What findings should be included in the neurological portion of a review of systems?

Neurological Review of Systems: Essential Components

The neurological review of systems should systematically assess six core domains: mental status/cognition, cranial nerve symptoms, motor function, sensory symptoms, coordination/gait, and autonomic function. 1

Mental Status and Cognitive Symptoms

• Level of consciousness changes: Ask about alertness, drowsiness, confusion, or episodes of unresponsiveness 1
• Orientation difficulties: Inquire about confusion regarding person, place, or time 1
• Memory problems: Screen for short-term memory loss, difficulty learning new information, or forgetting recent events 2, 1
• Attention and concentration: Ask about difficulty focusing, completing tasks, or following conversations 1
• Executive function: Inquire about problems with decision-making, judgment, problem-solving, or planning 1
• Language difficulties: Ask about word-finding problems, comprehension issues, or difficulty expressing thoughts 1
• Behavioral changes: Screen for personality changes, mood alterations, depression, anxiety, or anger 2, 1

Cranial Nerve Symptoms

• Vision changes (CN II): Ask about visual loss, blurred vision, double vision, visual field defects, or eye pain 2, 1
• Pupillary abnormalities (CN III): Inquire about unequal pupils or light sensitivity 1
• Eye movement problems (CN III, IV, VI): Ask about double vision, difficulty moving eyes in specific directions, or gaze abnormalities 2, 1
• Facial sensation changes (CN V): Inquire about facial numbness, tingling, or pain 1
• Facial weakness (CN VII): Ask about asymmetric smile, difficulty closing eyes, or drooping face 2, 1
• Hearing loss or tinnitus (CN VIII): Screen for sudden or progressive hearing loss, ringing in ears, or vertigo 2, 1
• Swallowing difficulties (CN IX, X): Ask about choking, coughing with eating/drinking, or aspiration 1
• Shoulder weakness (CN XI): Inquire about difficulty shrugging shoulders 1
• Tongue movement problems (CN XII): Ask about tongue deviation, difficulty moving tongue, or fasciculations 1

Motor Symptoms

• Weakness: Ask about difficulty lifting arms or legs, holding objects, rising from chairs, or climbing stairs 2, 1
• Muscle atrophy: Inquire about visible muscle wasting or loss of bulk 2
• Abnormal movements: Screen for tremor, involuntary jerking, rigidity, or slowness of movement 1
• Gait disturbances: Ask about difficulty walking, instability, shuffling, or frequent falls 2, 1
• Coordination problems: Inquire about clumsiness, difficulty with fine motor tasks, or limb incoordination 1

Sensory Symptoms

• Numbness or tingling: Ask about location, distribution (glove-and-stocking pattern suggests polyneuropathy), and progression 2, 3
• Pain: Inquire about burning, shooting, or stabbing sensations, particularly in extremities 2, 3
• Temperature sensation changes: Ask about inability to detect hot or cold 3
• Proprioception loss: Screen for difficulty knowing limb position or sensory ataxia 2
• Visual field defects: Inquire about missing areas of vision or visual inattention 1

Coordination and Balance

• Ataxia: Ask about unsteady movements, difficulty with precise tasks, or intention tremor 1
• Balance problems: Inquire about dizziness, unsteadiness, or need for assistive devices 4
• Vertigo: Screen for spinning sensation, nausea with head movement, or room-spinning episodes 2, 4

Autonomic Symptoms

• Orthostatic symptoms: Ask about lightheadedness or dizziness upon standing 2
• Sweating abnormalities: Inquire about decreased or absent sweating (anhidrosis or hypohidrosis) 2
• Bowel/bladder dysfunction: Screen for urinary retention, incontinence, or constipation 2
• Sexual dysfunction: Ask about erectile dysfunction or other sexual problems 2
• Temperature regulation: Inquire about heat or cold intolerance 2

Additional Critical Symptoms

• Headache: Ask about new-onset, severe, or progressive headaches, particularly with fever, confusion, or focal deficits 2
• Seizures: Screen for convulsions, staring spells, loss of awareness, or seizure-like activity 2
• Speech problems: Inquire about slurred speech (dysarthria) or difficulty articulating words 2, 1
• Regression: Specifically in children, ask if previously acquired skills have been lost 5

Important Clinical Context

When documenting positive findings, always note:

• Onset and progression: Acute (hours to days), subacute (days to weeks), or chronic (months to years) 2, 3
• Pattern: Symmetric versus asymmetric, proximal versus distal, ascending versus descending 6, 3
• Triggers or relieving factors: Relationship to activity, temperature, stress, or infection 2
• Associated systemic symptoms: Fever, weight loss, rash, joint pain, or other organ involvement 2

Common pitfalls to avoid:

• Don't overlook subtle cognitive changes that patients may not spontaneously report—ask specific questions about memory, attention, and executive function 1
• Don't dismiss vague complaints like "dizziness" without clarifying whether the patient means vertigo, lightheadedness, imbalance, or presyncope 4
• Don't forget to ask about autonomic symptoms, as they're often underreported but clinically significant 2
• Don't neglect to inquire about progression or regression of symptoms, as this critically informs differential diagnosis 2, 5, 3