Neurological Exam

System/Body Area

Elements of Examination

Constitutional

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration,

5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)

• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face

Eyes

• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

Ears, Nose, Mouth

and Throat

Neck

Respiratory

Cardiovascular

• Examination of carotid arteries (eg, pulse amplitude, bruits)

• Auscultation of heart with notation of abnormal sounds and murmurs

• Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

Gastrointestinal

(Abdomen)

Genitourinary

Lymphatic

Musculoskeletal

• Examination of gait and station

Assessment of motor function including:

• Muscle strength in upper and lower extremities

• Muscle tone in upper and lower extremities (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (eg, fasciculation, tardive dyskinesia)

Extremities

[See musculoskeletal]

Skin

Neurological

Evaluation of higher integrative functions including:

• Orientation to time, place and person

• Recent and remote memory

• Attention span and concentration

• Language (eg, naming objects, repeating phrases, spontaneous speech)

• Fund of knowledge (eg, awareness of current events, past history, vocabulary)

Test the following cranial nerves:

• 2nd cranial nerve (eg, visual acuity, visual fields, fundi)

• 3rd, 4th and 6th cranial nerves (eg, pupils, eye movements)

• 5th cranial nerve (eg, facial sensation, corneal reflexes)

• 7th cranial nerve (eg, facial symmetry, strength)

• 8th cranial nerve (eg, hearing with tuning fork, whispered voice and/or finger rub)

• 9th cranial nerve (eg, spontaneous or reflex palate movement)

• 11th cranial nerve (eg, shoulder shrug strength)

• 12th cranial nerve (eg, tongue protrusion)

• Examination of sensation (eg, by touch, pin, vibration, proprioception)

• Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (eg, Babinski)

• Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)

Psychiatric