A neurological examination is an essential component of a comprehensive
physical examination. It is a systematic examination that surveys the
functioning of nerves delivering sensory information to the brain and
carrying motor commands (peripheral nervous system) and impulses back to
the brain for processing and coordinating (central nervous system).
A careful neurological evaluation can help to determine the cause of
impairment and help a clinician begin to localize the problem. Symptoms
that occur unexpectedly suggest a blood vessel or seizure problem. Those
that are not so sudden suggest a possible tumor. Symptoms that have a
waning course with recurrences and worsen over time suggest a disease that
destroys nerve cells. Others that are chronic and progressive indicate a
degenerative disorder. In cases of trauma, symptoms may be evident upon
inspection and causes may be explained by third party witnesses. Some
patients may require extensive neurological screening examination (NSE)
and/or neurological examination (NE) to determine the cause. The NE will
assist the clinician in diagnosing illnesses as diverse as seizure
, migraine disorders,
, and dementia.
A neurological screening is an essential component of every comprehensive
physical examination. In cases of neurological trauma, disease, or
psychological disorders, patients are usually given an in-depth
neurological examination. The examination is performed in a systematic
manner, which means that there is a recommended order for procedures.
The NSE is basic procedure, especially in patients who have a general
neurological complaint or symptoms. The NSE consists of six areas of
The NE should be performed on a patient suspected of having neurological
trauma, or neurological or psychological diseases. The NE is performed in
a systematic and comprehensive manner. It consists of several
comprehensive and in-depth assessments of mental status, cranial nerves,
motor abilities, reflexes, sensory acuity, and posture and walking (gait)
MENTAL STATUS EXAMINATION (MSE)
There are two types of MSE, informal and formal. The informal MSE is
usually done as clinicians are obtaining historical information from a
patient. The formal MSE is performed for a patient suspected of a
neurological problem. The patient is commonly asked his/her name, the
location, the day, and date. Determining the number of digits that can be
repeated in sequence can assess retentive memory capability and immediate
recall. Recent memory is typically examined by testing recall potential of
a series of objects after defined times, usually within five and 15
minutes. Asking the patient to review in a coherent and chronological
fashion his or her illness or personal life events can provide the
opportunity for assessment of remote memory. Patient recall of common
historical or current events can be used to assess general knowledge.
Brain processing capabilities can be assessed by spontaneous speech,
repetition, reading, naming, writing, and comprehension. Modifications can
be made based on the age and maturity of the child. The child may be asked
to perform tasks such as identification of fingers, whistling, saluting,
brushing teeth motions, combing hair, drawing, and tracing figures. These
procedures allow for assessment of dominant (left-sided brain) functioning
or higher cortical function.
The MSE is particularly important in psychotherapy. Psychotherapists
recommend an in-depth MSE for all patients with possible organic
(physiologica) or psychotic disorders. This examination is also performed
in a systematic and orderly manner. It is divided into several categories:
CRANIAL NERVES (CN)
Cranial nerves are nerves that originate in the brain and connect to
specialized structures such as the nose, eyes, muscles in the face, scalp,
ear, and tongue.
The motor examination assesses the patient's muscle strength,
tone, and shape. Muscles could be larger than expected (hypertrophy) or
smaller due to tissues destruction (atrophy). It is important to assess if
there is evidence of twitching or abnormal movements. Involuntary
movements due to
can be observed. Additionally, movements can be abnormal during
maintained posture in some neurological disorders. Muscle tone is usually
tested by applying resistance to passive motion of a relaxed limb. Power
is assessed for movements at each joint. Decreases or increases in muscle
tone can help the examiner localize the affected area.
The patient's reflexes are tested by using a special instrument
that looks like a little hammer. The clinician taps the rubber triangular
shaped end in several different areas in the arms, knee, and Achilles heel
area. The clinician will ask the patient to relax and gently tap the area.
If there is a difference in response from the left to right knee, then
there may be an underlying problem that merits further evaluation. A
difference in reflexes between the arms and legs usually indicates of a
lesion involving the spinal cord. Depressed reflexes in only one limb,
while the other limb demonstrates a normal response usually indicates a
peripheral nerve lesion.
Although an essential component of the NE, the sensory examination is the
least informative and least exacting since it requires patient
concentration and cooperation. Five primary sensory categories are
assessed: vibration (using a tuning fork), joint position (examiner moves
the limb side-to-side and in a downward position), light touch, pinprick,
and temperature. Patients who have sensory abnormalities may have a lesion
above the thalamus. Spinal cord lesions or disease can possibly be
detected by pinprick and temperature assessment.
The patient is asked to repetitively touch his nose using his index
finger and then to touch the clinician's outstretched finger.
Coordination can also be assessed by asking the patient to alternate
tapping the palm then the back of one hand on the thigh. For coordination
in the lower extremities (legs), the patient lies on his or her back and
is asked to slide the heel of each foot from the knee down the shin of the
opposite leg and to raise the leg and touch the examiner's index
finger with the big toe.
Normal walking is a complex process and requires use of multiple systems
such as power, coordination, and sensation, all working together in a
coordinated fashion. The examination of gait can detect a variety of
disease states. Decreased arm swinging on one side is indicative of
corticospinal tract disease. A high-stepped, slapping gait may be the
result of a peripheral nerve disease.
A neurologic examination is not invasive and there are no risks or dangers
associated with these tests. The results and validity of this exam may be
affected by the child's age and ability to cooperate.
The MSE is the first step in a continuous assessment to determine the
diagnosis. A psychotherapist should take a detailed medical history in the
process of ruling out a general medical condition. Little preparation is
needed for this assessment, but parents should explain to young children
what will happen in order to encourage their cooperation.
For suspected neurological diseases, the doctor uses information gained
from the NE for ordering further tests. These tests may include a complete
blood analysis, liver function tests, kidney function tests, hormone
tests, and a lumbar puncture to determine abnormalities in cerebrospinal
fluid. In trauma cases (e.g. car accident,
injury), the NE is a quick and essential component of emergency
assessment. Once a diagnosis is determined, emergency measures may include
further tests and/or surgery.
In psychological cases the treatment may include therapy and/or
medication. In cases of an acute insult such as trauma, the patient is
usually admitted to the hospital for appropriate treatment. Some
neurological diseases are chronic and require conservative medical
treatment and frequent follow-up visits for monitoring and stability or
progression of the disease.
The MSE and NE are good diagnostic tools. There are no risks associated
with initial neurologic assessment.
—A tract of nerve cells that carries motor commands from the
brain to the spinal cord.
—An involuntary response to a particular stimulus.
—A pair of oval masses of gray matter within the brain that relay
sensory impulses from the spinal cord to the cerebrum.
Haslam, Robert H. A. "The Nervous System." In
Nelson Textbook of Pediatrics
, 17th ed. Edited by Richard E. Behrman et al. Philadelphia: Saunders,
Jozefowicz, Ralph F. "The Neurologic History." In
Cecil's Textbook of Medicine
, 21st ed. Edited by Lee Goldman et al. Philadelphia: Saunders, 2000.
Blumenthal, Hal. "An Interactive Online Guide to the Neurologic
, 2001. Available online at http://www.neuroexam.com (accessed
January 16, 2005).