Neurological Assessment
Dr. Belal Hijji, RN, PhD
February 13 & 15, 2012
Learning Outcomes
By the end of this lecture, students will be able to:
1. Describe the process of carrying out a neurologic assessment
of an adult patient.
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Neurologic Assessment 5 Components (4 are only
included due to time restraints)
• Examining the cerebral function
– Mental status: Is the patient oriented to time, place, & person?
– Intellectual function: Ask the patient to count backward from
100 or to subtract 7 from 100, then 7 from that, and so forth.
– Thought content: During the interview, find out whether the
patient’s thoughts are spontaneous, natural, clear, relevant, and
coherent? Does the patient have any fixed ideas, illusions, or
preoccupations?
– Emotional status: Is the patient’s affect (external manifestation
of mood) natural and even, or irritable and angry, anxious,
apathetic or euphoric? Does his or her mood fluctuate normally,
or does the patient unpredictably swing from joy to sadness
during the interview? Are verbal communications consistent
with nonverbal cues?
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• Examining the cerebral function (Continued…)
– Perception: Placing a familiar object (eg, key, coin) in the
patient’s hand and having him or her identify it with both eyes
closed is an easy way to assess tactile interpretation.
– Motor ability: Ask the patient to perform a skilled act (throw a
ball, move a chair). Successful performance requires the ability
to understand the activity desired and normal motor strength.
– Language ability: Does the patient answer questions
appropriately? Can he or she read a sentence from a newspaper
and explain its meaning? Can the patient write his or her name or
copy a simple figure that the examiner has drawn?
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• Examining the cranial nerves
– I (olfactory): With eyes closed, the patient identifies familiar
odors (coffee, tobacco). Each nostril is tested separately.
– II (optic): Snellen eye chart (See next slide); visual fields;
ophthalmoscopic examination.
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What do the numbers mean in 20/20?
The top number represents the distance between a person & chart.
The bottom number represents how far away a person with normal
vision can be from the chart and still read the letters in that line.
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• A person with normal vision can read the 20/20 line from 20
feet away. A person with 20/10 vision has better-than-normal
vision. He can read from 20 feet what a person with normal
vision must move up to 10 feet away to read. Conversely, a
person with 20/200 vision has poorer-than-normal vision. He
must be closer to the chart – he must be only 20 feet away to
clearly see what a normal person can read from 200 feet away.
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• Examining the cranial nerves (Continued…)
– (CN III, IV, VI): Hippus phenomenon: Apply pin light to pupils
and note their brisk constriction followed by dilation and
constriction.
Normal doll’s eyes: Eyes deviate to side opposite from way
head is turned.
Abnormal doll’s eyes (eyes fixed): Damage to oculomotor
nerves (CN III, IV, VI) or brainstem.
–V (trigeminal): Ask patient to close eyes and tell you when he or
she feels sensation on the face. Touch jaw, cheeks, and forehead
with cotton wisp. Touch same areas with toothpick. Compare both
bilaterally.
– VII (facial): Sweet: Tip of the tongue. Sour [‫]حامض‬: Sides of back
half of tongue. Salty: Anterior sides and tip of tongue. Bitter: Back
of tongue. Observe for symmetry while the patient performs facial
movements: smiles, whistles, elevates eyebrows, frowns, tightly
closes eyelids against resistance (examiner attempts to open them).
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• Examining the cranial nerves (Continued….)
–VIII (acoustic): Perform watch-tick test (left picture) by holding
watch close to patient’s ear. The Weber test (See right picture
below) is a hearing test for lateralization of sound.
–IX (glossopharyngeal): Assess patient’s ability to discriminate
between sugar and salt on posterior third of the tongue.
–X (vagus): Depress a tongue blade on posterior tongue, or
stimulate posterior pharynx to elicit gag reflex. Observe ability to
cough, swallow, and talk.
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• Examining the cranial nerves (Continued….)
–XI (spinal accessory): Palpate and note strength of trapezius
muscles while patient shrugs shoulders against resistance. Palpate
and note strength of each sternocleidomastoid muscle as patient
turns head against opposing pressure of the examiner’s hand.
–XII (hypoglossal): While the patient protrudes the tongue, any
deviation or tremors are noted. The strength of the tongue is tested
by having the patient move the protruded tongue from side to side
against a tongue depressor.
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• Examining the motor system
– Muscle strength: Ask the patient to flex or extend the extremities
against resistance. Using a five-point scale, assess muscle
strength. A 5, full range of motion against gravity and resistance;
4, full range of motion against gravity and a moderate amount of
resistance; 3, full range of motion against gravity only; 2, full
range of motion when gravity is eliminated; 1 indicates minimal
contractile power—weak muscle contraction can be palpated but
no movement is noted and 0, complete paralysis.
– Coordination: Instruct the patient to pat his or her thigh as fast as
possible with each hand separately. Then instruct him/ her to
alternately pronate and supinate the hand as rapidly as possible.
Lastly, ask the patient to touch each of the fingers with the
thumb in a consecutive motion. Note speed, symmetry, and
degree of difficulty. Have the patient touch the examiner’s
extended finger and then his/ her own nose. This is repeated
several times. This assessment is then carried out with the
patient’s eyes closed.
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• Examining the motor system (continued….)
– Balance: Ask the patient to stand with feet together and arms at
the side, first with eyes open and then with both eyes closed for
20 to 30 seconds. Slight swaying is normal, but a loss of balance
is abnormal and is considered a positive Romberg test.
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• Sensory examination: Eyes should be closed during exam.
– Tactile sensation: Lightly touch a cotton wisp to corresponding
areas on each side of the body. The sensitivity of proximal parts
of the extremities is compared with that of distal parts.
– Superficial pain perception: Ask the patient to differentiate
between the sharp and dull ends of a tongue blade; using a safety
pin is inadvisable because it breaks the integrity of the skin.
– Position sense (proprioception): Ask the patient to close both
eyes and indicate, as the great toe is alternately moved up and
down, in which direction movement has taken place.
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