How can I systematically assess a neurological examination?

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Last updated: February 8, 2026 • View editorial policy

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Systematic Neurological Examination

Core Framework

A systematic neurological examination should include six essential domains assessed in sequence: mental status, cranial nerves, motor function, sensory function, cerebellar function, and reflexes, with documentation using standardized scoring systems when applicable. 1, 2

Mental Status Examination

Level of Consciousness

  • Assess alertness using the Glasgow Coma Scale with three components: eye opening, verbal response, and motor response 2
  • Document orientation to person, place, and time by asking two specific orientation questions 1
  • Test command following with two simple commands (e.g., "open/close eyes" and "grip/release hand") 1, 2

Cognitive Screening

  • Use validated brief cognitive assessment instruments rather than informal testing 3
  • The Montreal Cognitive Assessment (MoCA) is preferred for detecting mild cognitive impairment, taking 10-15 minutes, with scores ranging 0-30 and domain-specific index scores for memory, attention, executive function, language, and visuospatial cognition 3
  • The Mini-Mental State Examination (MMSE) takes 7-10 minutes but has lower sensitivity for mild cognitive impairment 3
  • Assess attention, executive function (problem-solving, decision-making speed, judgment), memory, and language 1

Behavioral Assessment

  • Screen for depression using validated scales (Center for Epidemiological Studies-Depression or Geriatric Depression Scale) 1
  • Assess sleep disturbances using the Mayo Sleep Questionnaire or SCOPA, particularly for REM sleep behavior disorder symptoms 3

Cranial Nerve Examination

Test all 12 cranial nerves systematically: 2

  • CN I: Assess smell (optional in routine examination) 2
  • CN II-III: Check visual acuity, visual fields by confrontation testing, pupillary size and reactivity, and red reflexes (should be detectable and symmetric) 1, 2
  • CN III, IV, VI: Evaluate eye movements in all directions, documenting normal horizontal movements versus partial or complete gaze palsy 1, 2
  • CN V: Test facial sensation in all three divisions (ophthalmic, maxillary, mandibular) and jaw strength 2
  • CN VII: Assess facial movement including smile, eye closure, and facial expression, grading as normal, minor weakness, partial weakness, or complete unilateral palsy 1, 2
  • CN VIII: Evaluate hearing 2
  • CN IX, X: Assess oromotor movement, palate and tongue movement, and swallowing ability 1
  • CN XI: Test shoulder shrug quality 1
  • CN XII: Observe tongue movement and check for fasciculations 1

Motor System Evaluation

Strength Assessment

  • Have patients extend arms at 90° (seated) or 45° (supine) for 10 seconds to detect drift, documenting as no drift, drift before 5 seconds, falls before 10 seconds, no effort against gravity, or no movement for each side 1, 2
  • Test leg drift by having patients raise legs 30° and hold for 5 seconds 2
  • Assess strength in major muscle groups using the 0-5 Medical Research Council scale 2
  • Observe functional antigravity movement, posture, and quality of movement 1
  • In children or patients with suspected proximal weakness, observe the Gower maneuver (inability to rise from floor without pushing up with arms) 1

Tone and Movement

  • Evaluate muscle tone through passive range of motion 2
  • Assess muscle bulk and texture 1
  • Check for abnormal movements including tremor, myoclonus, asterixis, rigidity, and bradykinesia 1, 2

Sensory System Assessment

  • Test light touch, pain/temperature sensation using pinprick, vibration using a tuning fork, and proprioception (joint position sense) 2
  • Compare symmetry between sides 2
  • Grade sensory deficits as no sensory loss, mild sensory loss, or severe sensory loss 1
  • Assess visual attention and visual field testing 1
  • Test for extinction or inattention, grading as absent, mild loss in one sensory modality, or severe loss in two modalities 1
  • Note that polysensory neuropathy, particularly in feet/legs, is common in older individuals and represents a fall risk 3

Coordination and Cerebellar Function

  • Test finger-to-nose and heel-to-shin movements to detect ataxia 2
  • Assess rapid alternating movements 2
  • Document limb ataxia as no ataxia, ataxia in one limb, or ataxia in two limbs 1
  • Evaluate gait and balance if patient can stand and walk, assessing for postural/gait abnormalities 3, 2

Reflex Testing

  • Check deep tendon reflexes (biceps, triceps, brachioradialis, patellar, Achilles) 2
  • Test for pathological reflexes including Babinski sign 2

Language and Speech Assessment

  • Document language function as normal, mild aphasia, severe aphasia, or mute/global aphasia 1
  • Assess articulation, documenting as normal, mild dysarthria, or severe dysarthria 1
  • Evaluate reading comprehension 1

Additional Physical Findings

  • Record vital signs: blood pressure, heart rate, oxygen saturation, temperature 1
  • In children, measure growth parameters (head circumference, weight, length/height) with percentile interpretation 1
  • Assess parkinsonian signs when relevant: bradykinesia, rigidity, gait abnormalities, tremor 1
  • Perform vision and hearing screening 1

Standardized Documentation Systems

NIH Stroke Scale (NIHSS)

  • Use the NIHSS as the gold standard for quantifying neurological deficits in acute stroke settings, with scores ranging 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 1
  • Obtain additional NIHSS when neurological deterioration occurs (defined as 4-point increase) 1
  • Ensure proper certification and training to reduce interobserver variability 1, 2
  • Note that NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 1

Other Functional Measures

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

Clinical Context Documentation

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

Special Populations and Settings

Pediatric Considerations

  • Ask "Is there anything your child is not doing that you think he or she should be able to do?" to assess motor milestones 1
  • Ask "Is there anything your child used to be able to do that he or she can no longer do?" to assess regression 1
  • Assess for aberrant milestones (e.g., rolling supine to prone before prone to supine, asymmetric propping) 1

Critical Care Settings

  • Perform more frequent assessments (every 1-4 hours) in critically ill patients 2
  • Manage sedation to maximize clinical detection of neurological dysfunction except in patients with reduced intracranial compliance 1

Common Pitfalls to Avoid

  • Always assess both sides for comparison during motor testing 2
  • Account for systemic factors affecting neurological status (hypotension, hypoxemia) 2
  • Note medications that may affect the examination, particularly sedatives 2
  • Repeat examinations to detect neurological deterioration rather than relying on a single assessment 2
  • Consider timing of examination, as early assessments after injury may be less reliable 2
  • Recognize that patient factors (uncooperativeness, intoxication, cognitive impairment) may affect initial examination accuracy 2

When to Refer or Obtain Additional Testing

  • Refer to a specialist if unsure about interpretation or implication of abnormalities on the neurologic exam 3
  • Obtain neuropsychological evaluation when office-based cognitive assessment is insufficient, particularly when patients or caregivers report concerning symptoms but the patient performs within normal limits on cognitive examination 1
  • Comprehensive neuropsychological testing should minimally include normed testing of learning and memory, attention, executive function, visuospatial function, and language 1

References

1
Guideline

Neurological Examination in Clinical Practice

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Neurological Examination Protocol

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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