2. The nervous system is very complex and controls many parts of
the body. The nervous system consists of the brain, spinal cord, 12
nerves that come from the brain, and the nerves that come from
the spinal cord. The circulation to the brain, arising from the
arteries in the neck, is also frequently examined.
A neurological exam, also called a neuro exam, is an evaluation of
a person's nervous system The neurologic examination is typically
divided into eight components: mental status; cranial nerves;
motor examination; sensory examination; coordination; reflexes;
and gait & station. The mental status is an extremely important part
of the neurologic examination that is often overlooked.
3. A neurological examination is defined as the
assessment of Sensory
neuron and motor responses, especially reflexes,
to determine whether the nervous system is
It is a systematic examination that surveys the
functioning of nerves delivering sensory
information to the brain and carrying motor
commands (peripheral nervous system) and
impulses back to the brain for processing and
coordinating (central nervous system).
4. The purpose of neurological examination is to
determine the presence or absence of disease in the
Identify which component of the neurological system
If possible, determine the precise location of the
Screening for the presence of discrete abnormalities in
patients at risk for the development of neuro-
5. Big tray with cover
Sheet for cover patient
[ 128 and 512 (or 1024] Hz
A Snellen Eye Chart or Pocket
Pen Light or Otoscope
B P apperatus
Steel kidney tray
Test tube-2( one for cold water
and one for hot water)
Common pin or needle
Sugar , Salt , Coffee powder
6. Levels of consciousness
Mental status examination
Special cerebral functions
Cranial nerve function
7. 1.Levels of consciousness
• Assessment of levels of consciousness
includes following categories :
• a. Alertness: Patient is awake, responds
immediately & appropriately to all verbal
• b. Lethargic: Patient is drowsy &
inattentive but arouses easily, frequently off
• c. Stuporous: He arouses with great
difficulty & co-operates minimally when
8. • d. Semi-comatose: The patient has
lost his ability to respond to verbal
stimuli. There is some response to
painful stimuli. Little motor function is
• e. Comatose: When the patient
isstimulated there is no response
toverbal or painful stimuli, no
motoractivity is seen.
1.Levels of consciousness
14. • The components of mental status
examination include the assessment for
General appearance, speech, thought
process, mood , cognitive functions,
attention, concentration, orientation,
memory, general knowledge, abstract
reasoning, judgment & insight.
2. Mental Status
15. Assess for agnosia, apraxia & aphasia.
• Agnosia – inability to recognize
common objects through the senses
• Apraxia – patient cannot carry out
skilled act in the absence of
• Aphasia – inability to communicate.
3. Special Cerebral
17. Olfactory nerve (CN I)
1. The sense of smell is tested by having
the patient occlude one nostril and
close his or her eyes.
2. The examiner then takes a non
irritating substance and places it near
the non occluded nostril. patient is
asked to identify familiar odours
(coffee, tobacco). Each nostril is tested
3. Repeat the process for the opposite
side using a different scent.
18. Visual Field
Assesses peripheral vision:
Stand arm’s length from the patient.
Cover your left eye, while the patient covers their right
Have the patient look at your nose (tell the patient
NOT to look at your fingers)
In the top and bottom of the visual field (test it with
yours) hold up random numbers with your fingers and
have the patient recite them back to you.
Repeat again with the other eye (cover your right eye
while the patient covers their left eye).
Optic nerve (CN II) 4.Cranial nerve
19. 1.The optic nerve testing includes assessment of both
visual acuity and visual fields.
2. Each eye is examined separately while the patient
covers the other one.
3. Visual acuity is tested by having the patient read a
snellen chart from 20 feet away
4. Have the patient start with one eye covered and
read the lines from top to bottom (largest to smallest
5. Record the lowest line that the patient can read
with 50% accuracy.
Optic nerve (CN II)
20. Visual Inattention
Visual inattention can be tested
by moving both fingers at the
same time and checking the
patient identifies this.
Finally fundoscopy should be
performed on both eyes.
Optic nerve (CN II)
21. Test for eye movement toward the nose
Inspect for conjugate movements and
Evaluate papillary size and test for pupillary
reactivity to light
Inspect ability to open eyelids.
Have the patient follow your pen light
by moving it 12-14 inches from the
patient’s face in the six cardinal fields of
gaze (start in the midline)
Watch for any nystagmus (involuntary
movements of the eye)
Oculomotor (CN III)
22. • Trochlear - Test for
upward eye movement
inspect for conjugate
Trochlear (CN IV)
23. The trigeminal nerve is the largest of the cranial
1. The patient should have his or her eyes closed
during the testing procedure.
2. Touch cotton to forehead, cheeks, and jaw.
Sensitivity to superficial pain is tested in these
same three areas by using the sharp and dull ends
of a broken tongue blade. Alternate between the
sharp point and the dull end. Patient reports
“sharp” or “dull” with each movement. If
responses are incorrect, test for temperature
Trigeminal (CN V)
24. The corneal reflex should also be
examined as the sensory supply to
the cornea is from this nerve. Do this
by lightly touching the cornea with
the cotton wool. This should cause
the patient to shut their eyelids.
Have patient clench and move the
jaw from side to side. Palpate the
masseter and temporal muscles,
noting strength and equality.
Trigeminal (CN V) 4.Cranial nerve
25. Motor Supply
To test the motor supply, ask the patient to
clench their teeth together, observing and
feeling the bulk of
the masseter and temporalis muscles.
Ask the patient to then open their mouth
Finally perform the jaw jerk on the patient
by placing your left index finger on their chin
and striking it with a tendon hammer. This
should cause slight protrusion of the jaw.
Trigeminal (CN V) 4.Cranial nerve
26. • Abducens - Test for lateral eye movement • 3
cranial nerves are usually tested together because
they control the function of the extra ocular eye
muscles. • The functions include eyelid elevation,
constriction of the pupils, and movement of the eye
through the six cardinal directions.
Make the lights normal and have patient look at a
distant object to dilate pupils, and then have
patient stare at pen light and slowly move it
closer to the patient’s nose.
Watch the pupil response: The pupils
should constrict and equally move to cross.
Abducens (CN VI)
27. Motor :
• Observe for facial tics. Then, ask the patient to
perform the following movements: raise his or
her eyebrows, close his or her eyelids tightly, puff
out his or her cheeks, smile, and frown. Observe
for weakness or asymmetry of muscle
• Abnormal findings of upper motor neuron
lesion, lower motor neuron lesion, or a stroke can
cause weakness or paralysis of the facial muscles.
• Have the patient rinse his or her mouth with
water between tests.
Facial nerve (VII)
28. Sensory test
• The facial nerve is also a mixed cranial nerve with both
sensory and motor components.
• The sensory component includes the sense of taste on
the anterior two- thirds of the tongue. The testing of the
sensory component is often deferred, unless changes are
noted in the health history interview.
• When tested, have the patient stick out his or her
tongue and test each side separately.
• The taste is sweet and pleasant, but different from the
standard sweet taste. Test ability to discriminate between
sugar and salt.
Facial nerve (VII)
29. The acoustic nerve has two divisions: cochlear and
1. The cochlear division is involved in hearing- Do
weber and rinnes test
To carry out the Rinne test, place a sounding tuning
fork on the patient’s mastoid process and then next
to their ear and ask which is louder. A normal patient
will find the second position louder.
To carry out the Weber’s test, place the tuning fork
base down in the centre of the patient’s forehead
and ask if it is louder in either ear. Normally it should
be heard equally in both ears.
Acoustic nerve (CN VIII)
30. Assess patient’s ability to
swallow and discriminate
between sugar and salt on
posterior third of the
tongue. It can be tested
with the gag reflex or by
touching the arches of
Glossopharyngeal (CN IX)
31. • The glosso pharyngeal and vagus nerves are usually tested together.
In the pharynx, CN IX is primarily sensory, and CN X is mostly motor.
• observe the patient as he or she swallows a small amount of water.
Ask if he or she frequently chokes on food or has trouble swallowing.
Dysphagia (difficulty swallowing ) can often be seen after
neurosurgical procedures or CVA (stroke.)
• Depress a tongue blade on posterior tongue, or stimulate posterior
pharynx to elicit gag reflex. Note any hoarseness in voice. Check
ability to swallow.
•Asking the patient to speak gives a good indication to the efficacy of
the muscles. The uvula should be observed before and during the
patient saying “aah”. Check that it lies centrally and does not deviate
Vagus Nerve (CN X)
32. SPINAL ACCESSORY • Assess the trapezius
• Trapezius – examiner place the hands
on patient shoulder, ask the patient TO
shrug his /her shoulder. Observe strength
• Sternocledoid- examiner place hands
on one cheek and ask the patient to turn
his/her head against hand as the
movement is resisted
• Repeat the test on opposite
• Abnormality - CVA
Accessory nerve (CNXI)
33. • The hypoglossal nerve is tested by asking the
patient to open his or her mouth, stick out his or
her tongue, and wiggle it side to side.
• While patient protrudes the tongue, note any
deviation or tremors. Test the strength of the
tongue by having patient move the protruded
tongue from side to side against a tongue
• The tongue should be midline. Observe for
asymmetry, atrophy, or fasciculations. Carotid
endarterectomy is a common cause of dysfunction
of CN XIII.
• Hypoglossal nerve (CNXII)
34. • Motor function:
• Assessment of motor function involves assessing for muscle size,
muscle strength, muscle tone, muscle co-ordination, gait &
Muscle size: Inspect all major muscle groups bilaterally for
symmetry, hypertrophy, & atrophy.
Muscle Strength: Assess the power in major muscle groups
against resistance. Assess & rate muscle strength on a 5-pointscale
in all four extremities, comparing one side with other.
35. • Muscle tone: Assess muscle tone while moving each
extremity through its range of passive motion. When tone is
decreased (hypotonicity), the muscle are soft, flabby, or
flaccid; when tone is increased (hypertonicity), the muscles are
resistant to movement, rigid, or spastic. Note the presence of
abnormal flexion or extension posture.
• Muscle coordination: Disorders related to
coordination indicate Cerebellar or posterior column lesions.
36. Muscle Strength 5-
GRADE ABILITY TO MOVE
Grade - 5 The muscle can move the joint it cross through a full range of motion,
against gravity, and against full resistance applied by the examiner
Grade - 4 The muscle can move the joint it cross through a full range of motion,
against moderate resistance
Grade - 3 The muscle can move the joint it cross through a full range of motion,
against gravity, but without any resistance
Grade -2 The muscle can move the joint it cross through a full range of motion, only if
the part is properly positioned so that the force of gravity is eliminate.
Grade -1 Muscle contraction is seen or identified with palpation, but it is insufficient to
produce joint movement even with elimination of gravity
Grade -0 No muscle contraction is seen or identified with palpation, Paralysis;
37. • Gait & station: Assess gait station by having the patient stand
still, walk & in tandem(one foot in front of the other in a straight
line). Walking involves the functions of motor power, sensation &
coordination. The ability to stand quietly with the feet together
requires coordination & intact proprioception (sense of body
• Movement: Examine the muscles for fine &gross abnormal
movements. Move all the points through a full range of passive
motion. Abnormal findings include pain, joint contractures, &
38. • Sensory assessment involves testing for
touch, pain, vibration & discrimination.
• A complete sensory examination is possible
only on a conscious & co-operative patient.
• Always test sensation with patient’s eye
• Help the patient relax & keep warm.
• Conduct sensory assessment systematically.
• Test a particular area of the body, & then
test the corresponding are on the other
39. • Exam in this order
• Superficial (Exteroceptive) sensation
• Proprioceptive(deep) sensation
• Combined cortical sensations.
• If the superficial sensation is impaired then some impairment is also
seen in deep and combined sensations.
• Sensory tests are done from the distal to the proximal direction.
• Diabetes mellitus, thiamine deficiency and neuro toxin damage (e.g.
insecticides) are the most common causes of sensory disturbances
40. Superficial Sensation Deep Sensation Combined Cortical
Pain Perception Kinesthesia Awareness Stereognosis Perception
Temperature Awareness Vibration Perception Tactile Localization
Touch Awareness Two-Point
Pressure Perception Double Simultaneous
Recognition of Texture
41. • Pain Perception
• It is also known as sharp/dull discrimination. To test
this sensation, the sharp and dull end of any objects
like a safety pin, a reshaped paperclip, or
neurological pin is used. The sharp and dull end is
randomly applied perpendicular to the skin, should
not be applied too close to each other or in a too
rapid manner to avoid the summation of impulses.
The patient is asked verbally to indicate sharp/dull
when a stimulus is felt. All areas of the body should
be tested. After testing the instrument should be
sterilized or disposed.
42. • Temperature Awareness
Two test tubes with stoppers are required
for this examination; one should be filled
with the cold water (between 5°C to
10°C) and warm water( 40°C to 45°C). It
should be taken care that the temperature
should remain within this range for
accuracy. The test tubes are randomly
placed in contact with the skin area to be
tested. All skin surfaces should be tested.
The patient is asked to respond hot and
cold after each stimulus application.
43. • Touch Awareness
• A piece of cotton, camel-hair brush,
or tissue is used to perceive the
tactile touch input. Light touch or
stroke is applied in the area to be
tested. The patient is asked to
indicate where he/she recognizes
that a stimulus has been applied .
44. • Pressure Perception
• The therapist's fingertip or a
double-tipped cotton swab is
used to apply a firm pressure on
the skin surface. This test can
also be administered using the
thumb and finger to squeeze the
Achilles tendon. The patient is
asked to indicate when an
applied stimulus is recognized.
45. • Kinesthesia Awareness
• Awareness of movement is known
as kinesthesia. The Therapist
passively moves a joint through a
relatively small range of motion and
the patient is asked to describe the
direction of movement. The patient
can also respond by simultaneously
duplicating the movement with the
46. • Proprioception Awareness
• Proprioception includes position
sense and awareness of joint at rest.
The joint is moved through a range
of motion and held in static
position by the therapist, the patient
is asked to describe the position
either verbally or by demonstrating
on another limb.
47. • Vibration Perception
• The perception of a vibratory stimulus is
tested by placing the base of the vibrating
tuning fork on the bony prominence(
sternum, elbow, ankle). Generally, the
tuning fork should be of 128Hz. If there is
impairment patient will be unable to
distinguish between a vibrating and non
vibrating tuning fork. Therefore, there
should be a random application of
vibrating and non vibrating stimuli.
48. • Stereognosis Perception
• Tactile object recognition is determined
in this test. A familiar object of different
shape and size are required like keys,
coins, combs, safety pins, pencils). A
single object is placed in a hand and the
patient manipulates it to identify the
object and say it verbally. For speech
impairment patients sensory testing
shield can be used.
49. • Tactile Localization
• The test checks the ability to
localize touch sensation on the
skin. This test is not performed in
isolated manner rather it is done
in combination with pressure
perception or touch awareness.
50. • Two-Point Discrimination
• It determines the ability to perceive two points
applied to the skin simultaneously.
• Aesthesiometer or the circular two-point
discriminator are the devices to test. The two
tips of the instrument are applied to the skin
simultaneously with the tip spread apart. With
each successive application, the two tips are
gradually brought closer together until the
stimuli are perceived as one. The smallest
distance between the stimuli that is still
perceived as two distinct points is measured.
51. • Double Simultaneous
• DSS examines the ability to
perceive a simultaneous touch
stimulus on opposite sides of the
body; proximally and distally on a
single extremity; or proximally
and distally on one side of the
52. • Graphesthesia(Traced Figure
• The ability to recognize letters,
numbers, or designs traced on the
skin is examined using fingertip
or the eraser end of the pencil. the
patient is asked verbally the
figures drawn on the skin.
53. • Recognition of Texture
• The test examine the ability to differentiate
among various textures like cotton, wool, or
• Barognosis( Recognition of weight)
• For the test different weights are used. the
therapist may choose to place a seres of
different weights in the same hand one at a
time, place a different weight in each hand
54. • Astereognosis refers to the inability to recognize objects
placed in the hand. Without a corresponding dorsal
column system lesion, these abnormalities suggest a
lesion in the sensory cortex of the parietal lobe.
• Apraxias are problems with executing movements despite
intact strength, coordination, position sense and
comprehension. This finding is a defect in higher
intellectual functioning and associated with cortical
55. • For evaluation of balance & co-
ordination the tests used are:
a. Finger to finger test: It is performed
by instructing the patient to place her
index finger on the nurse’s index
finder. He is asked to repeat this for
several times in succession on both
56. b. Finger to nose test:
Tell the patient to extend his
index finger & then touch the
tip of his nose several times in
rapid succession. This test is
done with patient’s eyes both
57. • c. Romberg test: Here the nurse
instructs the patient to stand with
his feet together with arms
positioned at his sides. He is told to
close his eyes. This position is
maintained for 10 seconds. This test
positive only if there is actual loss of
58. • d. Tandom walking test:
• This is tested by having the
patient assume a normal standing
position. He is then instructed to
walk over heel on a straight line.
Any unsteadiness, lurching or
broadening of the gait base is
59. • A reflex is an involuntary and nearly
instantaneous movement in response to
a stimulus. The reflex is an automatic
response to a stimulus that does not
receive or need conscious thought as it
occurs through a reflex arc. Reflex arcs act
on an impulse before that impulse
reaches the brain
60. • Reflex testing evaluates the integrity of
specific sensory & motor pathways.
• Reflex activity assessment, always a part of
neurologic assessment, provides information
about the nature, location,& progression of
• Normal reflexes: Two types of reflexes are
• I. Superficial or cutaneous reflexes
• II. Deep tendon muscle-stretch reflexes
61. I. Superficial (cutaneous) reflexes:
• Abdominal reflex
The abdomen is mentally divided
into four quadrants, and the skin in
each quadrant is gently stroked, on
the diagonal, towards the navel. The
navel should twitch towards the
stimulus. It can be helpful in
determining the level of a central
nervous system (CNS) lesion.
62. • Plantar reflex
The plantar reflex is
a reflex elicited when the sole of
the foot is stimulated with a blunt
instrument. The reflex can take
one of two forms. In healthy
adults, the plantar reflex causes
a downward response of the
63. • Corneal reflex
The corneal reflex, also known as
the blink reflex, is an involuntary
blinking of the eyelids elicited by
stimulation of the cornea (such as
by touching or by a foreign body),
though could result from any
64. Pharyngeal (Gag)reflex
The gag reflex is a reflex
contraction of the back of the
throat, elicited by touching
the posterior pharyngeal wall,
tonsillar area, or the base of
65. • Cremasteric reflex
The cremasteric reflex is a
superficial reflex found in human
males that is elicited when the inner
part of the thigh is stroked. Stroking
of the skin causes
the cremaster muscle to contract and
pull up the ipsilateral testicle toward
the inguinal canal.
66. • Anal reflex
• The anal wink, anal reflex,
perineal reflex, or
anocutaneous reflex is the reflexive
contraction of the
external anal sphincter upon stroking
of the skin around the anus. A noxious
or tactile stimulus will cause
a wink contraction of
the anal sphincter muscles and also
67. Deep tendon (muscle-stretch) reflexes:
• A biceps jerk (fore arm flexion)
The forearm should be supported, either
resting on the patient's thighs or resting on
the forearm of the examiner. The arm is
midway between flexion and extension. Place
your thumb firmly over the biceps tendon,
with your fingers curling around the elbow,
and tap briskly. The forearm will flex at the
elbow. Biceps reflex is a reflex test that
examines the function of the C5 reflex arc
and the C6 reflex arc
68. • A triceps jerk (fore arm extension)
Support the patient's forearm by
cradling it with yours or by placing
it on the thigh, with the arm midway
between flexion and extension.
Identify the triceps tendon at its
insertion on the olecranon, and tap
just above the insertion. There is
extension of the forearm.
69. • A brachioradial jerk
• The brachioradialis reflex (also known
as supinator reflex by striking
the brachioradialis tendon (at its insertion at
the base of the wrist into the radial styloid
process (radial side of wrist around 4 inches
proximal to base of thumb)) directly with a
reflex hammer when the patient's arm is
relaxing. This reflex is carried by the radial
nerve (spinal level: C5, C6)
• The reflex should cause slight pronation
or supination and slight elbow flexion.
70. • A knee jerk, quadricepsjerk or patellar
• The patellar reflex or knee-jerk (in American
English knee reflex) is a stretch reflex which tests the
L2, L3, and L4 segments of the spinal cord. Striking of
the patellar tendon with a reflex hammer just below
the patella stretches the muscle spindle in
the quadriceps muscle. This produces a signal which
travels back to the spinal cord and synapses at the
level of L3 or L4 in the spinal cord, and triggering
contraction. This contraction, coordinated with the
relaxation of the antagonistic flexor hamstring muscle
causes the leg to kick.
71. • Achilles reflex
• The ankle jerk reflex, also known as
the Achilles reflex, occurs when
the Achilles tendon is tapped while
the foot is dorsiflexed. It is a type of
stretch reflex that tests the function
of the gastrocnemius muscle and
the nerve that supplies it. A positive
result would be the jerking of the
foot towards its plantar surface
72. • Babinski reflex
• It is one of the normal reflexes in
infants. Reflexes are responses
that occur when the body receives
a certain stimulus. The Babinski
reflex occurs after the sole of the
foot has been firmly stroked. The
big toe then moves upward or
toward the top surface of the
foot. The other toes fan out.
73. • Snout reflex
• The Snout reflex or a "Pout" is a
pouting or pursing of the lips that is
elicited by light tapping of the closed
lips near the midline. The
contraction of the muscles causes
the mouth to resemble a snout. This
reflex is tested in a neurological
exam and if present, is a sign of
brain damage or dysfunction.
74. • The jaw jerk reflex
• The jaw jerk reflex or the masseter reflex is a stretch
reflex used to test the status of a patient's trigeminal
nerve (cranial nerve V) and to help distinguish an upper
cervical cord compression from lesions that are above
the foramen magnum. The mandible—or lower jaw—is
tapped at a downward angle just below the lips at the
chin while the mouth is held slightly open. In response,
the masseter muscles will jerk the mandible upwards.
Normally this reflex is absent or very slight. However, in
individuals with upper motor neuron lesions the jaw
jerk reflex can be quite pronounced.
75. • Palm-chin (palmomental) reflex
The thenar eminence is stroked briskly with
a thin stick, from proximal (edge of wrist)
to distal (base of thumb) using moderate
pressure. A positive response is considered
if there is a single visible twitch of the
ipsilateral mentalis muscle (chin muscle on
the same side as the hand tested). A
strong, sustained, and easily repeatable
contraction of the mentalis muscle, which
can be elicited by stimulation of areas
other than the palm, is more likely to
indicate cerebral damage.
76. • Ankle Clonus
• Clonus is a rhythmic, oscillating,
stretch reflex, the cause of which is not
totally known; however, it relates to lesions
in upper motor neurons and therefore is
generally accompanied by hyperreflexia.
• Clonus at the ankle is tested by rapidly
flexing the foot into dorsiflexion (upward),
inducing a stretch to the gastrocnemius
muscle. Subsequent beating of the foot will
result, however only a sustained clonus (5
beats or more) is considered abnormal.
77. • The glabellar reflex
• It is elicited by repeatedly tapping the patient
between the eyebrows (the glabella area),
causing them to blink. Normally,
the adult patient habituates to the stimulus, and
ceases blinking after a few taps. If blinking
persists, it is abnormal in adults.
• Rooting reflexes
• It can be observed in adult patients with frontal
lobe pathology. They often present with other
primitive reflexes that are normally suppressed
by the frontal lobe of the cerebral cortex.
78. Grasp reflex
• It is an involuntary flexion-adduction
movement involving the hands and digits.As
the name implies, the action resembles a
grasping motion of the hand. The reflex can
be elicited by moving an object distally along
the palm.The movement breaks down into
two phases – a catching phase and a holding
phase.The catching phase features the initial
brief muscular contraction following
stimulation of the palm, whereas the holding
phase features traction of the tendons
associated with the contracting muscles.
79. Provide a clam, suitable environment
Collect the personal data with patient &family members
Set the equipment needed for neurological examination
Assess the current level of consciousness, monitor vital
parameters – temperature, pulse, respiration, blood
pressure, pupillary reaction, whether decerebrating or
Thorough mental status examinations should be done &
80. Assessment of cranial nerves should be done correctly &
Assessment of motor, sensory & cerebellar functions should be
done & be recorded accurately.
During the examination, she should maintain a good support
with patient &family members
She should instruct the procedure correctly& then they should
be asked to do it.
Should be informed to the concerned unit doctors if there is