1. NEUROLOGICAL
EXAMINATION

2. INTRODUCTION:
A neurological examination is the
assessment of sensory neuron and motor
responses, especially reflexes, to determine
whether the nervous system is impaired. This
typically includes a physical examination and a
review of the patient's medical history but not
deeper investigation such as neuroimaging. It
can be used both as a screening tool and as an
investigative tool.

3. Examples of Definitions
• Alert:
o awake, looks about
o responds in a meaningful manner to verbal instructions or
gestures
• Drowsy:
o oriented when awake but if left alone will sleep
• Confused:
o disoriented to time, place, or person
o memory difficulty is common
o has difficulty with commands
o exhibits alteration in perception of stimuli, may be agitated

4. • Stuporous:
o generally unresponsive except to vigorous stimulation
o may make attempt at verbalization to vigorous/repeated
stimuli
o Opens eyes to deep pain
• Comatose:
o unarousable and unresponsive
o some localization or movement may be acceptable within
the comatose category
depending on the coma definitions e.g. light coma to deep
coma
o Does not open eyes to deep pain

5. The difference between Coma and Sleep:
• sleeping persons respond to unaccustomed stimuli
• sleeping persons are capable of mental activity
(dreams)
• sleeping persons can be roused to normal
consciousness
• cerebral oxygen uptake does not decrease during
sleep as it often does in coma

6. Special States of Altered Levels of Consciousness
• Brain Death:
An irreversible loss of cortical and brain stem activity.
• Persistent Vegetative State:
A condition that follows severe cerebral injury in
which the altered state becomes
chronic or persistent.
• Locked-in Syndrome:
A state of muscle paralysis, involving voluntary
muscles, while there is preservation of full
consciousness and cognition.

7. Indications:
A neurological examination is indicated
whenever a physician suspects that a patient
may have a neurological disorder. Any new
symptom of any neurological order may be
an indication for performing a neurological
examination.

8. Organic Disease ?
 Signs &/or symptoms that cannot be faked must
be examined closely.
 Examples include, asymmetry in pupils, abnormal
retinal exams, nystagmus, muscle atrophy, and
muscle fasciculation.

9. Where are the Connections
 Upper Motor Neurons (UMN) are defined as the
connections of motor nerves before they leave
the spinal cord
 Lower Motor Neurons (LMN) are defined as after
the synapse (connection) into the peripheral
nerve cell bodies.

10. Objectives
 Organize Exam into the 6 Subsets of Function
 Concept of Screening Examination
 Understand Afferent and Efferent Pathways for
Brainstem Reflexes
 Differentiate Between Upper and Lower
Motor Neuron Findings

11. Six Subsets of the Neuro Exam
 Here’s what you need to examine.
 Mental Status
 Cranial Nerves
 Motor
 Sensory
 Coordination
 Reflexes

12. Concept of a Screening Exam
Screening each of the subsets allows one to check on
the entire neuroaxis (Cortex, Subcortical White Matter,
Basal Ganglia/Thalamus, Brainstem, Cerebellum,
Spinal Cord, Peripheral Nerves, NMJ, and Muscles)
Expand evaluation of a given subset to either
• Answer questions generated from the History
• Confirm or refute expected or unexpected findings on Exam

13. Neurological Examination
Mental Status Exam
 “FOGS”
 Family story of memory loss
 Orientation
 General Information
 Spelling &/or numbers
 Recognition of objects

14. 1. INTERVIEW
The patient/family interview will allow the nurse to:
• ƒgather data: both subjective and objective about the
patient's previous/present health state
• ƒprovide information to patient/family
• ƒclarify information
• ƒmake appropriate referrals
• ƒdevelop a good working relationship with both the patient
and the family
• ƒinitiate the development of a written plan of care which is
patient specific

15. Interview to identify presence of:
• headache
• difficulty with speech
• inability to read or write
• alteration in memory
• altered consciousness
• confusion or change in thinking
• disorientation
• decrease in sensation, tingling or pain
• motor weakness or decreased strength
• decreased sense of smell or taste
• change in vision or diplopia
• difficulty with swallowing
• decreased hearing
• altered gait or balance
• dizziness
• tremors, twitches or increased tone

16. Physical Examination Considerations
• Level of Consciousness
– Most important aspect of neurologic examination
– Level of consciousness first to deteriorate; changes often subtle,
therefore requiring careful monitoring.
• Consciousness:
– Composed of Two Components:
• Arousal (Alertness)
• Awareness (Content)
– Assessment: Orientation vs. Disorientation
» Person, Place & Time
» Varying sequence of questions is important !!

17. Assessing LOC
• Glasgow Coma Scale (GCS)
– Three Categories:
• Eye opening
• Best motor response
• Best verbal response
– Scoring
• Highest or best possible score 15
• A score of < 8 indicates coma
• Lowest or worst possible score 3

18. Glasgow Coma Scale

19. Pupillary Examination
• The pupillary examination can be quickly and easily
performed in the unconscious or minimally responsive
patient when a TBI is suspected, and can provide valuable
information about the degree of initial or progressing brain
injury. Several types of TBI’s may cause pupillary changes,
which indicate the need for rapid interventions to decrease
ICP caused by cerebral bleeding and/or edema. Nurses are
in a key position to detect early changes in a patient's
condition and administer or advocate for immediate
interventions.

20. Check pupil size in lighted room, and
reactivity to light in a darkened room.

21. Unequal
pupil size
can be a sign
of a serious
brain injury.

22. Brain
Injury with
bleeding
or swelling
Rapid interventions
are needed to prevent
death or permanent
brain damage – TBI’s
can progress rapidly!

23. Mental Status
Level of Alertness
• Subjective view of Examiner
• Definition of Consciousness
• Terminology for Depressed Level of Consciousness
• Concept of Coma
• Delerium
Degree of Orientation
• To what?

24. Mental Status
Concentration
• Serial 7’s or 3’s
• “WORLD” backwards
• Months of the Year Backwards
• Try to quantify degree of impairment
* A and O and Concentration need to be intact for other
aspects of the Mental Status Exam to have localizing
value!

25. Mental Status
Memory
Immediate Recall
• A task of concentration
Short-Term Memory
• “3/3 objects after 5 minutes”
Long-Term Memory
• Last thing to go

26. Mental Status
Language
Aphasia vs Dysarthria
Receptive Language
• Command Following
Expressive Language
• Fluency
• Word Finding
Repetition
• Screens for Receptive, Expressive, and Conductive
Aphasias

27. Language

28. Mental Status
Calculations, R-L confusion, finger agnosia,
agraphia
• Gerstmann’s Syndrome (Dominant Parietal Lobe)
Hemineglect
• Non-Dominant Parietal Lobe
Delusional Thinking, Abstract Reasoning, Mood,
Judgement, Fund of Knowledge, etc
• Important for Psychiatry
• Does not localize well to one region of the cortex
• Neurocognitive Testing required to get at more specific deficits

29. Olfactory Nerve - I

30. Olfactory Nerve
 Distinguish Coffee from Cinnamon
 Smelling Salts irritate nasal mucosa and test V2
Trigemminal Sense
 Disorders of Smell result from closed head injuries

31. Optic Nerve
Cranial nerve II

32. Optic Nerve
 Visual Acuity
 Visual Fields
 Afferent input to Pupillary Light
Reflex
• APD
 Look at the Nerve (Fundoscopic
Exam)
“VA equals 20/20 OU at near”
“PERRLA”

33. Trochlear Nerve
c.n. IV
Oculomotor Nerve
Cn III
Abducens Nerve
Cn VI

34. CN III Oculomotor: moves
eyes in all directions except
outward and down & in; opens
eyelid; constricts pupil
CN IV Trochlear:
moves eyes
down and in…..

35. CN VI Abducens: moves eyes outward
EOM’s:
(extraoccular movement)
assessment of eye
movement in all
directions ( III, IV VI)

36. Trigeminal Nerve - V

37. CN V Trigeminal:
3 branches;
sensation to the face,
cornea and scalp;
opens jaw against resistance

38. Facial Nerve-VII

39. CN VII Facial:
moves the face;
taste.
CN VII paralysis

40. Vestibulocochlear Nerve-VIII

41. Vestibulocochlear Nerve
Hearing and Balance
• Patients will complain of tinnitis, hearing loss, and/or vertigo
Weber and Renee Test
• Differentiates Conductive vs Sensorineural hearing loss
Afferent input to the Oculocephalic Reflex
• Doll’s Eye Maneuver
• Cold Calorics
• Not “COWS”
“Hearing grossly intact AU”

42. Glossopharyngeal and Vagus Nerves
c.n.’s IX and X

43. CN IX Glossopharyngeal:
moves the pharynx (swallow,
speech & gag)
CN X Vagus:
voice quality

44. Spinal Accessory Nerve
c.n. XI
Trapezius
strength
Sternocleido-
Mastoid
strength

45. CN XI Spinal Accessory:
turns head and elevates
shoulders
Shoulder
Shrug

46. Hypoglossal Nerve
c.n. XII

47. Hypoglossal Nerve
Protrudes the tongue to the
opposite side
Tongue in cheek (strength)
Hemi-atrophy and fasiculations
(LMN)

48. Strength
Tone
DTR’s
Plantar Responses
Involuntary Movements

49. Strength
Medical Research Council Scale
5/5 = Full Strength
4/5 = Weakness with Resistance
3/5 = Can Overcome Gravity Only
2/5 = Can Move Limb without Gravity
1/5 = Can Activate Muscle without Moving
Limb
0/5 = Cannot Activate Muscle

50. Weakness
Describe the Distribution of Weakness
• Upper Motor Neuron Pattern
• Peripheral neuropathy Pattern
• Myopathic Pattern

52. Tone
 Tone is the resistance appreciated when moving a limb
passively
 “Normal Tone”
 Hypotonia
• “Central Hypotonia”
• “Peripheral Hypotonia”
Increased Tone
• Spasticity (Corticospinal Tract)
• Rigidity (Basal Ganglia, Parkinson’s Disease)
• Dystonia (Basal Ganglia)

53. DTR’s
0/4 = Absent
1-2/4 = Normal Range
3/4 = Pathologically Brisk
4/4 = Clonus

54. Involuntary Movements
Hyperkinetic Movements
• Chorea
• Athetosis
• Tics
• Myoclonus
Bradykinetic Movements
• Parkinsonism (Bradykinesia, Rigidity, Postural Instability,
Resting Tremor)
• Dystonia

55. Drift Assessment
Drift Assessment: test for motor weakness
Arm: hold arms out with palms up; eyes closed
• Pronator drift: hands pronate (roll over);
• Motor drift: arm “drifts” downward
• Cerebellar drift: arm “drifts” back
toward head or out to side
Leg: no need to close eyes
motor: leg “drifts”toward bed

56. Movement Assessment
Movements are purposeful or non-purposeful purposeful: picking at
tubings or bed linens, scratching nose
localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in
the cortex
withdrawal: pulling away from pain; occurs in the hypothalamus
non-purposeful: do not cross the midline
abnormal flexion: (decorticate)
rigidly flexed arms and wrists; fisted
hands; occurs in upper brainstem
abnormal extension: (decerebrate)
rigidly, rotated inward extended arms
with flexed wrists and fisted
hands; occurs in midbrain or pons.
Decorticate
Decerebrate

58. Primary Sensory Modalities
 Light Touch (Multiple Pathways)
 Pain/Temperature Sensation (Spinothalamic Tract)
 Vibration/Position Sensation (Posterior Columns)
Cortical Sensory Modalities
 Stereognosis
 Graphesthesia
 Two-Point Discrimination
 Double Simultaneous Extinction

59. Pain and Temperature
• Pinprick (One pin per patient!)
• Sensation of Cold
• Look for Sensory Nerve or
Dermatomal Distribution
Vibration Sensation
• C-128 Hz Tuning Fork (check great toe)
Joint Position Sensation
• Check great toe
• Romberg Sign

60. Higher Cortical Sensory Function
Graphesthesia
Stereognosis
Two-Point Discrimination
Double Simultaneous Extinction
Gerstmann’s Syndrome (acalculia, right-left
confusion, finger agnosia, agraphia)
• Usually seen in Dominant Parietal Lobe lesions

61. Hemisphere Dysfunction
 Dysmetria on Finger-Nose-Finger Testing*
 Irregularly-Irregular Tapping Rhythm*
 Dysdiadochokinesis*
 Impaired Check*
 Hypotonia*
 Impaired Heel-Knee-Shin*
 Falls to Side of Lesion*
 Nystagmus (Variable Directions)
* All Deficits are Ipsilateral to the side of the lesion

62. Midline Dysfunction
Truncal Ataxia
Titubation
Ataxic Speech
Gait Ataxia
• Acute Ataxia (unsteady Gait)
• Chronic Ataxia (wide-based, steady Gait)

63. REFLEXES

64. MUSCLE STRETCH REFLEXES (DEEP TENDON
REFLEXES)
• GRADED 0 - 5
– 0 - ABSENT
– 1 - PRESENT WITH REINFORCEMENT
– 2 - NORMAL
– 3 - ENHANCED
– 4 - UNSUSTAINED CLONUS
– 5 - SUSTAINED CLONUS

65. MSR / DTR
• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE

66. OTHER REFLEXES
• Upper motor neuron dysfunction
– BABINSKI
• present or absent
• toes downgoing/ flexor plantar response
– HOFMAN’S
– JAW JERK
• Frontal release signs
– GRASP
– SNOUT
– SUCK
– PALMOMENTAL

67. Abmornal Reflexes
Abnormal Reflexes:
Babinski: initial inflection of great toe in response
stroking of sole; upgoing toe is abnormal
Grasp: involuntary grasp in response to stimulation
of palm; abnormal in an adult
Doll’s eyes: impairment of eye movement to opposite
side when head is turned = damage to brainstem; no
movement = loss of
brainstem

68. Neuro Aessessment Quiz
• 1. Peripheral Nervous System (PNS)
is made up of the following except::
a) Cranial nerves (12)
b) Ventricles
c) Axons and Neurons
d) Spinal nerves (31)
e) Cerrebellar nerves
• 2. The Autonomic Nervous System
contains both the Sympathetic
Division of nerves and the
Parasympathetic Division of nerves.
True or False________________.
• 3. Intracranial Hemorrhage can occur
in the following places except:
a) Epidural space
b) Subdural space
c) Subarachnoid space
d) Ethmoid space
• .4. A Coup Contracoup injury is defined
as: When the head strikes a fixed object,
the coup injury occurs at the site of impact
and the contrecoup injury occurs at the
opposite side. True or
False____________________
• 5. The Facial nerve controls:
a) Movement of the chin, tongue and parotid
glands.
b) Movement of the tongue, soft palete and
eyebrows.
c) Movement of the chin and cheeks
muscles.
d) Movement of all the facial expression
muscles.
• 6. Which nerve controls movement on the
neck and shoulders?
a) Abducens
b) Accoustic
c) Spinal Assesory
d) Occulomotor

69. • 7. A serious injury to the cervical spine
and spinal cord most likely will result in
the following condition:
a) Hemiplegia
b) Quadraplegia
c) Paraplegia
d) Contralateral paralysis
• 8. Any suspected head, neck or spine
injured victim should immediately be
given spinal immobilization precautions,
except:
a) When the victim complains of pain only
upon turning his head to one side.
b) When the victim refuses to allow spinal
immobilization even after listening
carefully to multiple attempts to explain
the dangers and risk involved.
c) When the victim is intoxicated on alcohol
and cannot speak clearly.
d) When the victim was never unconscious
and denies any pain.
• 9. When assessing a patient with altered LOC,
you feel his state of awareness/arousal is best
described as “Obtunded”, this means:
a) Very drowsy, when not stimulated, but can
follow simple commands when stimulated (i.e.
shaking or shouting); verbal responses include
one or two words, but will drift back to sleep
without stimulation.
b) A state of drowsiness; client needs increased
external stimuli to be awakened but, remains
easily arousable; verbal, mental & motor
responses are slow or sluggish.
c) Awakens only to vigorous and continuous
noxious (painful) stimulation; minimal
spontaneous movement; motor responses to
pain are appropriate but, verbal responses are
minimal and incomprehensible (i.e. moaning).
d) Vigorous external stimulation fails to produce
any verbal response; both arousal and
awareness are lacking; no spontaneous
movements but, motor responses to noxious
stimuli maybe be purposeful

70. • 10. The Glasgow Coma scale tests for
three kinds of responses, they are:
a) Eye Opening
b) Motor Response
c) Verbal Response
d) Auditory Response
• 11. The best and worst possible score on
the GCS is:
a) 15 and 0
b) 13 and 3
c) 15 and 3
d) 18 and 5
• 12. When assessing pupillary response,
you are looking for the following
conditions except:
a) Coordinated eye movement and bilateral
blinking.
b) Reactivity to and accommodation to light.
c) Symmetry of pupils and accommodation
to light.
d) Abnormal pupil shape.
• 13. A constricted “pin point” pupil indicates:
(best answer)
a) Brain Stem herniation
b) Cardiac Arrest
c) Cerebral Infarction of the parietal lobe
d) Cerebral Infarction of the occipital lobe
e) A wide variety of conditions, some being
extremely life threatening.
• 14. What Cranial nerve(s) controls the
movement of the eyes down and in?
a) CN VI Abducens
b) CN III Oculomotor
c) CN IV Trochlear
d) CN II Optic
• 15. The Motor strength scale goes from 0/5 to
5/5, 0 being no strength at all and 5 being
normal strength. A person with a motor strength
of 4/5 would be:
a) overcomes gravity; offers no resistance
b) strong against resistance
c) weak against resistance
d) no muscle movement

71. • 16. Match the following postures with its
definition:
• Decerebrate_____________
• Decorticate______________
a) Abnormal flexion: rigidly flexed arms and
wrists; fisted hands; occurs in upper
brainstem
b) Abnormal extension: rigidly, rotated
inward, extended arms with flexed wrists
and fisted hands; occurs in midbrain or
pons.
• 17. The Babinski reflex is the initial
inflection (extension) of great toe in
response stroking of the sole of the foot,
select the correct answer:
a) An upgoing great toe is abnormal.
b) An upgoing great toe is normal.
c) An upgoing great toe is abnornal in
adults.
d) An upgoing great toe is normal in infants.
• Answers
• 1 e
• 2 True
• 3 d
• 4 True
• 5 d
• 6 c
• 7 b
• 8 b
• 9 a
• 10 d
• 11 c
• 12 a
• 13 e
• 14 c
• 15 c
• 16 Decer = b. Decor = a
• 17 c&d