV, VI (Eye movements): Assess gaze in all directions, looking for conjugate movement and nystagmus 1
• CN VII (Facial strength): Test symmetry of facial movements, particularly smile and eye closure 5
• CN IX, X (Tongue, palate): Observe tongue protrusion for deviation 1
• CN XI, XII: Assess shoulder shrug and tongue movements 1

Common pitfall: Eye movement assessment has the poorest interrater reliability on telemedicine and bedside exams—repeat if findings are unclear 1

Motor Examination

Assess strength systematically in all major muscle groups 1, 6:

• Upper extremity: Test shoulder abduction, elbow flexion/extension, wrist extension, finger grip 1
• Lower extremity: Test hip flexion, knee flexion/extension, ankle dorsiflexion/plantarflexion 1
• Use standardized grading: Grade 0 = no movement, Grade 1 = flicker only, Grade 2 = movement without gravity, Grade 3 = movement against gravity, Grade 4 = movement against some resistance, Grade 5 = normal strength 6
• Observe for arm drift with eyes closed, arms extended 5

Common pitfall: Ensure the patient understands commands and is attempting movement—distinguish true weakness from sensory deficits or comprehension issues 6

Tone Assessment

Assess muscle tone passively 1:

• Test at major joints (elbow, wrist, knee, ankle) by moving limbs through range of motion
• Note rigidity, spasticity, or flaccidity 1
• Do not confuse absence of movement with flaccidity—grade 0 motor strength can occur with any tone 6

Sensory Examination

Screen tactile, pain, proprioception, and vibration sense 1:

• Test light touch and pinprick in all extremities, comparing side-to-side 1
• Assess proprioception at distal joints (fingers, toes) 1
• Note any sensory level or dermatomal pattern 1

Clinical note: Distal polysensory neuropathy is common in older patients and represents a fall risk requiring intervention 1

Deep Tendon Reflexes

Test major reflexes bilaterally 1:

• Biceps, triceps, brachioradialis (upper extremity)
• Patellar, Achilles (lower extremity)
• Plantar response (Babinski) 1
• Grade 0 (absent) to 4+ (hyperactive with clonus) 1

Coordination Testing

Assess cerebellar function 1:

• Finger-to-nose testing (upper extremity dysmetria) 1
• Heel-to-shin testing (lower extremity coordination) 1
• Rapid alternating movements (dysdiadochokinesia) 1

Gait and Balance

Observe ambulation and postural stability 1:

• Watch patient walk normally, then on heels and toes 1
• Assess sitting balance if unable to stand 1
• Note any asymmetry, ataxia, or instability 1

Critical consideration: Gait and balance disorders predict future dementia risk and represent immediate fall hazards requiring intervention 1

Documentation Approach

Use standardized scales when applicable 7:

• NIH Stroke Scale for stroke patients (13-item graded examination covering consciousness, visual fields, gaze, motor, sensory, speech, language, inattention) 1
• Glasgow Coma Scale for altered mental status 7
• Document specific findings rather than general impressions 7

Key principle: Periodic reassessment with the same standardized tools documents progress and detects deterioration 1