Common Neurologic Problems

Full Neurologic Exam (Awake Patient)

• Higher Integrative functions (Mental Status). 
  • Attention / Arousal: Is the patient awake and able to participate? Describe level of alertness (alert, drowsy, somnolent, sedated). Best bedside test is days of week backward. 
  • Orientation: Assess orientation to person, place, time, and situation. 
  • Memory: Test short-term recall with 3–5 word recall after 5 minutes. 
  • Language: assess for aphasia by testing Fluency (naming objects), Comprehension (complex commands “touch your right shoulder with your left hand”), and Repetition.

Cranial Nerves 

• CN I: Olfaction. Rarely tested but can use common bedside objects like coffee. 
• CN II: Pupillary light response, visual fields, visual acuity (can use pocket Snellen chart). 
• CN III, IV, VI: Extraocular movements.
• CN V: Facial sensation - compare symmetry in V1, V2, V3. 
• CN VII: Facial strength - Facial symmetry at rest and with movement (eyebrow raise, eye closure, smile, puff cheeks). 
• CN VIII: Hearing – assess grossly when talking during interview, could also test with Weber/Rinne.
• CN IX, X: Palate elevation and symmetry.
• CN XI: Shoulder shrug (trapezius) and head turn (sternocleidomastoid). 
• CN XII: Tongue protrusion - Deviation suggests ipsilateral injury; assess for fasciculations (LMN injury).

Motor Function

• Muscle tone (decreased, normal, increased). 
  • Strength (5-point scale): 
    • 0 = No muscle activation.
    • 1 = trace activation (twitch) but unable to move across ROM of joint.
    • 2 = muscle action with gravity eliminated (plane of bed), with full ROM. 
    • 3 = anti-gravity only; no action against resistance.
    • 4 = action against some resistance.
    • 5 = full strength against resistance.

Abnormal movements (tremor, chorea, fasciculations, other), If not sure, describe what you see. 

Coordination: Finger-To-Nose and Heel-To-Shin testing to assess for ataxia or dysmetria.

Sensation 

Assess for symmetry (left/right and distal/proximal) using light touch and/or pinprick. Can assess other modalities (temperature, vibration, proprioception) when indicated by clinical context.

Reflexes 

• Deep tendon reflexes graded on 4-point scale: 0 = Areflexia, 1 = Decreased, 2 = Normal, 3 = Increased, 4 = increased with clonus (sustained response).
  • Increased DTR indicates UMN etiology, but 3+ can be normal in young adults.
  • Decreased DTR indicates LMN, NMJ, or muscle issue, can be normal in older adults.
• Plantar Reflex (Babinski’s): tested by scraping along lateral edge of sole then across top towards the big toe. Positive (indicative of UMN injury) if great toe moves upward. Normal/Negative if downward or no response is elicited.

Neurologic Exam in Unconscious Patient