A neurological exam, also called a neuro exam, is an evaluation of a person's nervous system that can be done in the healthcare provider's office.

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Neurological Assessment
Ghaffar Ahmed
Rubina Nathaniel

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Objectives
By the end of the unit, learners will be able to
 Review Anatomy/Physiology of Nervous System
 Perform mental status examination of a client
 Assess cranial nerve
 Assess sensory, sense of proprioception
 Assess cerebellar functions and deep tendon
reflexes
 Document findings

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How to Assess Nervous System
 Mental status examination
 Cognitive functions
 Cranial nerves
 Sensory and motor
 Deep tendon reflex

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MSE
Mood
Speech
&
Language
Appearance
&
Behavior
Thought
&
Perception

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MSE Cont……
Appearance and Behavior
–LOC
State of awareness of environment
–Posture and behavior
Tense, restlessness, dull

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MSE Cont…….
Appearance and Behavior Cont……..
–Dressing and grooming
Appropriateness
–Facial expressions
Flat, elated, immobile
–Manner and affect
Observable feature and their
appropriateness

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MSE Cont…….
Speech and Language
–Quantity
Talkative, silent
–Rate
Rapid, Slow
–Loudness
Soft, loud
–Articulation
–Fluency

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MSE Cont………
Mood
– A sustained emotion which represents a
person’s world. (anger, depressed)
– Can ask question such as how do you feel
today?

15. Thought Process
 Circumstantiality
–Delay in getting to the point
 Tangentiality
–Responses never approach the point of
the questions
 Derailment
–Constant jumping from one topic to
another
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16. Cont…….
 Neologism
–A newly coined word
 Incoherence
–illogical connection
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17. Cont……..
 Blocking
–An interruption in the spontaneous flow
of speech or thought
 Confabulation
–Information provided with gaps
 Perseveration
–The tendency to continue or repeat an
act or activity
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18. Cont……..
 Echolalia
–The immediate and involuntary
repetition of words or phrases just
spoken by others
 Hypochondriasis
–Chronic and abnormal anxiety about
imaginary symptoms
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Thoughts and Perceptions
– Thought content
 Compulsions
– An irresistible impulse to act, regardless of the
rationality of the motivation (Repetitive behavior)
 Obsessions
– Uncontrollable thoughts
 Phobias
– Irrational fear
 Delusions
– False belief which is not shared by other

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Thoughts & Perceptions Cont….
–Perceptions
Illusions
Hallucination
–Insight and judgment
What do you think that what is wrong
with you?
What would you do if …………

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Cognitive Functions
–Orientation
Time, place and person
–Attention
Digit span
Serial of 7
Spelling backward

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Cognitive Functions Cont……
–Remote memory
Birthdays, anniversaries, job held etc.
–Recent memory
Medications

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Cognitive Functions cont……..
Higher Cognitive Function
–Information and vocabulary
–Constructional ability

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Higher Cognitive Function Cont…
–Calculating ability
Begin with simple ones (3+4, 9x5, 9+15)
–Abstract thinking
Proverb: should be commonly used)
Similarities (how the things are alike
such as similarities between orange &
apple)

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•Smell should be familiar
•Check nasal patency
•Close both eyes of the patient
•Odor should be non-irritant

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•Test visual acuity
•Visual field by confrontation

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•Test
•Pupil size, shape & Compare
•Reaction to light

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Cranial Nerves 3,4 & 6
Check cardinal gaze
Convergence test

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Cranial Nerve 7
• Raise both eyebrows
• Frown
• Close both eyes tightly
• Show both upper &
lower teeth
• Smile
• Puff out cheeks

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Cranial Nerve 8
• Assess hearing
• Test for
lateralization
• Compare AC & BC

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Cranial Nerve 9
• Hoarseness
• Swallowing
• Gag reflex

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Cranial Nerve 10
• Assess
movement of
soft palate
and pharynx

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Cranial Nerve11
• Assess back for
atrophy, fasciculation
of trapezius muscles
• Compare both sides
• Shrug shoulders

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Hypoglossal CN.12
• Observe articulation
of words
• Assess for atrophy &
fasciculation
• Inspect tongue for
any deformity and
check strength

35. Document Findings
“25 year old Mr. X is alert, well-groomed, and
cheerful. Speech is fluent and words are clear.
Thought processes are coherent, insight is
good. The patient is oriented to person, place,
and time. Serial 7s accurate; recent and remote
memory intact. Calculations intact.”
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36. Cont……
“25 year old Mr. x appears sad and fatigued;
clothes are wrinkled. Speech is slow and words
are mumbled. Thought processes are coherent,
but insight into current life reverses is limited.
The patient is oriented to person, place, and
time. Digit span, serial 7s, and calculations
accurate, but responses delayed. Clock
drawing is good. Cranial nerves 1-12 intact. ”
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Documentation
25 years old Mr. X sitting/lying in his bed,
looking well groomed/unkempt, alert/dull,
relax/irritated, cooperative/uncooperative
(angry, depressed, silent); oriented to time
place and person; thought process and
content coherent; detailed cognitive
functions intact. Cranial nerves 1-12 intact.

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Motor System
• Body position
– At movement and rest
• Involuntary movement
– Tremors, tics, fasciculations
– Note their location, rate, amplitude, relation to
posture, activity and emotion.
• Muscle bulk
– Compare the size and contour of muscles

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Motor System
• Muscle tone
– Can be assessed best by feeling the muscle
resistance to the passive stretch.
• Muscle strength
– Impaired strength (paresis), Absent strength
(plegia)

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Muscle Strength Grading
0 No muscle contraction detected
1 A barely detectable contraction
2
Active movement of body part with gravity
eliminated
3 Active movement against gravity
4
Active movement against gravity and some
resistance
5 Active movement without evident gravity

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Motor System
• Pull against your
hand
• Push against your
hand
C5, C6
C6, C7 & C8

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Motor System
• Test flexion and
extension at wrist
• Ask patient to make a
fist and resist your
pulling and pushing
down.
C6, C7 & C8

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Motor System
• Test grip
– Ask patient to squeeze two of your fingers as
hard as possible and not let them go.
C7, C8 & T1

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Motor System
• Test finger abduction
– Instruct patient not to let you move the fingers,
try to force them togather.
C8, T1

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Motor System C8, T1
• Test opposite of thumb
– Instruct patient to touch the little finger against
your resistance.

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Motor System
• Test flexion at hip (L2,3,4)
– Instruct patient to raise leg against your resistance
• Extension at hip (S1)
– Instruct patient to push down against you resistance
• Adduction at hip (L2,3,4)
– Place your hand between knees and ask patient to
bring them together against resistance.
• Abduction at hip (L4,5 & S1)
– Place hand outside knees firmly and ask patient to
spread them against resistance.

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Motor System
• Instruct patient to
straight the leg
against your
resistance.
• Instruct the patient to
keep the foot down as
you try to straight.
L2,3 & 4
L4,5 & S1,2

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Motor System
• Test dorsi and planter
flexion
• Instruct patient to pull
and push against
resistance.
L4,5
S1

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Motor System
Coordination test
– Rapid alternating movements
– Point to point movement
• Instruct patient to touch nose and
then your fingers and change the
position of finger
– Gait
• Walk across the room
• Walk heal to toe in straight line
• Hop in place on each foot

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Motor System
Coordination test
– Romberg test
• Instruct patient to stand with feet together then
close eyes for 20-30 seconds
– Pronator drift
• Instruct patient to straight arms with palms up and
close eyes for 23-30 seconds

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Sensory
• Pattern of testing
– Compare both sides
– Compare distal with proximal
– Vary your pace of testing

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Sensory
• Pain
– Is it sharp or dull
• Temperature
– Is it cold or hot
• Position
– Hold the big toe between thumb and finger
and change its position and ask position

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Sensory
• Vibration
– Tap a tuning fold and place over
interphalangeal joint and ask patient to what
does he/she feels and when the vibration
stops.
• Light touch
– Use fine wisp of cotton to touch and ask
patient to respond
– Avoid pressure

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Sensory
• Discriminative sensations
– Stereognosis
– Graphesthesia
– Point to point
– Point localization
– Extinction

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Deep Tendon Reflexes
• Reflex is an involuntary response that may
involve afferent (sensory), efferent
(motor), across a single synapse.
• For a reflex to fire, all component of reflex
arc must be intact.
– Sensory nerve fiber
– Motor nerve fiber
– Spinal cord synapse
– Neuromuscular junction and muscle fibers.

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Deep Tendon Reflexes
Graded on a 0 to 4+ Scale
4+ Very brisk, hyperactive
3+ Brisk then average
2+ Average; normal
1+ Diminished, low
0 No response

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C5, C6
• Bicep Reflex
– Patient sitting and
relaxed
– Therapist places
her thumb over
biceps tendon and
applies a brisk tap
(to her thumb nail)
with reflex hammer

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C6, C7
• Triceps reflex
– Identify the triceps
tendon posteriorly just
above its insertion on
the olecranon. Tap
briskly on the tendon
with the reflex hammer.
Note extension of the
forearm and contraction
of tricep muscle

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C5,C6
• Brachioradialis reflex
– Strike the radius about 1 to
2 inches above wrist
– Note flexion and supination
of the forearm.

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• Abdominal reflex
– Stroke each side of
abdomen using
key, cotton tipped
applicator or
tongue blade.
– Note contraction of
muscles and
deviation towards
umbilicus.
T8, T9 & T10
T10, T11 & T12

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L2, L3 & L4
• Knee reflex
–Briskly tap just
below the
patella.
–Note contraction
of quadriceps
with extension at
the knee.

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Primary S1
• Ankle reflex
–Strike at the Achilles
tendon.
–Watch and feel for
planter flexion.

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L5, S1
• Planter response
–Stroke the lateral aspect of
the foot using lightest
stimulus
–Note the Babinski response

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Normal Neurological Changes
in Aging

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Vision
Corneal Flattening.
 Reduces the transmitted light into the elderly eye by one
third.
• Lens Transparency.
– Weakens available light to receive colors.
– Blue actually appears more green.
– Warmer colors like reds and oranges, seem stronger in
comparison.
• Less Efficient Retina.
– Decreased spatial discrimination, black and white contrast
– Less able to tolerate glare
– Trouble adapting to darkness or bright light.

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Vision
• Reduced Lens Elasticity.
– Decline in visual acuity. This changes is usually
first noticed around age 40 and is called
presbyopia.
– Fortunately, only 5% become unable to read and
about 20% have enough visual impairment to
prevent driving.
– With aging, it is normal for decreased secretions
and tears in eyes, causing dryness and itching.

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Hearing
• About 25% of people between 65 and 74 years
of age and 50% of people age 75 or older
report difficulty hearing. Unfortunately,
although 65% of those age 85 and older report
hearing difficulty only 8% use a hearing aid or
other assistive listening device.
– Presbycusis
– Tinnitus

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Smell
– After the age of 50 the sense of smell decreases
rapidly. By age 80, the sense of smell is reduced
by about half. The lack of ability to smell spoiled
food can lead to indigestion and food poisoning.

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Taste
– Some atrophy of the tongue occurs with age and
this may diminish sensitivity to taste. Receptor
cells for taste are found in the taste buds on the
tongue and are replaced continuously.

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Touch
• The actual number of touch receptors we have
decreases which results in a higher threshold
for touch. The major concern a loss in touch
sensitivity raises relate to personal safety. For
example, older adults do not sense heat as
quickly so they tend to have worse burns.

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• Decrease blood flow to brain
• speed, balance, coordination, and fine motor
activities (buttoning buttons, opening bottles,
etc.).

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Reference
Bickley, L.S., & Szilagyi, P.G. (2016). Bates’
Guide to: Physical Examination and History
Taking. (ed. 11th). Lippincott: Williams &
Wilkins.
Ellen, E.M. (1998). Helath Assessment and
Physical Examination. DelmarPublishers:
Albany, N.Y.
Acknowledgement: Gideon Victor

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