NEUROLOGIC TESTING
PHYSICAL EXAM Physical exam is less costly and less sensitive than neurophysiologic
testing.
 Brief neurocognitive (patients rarely fake: they hate feeling dumb).
All tests must be performed eyes open. Toxic encephalopathy patients tend to close eyes to
improve performance (by sparing neurovisual tract and cortex brain demands).
Hand Grip:
R
L
Arm Strength:
R
L
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Neurological:
DTRs:
Ankle
Biceps
Triceps
Brachioradialis
Patellar
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_______
Balance:
Romberg 2 Leg:R Leg:+
L Leg:+
Heel to toe:+
+= eyes open
- = eyes closed
2 Leg, tiptoe+
2 Leg, tiptoe________________________________________________________________________________________________
Tremor. Resting:
R
L
Vibratory Sense. 128 cps.
R
L
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Sensation - Touch:
R Upper:
L Upper:
Pain:
R Upper:
L Upper:
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Mental Status:
Attention & Digit Span:
9,1,5,4 (4)
4,7,2,9,3 (5)
3,6,7,9,5,2 (6) 7,2,4,8,3,5,9 (7)
Complex Tasks: Serial 7’s:
5,3,8,7
6,1,9,7,0
9,0,5,4,7,1
6,1,3,9,4,7,2
6,0,4,9
8,3,4,1,5
6,3,1,2,4,8
0,8,6,5,2,9,1
100, 93, 86, 79, 72, 65, 58, 51, 44, 37, 30, 23, 16, 9, 2
and/or spell backwards: world, clock, bench; pencil, flower, pretty; sharing, helpful, studies
and/or Instructions: roll eyes back, cross arms, tap foot, relax arms; snap fingers, flex wrists, cross ankles, raise eyebrows
clench jaws, shrug shoulders, close your eyes, puff cheeks out; blink 3 times; make fist. relax hand, extend little finger
Recent Memory:
George Segall, 624 York Road, Bellona, MA (repeat now & in 5 min).
Cynthia Jeffers, 509 Kings Lane, Shady Grove, NJ
James Oliver, 419 Oak Avenue, Grove City, NV
Candice Walker, 279 Melrose Street, Davison, NE
Thomas Brady, 934 Jason Drive, Benson, NY
Objects: eraser, light, tree, candle;
needle, book, watch, bird;
chair, picture, zebra, onion
 Short Term (“Recent”) Memory: Tell patient you will give simple name and address and
ask them to repeat it immediately and again in 5 minutes. After immediate patient repeating,
mark (eg., underline what they recalled correctly and PROMPTLY move to attention span to
prevent them from constant repetition, memorization and false 5 minute results). In followup tests use different name, address. Recall of 4 objects (adult) or 3 (child) can be used as
additional short term memory.
 Attention Span: Ask them to repeat promptly after you give them some numbers in a row
(repeating in the same order you gave to them). As repeated by patient, the series is either
correct or incorrect. A normal adult should be able to correctly repeat 7 numbers (eg phone
number). In follow up tests, mix numbers differently when you give to patient.
Neurologic Testing
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 Complex Mental Tasks: Ask patient former (pre-illness) arithmetic ability. If average or
above high school, they should be able to mentally subtract 7’s. Ask them to start with 100,
mentally subtract, NOT counting down in head/fingers (invalid), give you the answer, then
again subtract 7 and work their way down as best they can. Note/write errors, problems.
Other complex mental tasks include spelling simple words backwards in their head, one
each of 5 letters, 6 letters, 7 letters). Use different words for follow-up. Another is
performing 4 (adult) or 3 (child) instructions immediately after hearing them (see exam
sheet examples above).
Other Physical Exam
 Vibration perception at 128 cps (128 cps tuning fork) for peripheral neuropathy. Place over
bone, eg, knuckle/hand, etc. After you test to ensure the patient can distinguish between 128
cps vibration and your minor hand motion without vibration, place the mild to moderately
vibrating tuning fork over a bony surface and ask them to tell you as soon as the vibration
is completely stopped. Then quickly compare with your own vibrating perception (eg. their
knuckle and yours). Vibration perception declines slightly with age. A younger (than you)
patient with repeated levels below yours is abnormal: the degree of abnormality is how
strong you perceive the vibration when they cannot detect it.
 Tremor is tested by using a standard (eg. from a paper tablet) 3½ x 5 or similar size paper
on the extended hand. This picks up the finer tremor (if present in toxic encephalopathy) that
affects use of camera, binoculars, and other finer coordinated movements.
 Grip strength – hand dynamometer or squeezing (fingers, etc.). This is only impaired in
severely affected patients – neurologic and/or hand pain.
 Romberg – Look for sway 2 leg, eyes closed, and one leg eyes open.
 Head to toe – eyes open. Per standard method. Toxic encephalopathy unless severe will not
have major (near falling) changes, watch for more subtle changes.