Neurological Examination Templates

Normal Neurological Examination

Normal Adult Exam

GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP

NEURO

MENTAL STATUS: AAOx3, memory intact, fund of knowledge appropriate

LANG/SPEECH: Naming and repetition intact, fluent, follows 3-step commands

CRANIAL NERVES:

  II: Pupils equal and reactive, no RAPD, no VF deficits, normal fundus

  III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.

  V: normal sensation in V1, V2, and V3 segments bilaterally

  VII: no asymmetry, no nasolabial fold flattening

  VIII: normal hearing to speech

  IX, X: normal palatal elevation, no uvular deviation

  XI: 5/5 head turn and 5/5 shoulder shrug bilaterally

  XII: midline tongue protrusion

MOTOR:

5/5 muscle power in Rt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors.  5/5 in Rt hip flexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.

 

5/5 muscle power in Lt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors.  5/5 in Lt hip flexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.

 

REFLEXES: 2/4 throughout, bilateral flexor planter response, no Hoffman's, no clonus

SENSORY:

Normal to touch, pinprick, vibration, temp all limbs

No hemineglect, no extinction to double sided stimulation (visual & tactile)

Romberg absent

COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria

STATION: normal stance, no truncal ataxia

GAIT: Normal; patient able to tip-toe, heel-walk.

Normal Adult Exam - Paragraph format

GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP

NEURO:

Mental Status: Alert and oriented x3. Language is fluent with good comprehension.

Cranial Nerve: Pupils are equal, round, and reactive to light. Visual fields are intact to confrontation. Normal fundi. Ocular movements are intact. Face is symmetric at rest and with activation with intact sensation throughout. Hearing intact to finger rub bilaterally. Muscles of tongue and palate activate symmetrically. No dysarthria. Strength is full in sternocleidomastoid and trapezius bilaterally.

Motor: Muscle bulk and tone are normal. Strength is 5/5 in all four extremities both proximally and distally. Intact fine motor movements bilaterally. There is no pronator drift or satelliting on arm roll.

Sensory: Sensation is intact to light touch, pinprick, vibration, and proprioception throughout. Romberg is negative.

Reflexes: 2+ and symmetric at the biceps, triceps, brachioradialis, patella, and Achilles bilaterally. Plantar response is flexor bilaterally.

Coordination: No dysmetria on finger-nose-finger or heel-knee-shin. Normal rapid alternating movements. Fast finger tapping with normal amplitude and speed.

Gait: Narrow based with normal stride length and good arm swing bilaterally. Able to walk on heels, toes, and in tandem.

Normal Adult Exam - Brief

GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of  distress, on room air
ABD: Soft, NTTP
NEURO: 
  MENTAL STATUS: AAOx3
  LANG/SPEECH: Fluent, intact naming, repetition & comprehension
  CRANIAL NERVES:
  II: Pupils equal and reactive, no RAPD, normal visual field and fundus
  III, IV, VI: EOM intact, no gaze preference or deviation
  V: normal
  VII: no facial asymmetry
  VIII: normal hearing to speech
  MOTOR: 5/5 in both upper and lower extremities
  REFLEXES: 2/4 throughout, bilateral flexor planters
  SENSORY: Normal to touch, temperature & pin prick in all extremiteis
  COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria

Normal Adult Neuro-Muscular Exam


GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP


NEURO:

  • Mental status: The patient is alert, attentive, and oriented.
  • Speech: clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes.
  • Cranial nerves:
    CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
    CN III, IV, VI: EOMI, no nystagmus, no ptosis
    CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally.
    CN VII: Face is symmetric with normal eye closure and smile.
    CN VII: Hearing is normal to rubbing fingers
    CN IX, X: Palate elevates symmetrically. Phonation is normal.
    CN XI: Head turning and shoulder shrug are intact
    CN XII: Tongue is midline with normal movements and no atrophy.
  • Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.
  Deltoid Biceps  Triceps  Wrist ext  Finger abd Hip flex Hip ext Knee flex Knee ext Ankle flex  Ankle ext
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
  •  Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.
  Biceps Brachio Triceps Knee Ankle Hoffman Crossed adductor Planter
R 2 2 2 2 2 - - down
L 2 2 2 2 2 - - down

Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.

Coordination:
Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent.

Gait/Stance:
Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes.

Normal Infant Exam

GEN: NAD
CVS: RRR,
CHEST: No signs of resp distress
ABD: Soft, NTTP
NEURO:
  HC:
  AF: Soft and flat
  Mental status: Alert, awake 
  CN: Pupils b/l equal and reactive, EOMI, VF seem intact, face symmetrical, facial sensation intact b/l, head turn seems normal.
  Motor: Moving all 4 extremities equally 
  Sensory: Intact to tickle in all 4 extremities and face b/l
  Reflexes: +ve b/l palmar and plantar grasp, +rooting, +suck, + moro's, b/l babinksi present

Normal Toddler Exam

GEN: NAD, pleasant, playing, running around in room. 
CVS: RRR,
CHEST: No signs of resp distress
ABD: Soft, NTTP
NEURO:
  Mental status: Alert, awake, oriented to mom, dad, playing
  Language: Speaks in one or two words.  
  CN: Pupils b/l equal and reactive, EOMI, VF seem intact, face symmetrical, facial sensation intact, haed turn seems normal.
  Motor: Moving all 4 extremities equally 
  Sensory: Intact to touch in all 4 extremities and face b/l
  Reflexes: 2/4 throughout, no Hoffman's, no clonus, bilateral flexor planter responses
  Coord/Rhombergs/Stance/Gait: walking and running in room, normal gait, no ataxia. 

Neurological Examination in Specific Situations:

Adult with encephalopathy, non-focal exam
Gen: Laying in bed, eyes closed, not following commands consistently
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
Neuro: 
  MS: Drowsy, awakens to repeated stimuli, not attentive, sometime tracks but not following commands. 
  Language: Not following simple commands, occasionally saying yes to random questions.
  CNs: Pupils b/l equal 3mm, reactive, EOMI seems intact, face symmetric, tongue midline. 
  Motor: Limited due to patient not following commands but moving all 4 extremities equally and spontaneously. Roughly 4+/5 throughout
  Sensory: Intact to pin prick in all 4 extremities and face bilaterally. 
  Reflexes: 2/4 throughout, bilateral flexor planter response, no Hoffman's, no clonus
  Coordination no observed nystagmus or appendicular ataxia on spontaneous movements

Right MCA occlusion - Acute, without mass effect

GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of  distress, on room air
ABD: Soft, NTTP
NEURO: 
  MENTAL STATUS: AAOx3
  LANG/SPEECH: dysarthria with intact naming and repetition
  CRANIAL NERVES:
   II: Pupils equal and reactive, no RAPD, Lt hemianopia
   III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.
   V: normal
   VII: Lt facial weakness
   VIII: normal hearing to speech
  MOTOR:
   3/5 in Lt upper extremity and 1/5 in Lt  lower extremity
   5/5 in Rt upper and lower extremity
  REFLEXES: 2/4 throughout, right extensor planter
  SENSORY: decreased to touch and PP in Lt side
  COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria

Left MCA occlusion - Acute, without mass effect

GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of  distress, on room air
ABD: Soft, NTTP
NEURO: 
  MENTAL STATUS: awake, alert, follows simple commands - non-verbal
  LANG/SPEECH: Expressive aphasia - follows simple commands
  CRANIAL NERVES:
   II: Pupils equal and reactive, no RAPD, Rt hemianopia
   III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.
   VII: Rt facial weakness
   VIII: normal hearing to speech
  MOTOR:
   3/5 in Rt upper and lower extremities  - drift present
   5/5 in Lt upper and lower extremities
  REFLEXES: 2/4 throughout, Rt extensor planter response
  SENSORY: reacts to pain in all limbs

Parkinson's Disease patient

--> Parkinsonian gait & bilateral rigidity, the rest of motor/sensory exam is normal - UPDRS motor part is added to describe parkinsonian features.

GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP


NEURO:
Mental Status:  The patient is alert, attentive, and oriented to time, place and person.
Speech: clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes.
Cranial nerves:
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: EOMI, no nystagmus, no ptosis
CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally.
CN VII: Face is symmetric with normal eye closure and smile.
CN VII: Hearing is normal to rubbing fingers
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact
CN XII: Tongue is midline with normal movements and no atrophy.

Motor: There is no pronator drift of out-stretched arms. Muscle bulk is normal. Strength is 5/5 throughout. Tone is increased (rigidity) in both upper and lower extremities and around the neck.
Deltoid Biceps Triceps Wrist ext Finger abd Hip flex Hip ext Knee flex Knee ext Ankle flex Ankle ext

Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.
Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.
Coordination: Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg test is negative.
Gait/Stance: Stooped posture, short steppage gait with decreased arm associative movements. Turns in block but no gait freezing.

UPDRS: (each item scored from 0 to 4, 0 is normal) -Speech
-Facial expression
-Resting tremors
-Postural/action tremors
-Rigidity
-Finger taps
-Hand movements
-Rapid alternating movements
-Leg agility
-Arising from a chair
-Posture
-Gait
-Postural stability
-Bradykinesia
TOTAL SCORE:

 

 

 

Notes for Neurological Exam Templates:

  • Although billing is not required for residents, it is a good habit for senior residents to learn and follow the correct billing maneuvers.
  • The "Normal Adult Exam" and its paragraph and neuromuscular versions are compatible with comprehensive exam requirements for highest level of billing (level III for admissions, V for consults and office visits) according to CMS.
    • Comprehensive single system exam (neurological) with auscultation of either the carotid or the heart.
  • For more information on billing, please refer to out page: Billing