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Normal Neurological Examination
CVS: RRR, no carotid bruit
CHEST: No signs of distress, on room air
ABD: Soft, NTTP
NEURO:
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 hipflexors/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 hipflexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.
REFLEXES: 2/4 throughout, bilateral flexor plantar 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.
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.
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 | Plantar | |
| 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.
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
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.
NIH Stroke Scale (NIHSS) +------------------------------+----------------------------------------------------+--------+ | Item | Description | Score | +------------------------------+----------------------------------------------------+--------+ | 1a. LOC | Alert, drowsy, stuporous, unresponsive | *** | | 1b. LOC Questions | Month and age | *** | | 1c. LOC Commands | Open/close eyes, grip/release hand | *** | | 2. Best Gaze | Horizontal eye movements | *** | | 3. Visual Fields | Upper and lower quadrants | *** | | 4. Facial Palsy | Smile, raise eyebrows | *** | | 5a. Motor Arm - Left | Arm drift | *** | | 5b. Motor Arm - Right | Arm drift | *** | | 6a. Motor Leg - Left | Leg drift | *** | | 6b. Motor Leg - Right | Leg drift | *** | | 7. Limb Ataxia | Finger-to-nose, heel-to-shin | *** | | 8. Sensory | Pinprick to face, arm, leg | *** | | 9. Best Language | Naming, repetition, comprehension | *** | |10. Dysarthria | Clarity of speech | *** | |11. Extinction & Inattention | Neglect, double simultaneous stimulation | *** | +------------------------------+----------------------------------------------------+--------+ Total NIHSS Score: *** / 42
Montreal Cognitive Assessment (MoCA) +----------------------------+-------------------------------------------------------+--------+ | Domain | Task | Score | +----------------------------+-------------------------------------------------------+--------+ | 1. Visuospatial/Executive | Trail Making (1 pt) | *** | | | Copy Cube (1 pt) | *** | | | Clock Drawing – Contour (1 pt) | *** | | | Clock Drawing – Numbers (1 pt) | *** | | | Clock Drawing – Hands (1 pt) | *** | | 2. Naming | Identify lion, rhino, camel (3 pts) | *** | | 3. Memory | Recall 5 words (delayed recall) | *** | | 4. Attention | Digit Span Forward (1 pt) | *** | | | Digit Span Backward (1 pt) | *** | | | Vigilance (tap at "A") (1 pt) | *** | | | Serial 7s subtraction (3 pts) | *** | | 5. Language | Repeat 2 complex sentences (2 pts) | *** | | | Verbal fluency (≥11 words in 60 sec) (1 pt) | *** | | 6. Abstraction | Similarities (e.g., train/bicycle, watch/ruler) (2) | *** | | 7. Delayed Recall | Recall 5 words (no cues) (5 pts) | *** | | 8. Orientation | Date, month, year, day, place, city (6 pts) | *** | +----------------------------+-------------------------------------------------------+--------+ Total MoCA Score: *** / 30 (Add 1 point if education <12 years)
<pre>
Mini-Cog Cognitive Screening
+-----------------------+---------------------------------------------------+--------+
| Section | Task | Score |
+-----------------------+---------------------------------------------------+--------+
| 1. Word Registration | Give 3 unrelated words, then immediate recall | *** |
| 2. Clock Drawing | Draw clock face, place numbers, and hands | *** |
| | - Circle drawn? | (Y/N) |
| | - All numbers present & correct? | (Y/N) |
| | - Hands show correct time? | (Y/N) |
| 3. Delayed Recall | Recall original 3 words after distraction | *** |
+-----------------------+---------------------------------------------------+--------+
Interpretation: *** (Normal / Impaired)
</pre>
UPDRS Part III – Motor Examination +-----+-------------------------------------------------------------+--------+ | No. | Task | Score | +-----+-------------------------------------------------------------+--------+ | 1 | Speech | *** | | 2 | Facial Expression | *** | | 3 | Tremor at Rest (head, limbs) | *** | | 4 | Action/Postural Tremor of Hands | *** | | 5 | Rigidity (neck and limbs) | *** | | 6 | Finger Taps | *** | | 7 | Hand Movements (open/close hands) | *** | | 8 | Rapid Alternating Movements of Hands | *** | | 9 | Leg Agility | *** | | 10 | Arising from Chair | *** | | 11 | Posture | *** | | 12 | Gait | *** | | 13 | Postural Stability (pull test) | *** | | 14 | Global Bradykinesia/Hypokinesia | *** | +-----+-------------------------------------------------------------+--------+ Total UPDRS Part III Score: *** / 56 (Each item scored 0–4: 0 = normal, 4 = severe impairment)
Burke-Fahn-Marsden Dystonia Rating Scale – Motor (BFMDRS-M) +------------------+--------------------+-----------------------+ | Body Region | Severity (0–4) | Provoking Factor (0–4)| +------------------+--------------------+-----------------------+ | Eyes | *** | *** | | Mouth | *** | *** | | Speech/Swallow | *** | *** | | Neck | *** | *** | | Right Arm | *** | *** | | Left Arm | *** | *** | | Trunk | *** | *** | | Right Leg | *** | *** | | Left Leg | *** | *** | +------------------+--------------------+-----------------------+ Total Motor Score: *** / 120 (Each region: max 8 pts; 9 regions total)
Modified Ashworth Scale – Spasticity (0–4) +-----------+--------------------------------------------------------------+ | Score | Description | +-----------+--------------------------------------------------------------+ | 0 | No increase in muscle tone | | 1 | Slight increase in tone; catch & release, or min resistance | | 1+ | Slight increase in tone; catch & minimal resistance through | | | less than half of ROM | | 2 | More marked increase in tone through most of ROM | | 3 | Considerable increase in tone; passive movement difficult | | 4 | Affected part(s) rigid in flexion or extension | +-----------+--------------------------------------------------------------+ Assessment: • Muscle group tested: *** • Side: Left / Right • Score: ***
Barthel Index – ADLs (Max score: 100) +--------------------------+----------------------------+--------+ | Task | Description | Score | +--------------------------+----------------------------+--------+ | Feeding | Independent = 10 | *** | | | Needs help = 5 | | | | Dependent = 0 | | | Bathing | Independent = 5 | *** | | | Dependent = 0 | | | Grooming | Independent = 5 | *** | | | Dependent = 0 | | | Dressing | Independent = 10 | *** | | | Needs help = 5 | | | | Dependent = 0 | | | Bowel Control | Continent = 10 | *** | | | Occasional accidents = 5 | | | | Incontinent = 0 | | | Bladder Control | Continent = 10 | *** | | | Occasional accidents = 5 | | | | Incontinent = 0 | | | Toilet Use | Independent = 10 | *** | | | Needs help = 5 | | | | Dependent = 0 | | | Transfers (bed to chair) | Independent = 15 | *** | | | Major help = 10 | | | | Unable = 0 | | | Mobility (on level) | Independent = 15 | *** | | | Needs help = 10 | | | | Immobile = 0 | | | Stairs | Independent = 10 | *** | | | Needs help = 5 | | | | Unable = 0 | | +--------------------------+----------------------------+--------+ Total Score: *** / 100
Expanded Disability Status Scale (EDSS) Functional System Scores (0 = normal, 5–6 = severe dysfunction): • Pyramidal (motor): *** • Cerebellar (coordination): *** • Brainstem (speech/swallow/eye):*** • Sensory: *** • Bowel/Bladder: *** • Visual: *** • Cerebral (mental status): *** • Other: *** Ambulation & Disability Level: +-------+-------------------------------------------------------------+ | EDSS | Description | +-------+-------------------------------------------------------------+ | 0.0 | Normal neurologic exam | | 1.0 | No disability; minimal signs in 1 FS | | 2.0 | Minimal disability in 1 FS | | 3.0 | Moderate disability in 1 FS or mild in ≥2 FS; ambulatory | | 4.0 | Significant disability but ambulatory w/o aid (≥500m) | | 4.5 | Ambulates w/o aid, limited in activities (≥300m) | | 5.0 | Ambulatory w/o aid (200m); disability impairs full activity | | 5.5 | Ambulatory w/o aid (100m); disability limits activity | | 6.0 | Requires unilateral aid (cane/crutch) to walk ≥100m | | 6.5 | Requires bilateral aid to walk ≥20m | | 7.0 | Restricted to wheelchair; can transfer and propel self | | 7.5 | Wheelchair-bound; may need assistance for transfers | | 8.0 | Restricted to bed/chair; retains some self-care | | 8.5 | Bedridden; mostly dependent | | 9.0 | Helpless bed patient; can communicate/feed | | 9.5 | Totally dependent, no communication or self-care | | 10.0 | Death due to MS | +-------+-------------------------------------------------------------+ Assigned EDSS Score: *** / 10.0
Neuro-Ophthalmologic Examination Visual Acuity: • OD (right): *** (e.g., 20/20) • OS (left): *** (e.g., 20/80) • Note: ***(e.g., decreased in dim light, improved with pinhole) Pupils: • Size: OD: *** mm / OS: *** mm • Light response: Brisk / Sluggish / Non-reactive • RAPD (swinging flashlight): Present in *** eye / Absent • Light-near dissociation: Present / Absent Color Vision: • Ishihara plates (correct out of 14): OD: ***/14, OS: ***/14 • Red desaturation: Present in *** eye Visual Fields (confrontation or formal): • OD: Full / *** defect (e.g., central scotoma, hemianopia) • OS: Full / *** defect Extraocular Movements: • EOM: Full / Limited in *** • INO: Present / Absent (side: ***) • Gaze Palsy: *** horizontal / vertical • Nystagmus: Present (*** type) / Absent • Saccades: Delayed / Dysmetric / Normal • Smooth pursuit: Normal / Impaired • Skew deviation: Present / Absent Eyelids: • Ptosis: Absent / Present (*** eye) • Lid retraction / Collier sign: Present / Absent Optic Disc (Fundus exam or OCT if available): • OD: Sharp / Blurred, Color: Pink / Pale / Edematous • OS: Sharp / Blurred, Color: Pink / Pale / Edematous • Note: *** (e.g., papillitis, optic atrophy, disc cupping) Other: • Visual Hallucinations / Oscillopsia: Yes / No • Diplopia: Present (*** gaze) / Absent • Light-near dissociation / Argyll Robertson pupils: Yes / No Summary Impression: • Likely lesion location: *** (e.g., optic nerve, MLF, PPRF, dorsal midbrain)
Neurological Examination in Specific Situations:
Gen: Lying in bed, no acute distress
CVS: Regular rate and rhythm, no carotid bruits
CHEST: No signs of respiratory distress, breathing comfortably on room air
ABD: Soft, non-tender, non-distended
Neuro:
MS: Awake; alerts to name but inattentive; not consistently following commands
Language: Speaks in brief phrases; requires repeated prompting to follow simple commands
CNs: Pupils equal bilaterally at 3 mm, reactive to light; EOMI; face symmetric; tongue midline
Motor: Exam limited by poor cooperation; moves all four extremities spontaneously and symmetrically; estimated strength 4+/5 throughout
Sensory: Withdraws to noxious stimuli in all extremities
Reflexes: 2+ throughout; bilateral flexor plantar responses; no Hoffman's sign; no clonus
Coordination: No nystagmus or spontaneous appendicular ataxia observed
Gen: Lying in bed, eyes closed; not following commands consistently
CVS: Regular rate and rhythm, no carotid bruits
CHEST: No signs of respiratory distress
ABD: Soft, non-tender, non-distended
Neuro:
MS: Somnolent; awakens to repeated verbal or tactile stimuli; inattentive; occasionally tracks examiner but does not reliably follow commands
Language: Not consistently following simple commands; occasionally responds “yes” inappropriately
CNs: Pupils equal bilaterally at 3 mm, reactive to light; EOMI; face symmetric; tongue midline; remainder grossly intact to extent assessable
Motor: Exam limited by cooperation; withdraws equally to noxious stimuli in all extremities
Sensory: Reacts to pain in all extremities
Reflexes: 2+ throughout; plantar responses flexor bilaterally; no Hoffman's sign; no clonus
Coordination: No evident nystagmus or spontaneous ataxia
Gait: Deferred due to mental status
Gen: Lying in bed, eyes closed, not following commands
CVS: Regular rate and rhythm, no carotid bruits
CHEST: No signs of respiratory distress
ABD: Soft, non-tender, non-distended
Neuro:
MS: Stuporous; opens eyes only to painful stimuli; not attentive, not tracking, does not follow commands
Language: Non-verbal; unable to assess comprehension or expressive function due to unresponsiveness
CNs: Pupils equal bilaterally at 3 mm, reactive to light; cephalo-ocular reflex present; face symmetric; tongue midline; remainder grossly intact to extent assessable
Motor: Exam limited; withdraws equally to noxious stimuli in all extremities
Sensory: Reacts to pain in all extremities
Reflexes: 2+ throughout; plantar responses flexor bilaterally
Coordination: Deferred due to unresponsiveness
Gait: Deferred due to mental status
Gen: Laying in bed, eyes closed, no spontaneous movements
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress
ABD: Soft, NTTP
Neuro:
MS: no response to verbal or painful stimuli
Language: intubated - comatose
CNs: Pupils b/l equal 2mm with sluggish reaction, cephalo-ocular reflex intact, face symmetric, cough and gag present, rest of cranial nerves exam is limited by mental status.
Motor: no response to painful stimulation 0/5 throughout
Sensory: no response to pain
Reflexes: no reflexes could be elicited
Coordination: not assessed, patient is unresponsive
GAIT: deferred due to mental status
General: Lying in bed, no apparent distress; deeply sedated; no spontaneous movements
CVS: Regular rate and rhythm; no carotid bruits
Lungs: On mechanical ventilation; breath sounds clear bilaterally
Abdomen: Soft, non-tender, non-distended
Extremities: No edema or cyanosis
Neuro:
Mental Status: Unresponsive; sedated on propofol
Language/Speech: Non-verbal due to sedation
Cranial Nerves: Pupils equal and reactive to light; face symmetric; poor cough and gag response to suctioning; remainder deferred due to sedation
Motor: No spontaneous movement; no withdrawal to noxious stimuli bilaterally (consistent with sedation)
Reflexes: Hyporeflexic throughout
Sensory: No reaction to pain in upper or lower extremities
Coordination: Deferred due to sedation
Gait: Deferred due to sedation
General: No apparent distress
CVS: Regular rate and rhythm; no carotid bruits
Chest: No signs of respiratory distress; breath sounds clear bilaterally
Abdomen: Soft, non-tender, non-distended
Extremities: No edema or cyanosis
Neuro:
Mental Status: Awake, alert, globally aphasic; unable to assess fund of knowledge
Language/Speech: Global aphasia
Cranial Nerves:
CN II: Pupils equal and reactive to light; no RAPD; right homonymous hemianopia
CN III, IV, VI: EOMI; left gaze preference
CN VII: Right lower facial weakness (upper motor neuron pattern)
CN VIII: Normal hearing to speech
Remaining cranial nerves grossly intact
Motor:
Withdraws right upper and lower extremities to pain; no spontaneous movement
5/5 strength in left upper and lower extremities
Reflexes: 2+ throughout; right extensor plantar response
Sensory: Reacts to noxious stimuli in all extremities
Gait: Deferred due to right-sided weakness
MENTAL STATUS: Alert and oriented to person, place, and time
LANGUAGE/SPEECH: Dysarthric but able to name and repeat; follows commands appropriately
CRANIAL NERVES:
CN II: Pupils equal and reactive to light; no RAPD; left homonymous hemianopia
CN III, IV, VI: EOMI; right gaze preference; no nystagmus
CN V: Facial sensation intact bilaterally
CN VII: Left lower facial weakness (UMN pattern)
CN VIII: Normal hearing to speech
Remaining cranial nerves intact
MOTOR:
1/5 strength in left upper and lower extremities
5/5 strength in right upper and lower extremities
REFLEXES: 2+ throughout; left extensor plantar response
SENSORY: Decreased pinprick and light touch on the left side
COORDINATION: Normal finger-to-nose on right; no dysmetria or tremor
GAIT: Deferred due to weakness
GEN: No acute distress; pleasant and cooperative
CVS: Regular rate and rhythm; no carotid bruits
CHEST: No signs of respiratory distress; breathing comfortably on room air
ABD: Soft, non-tender, non-distended
NEURO:
Mental Status: Alert, attentive, and oriented to time, place, and person
Speech: Clear and fluent with intact repetition, comprehension, and naming; recalls 3/3 objects at 5 minutes
Cranial Nerves:
CN II: Visual fields full to confrontation; fundi with sharp discs; pupils 4 mm and briskly reactive to light; visual acuity 20/20 bilaterally
CN III, IV, VI: EOMI; no nystagmus or ptosis
CN V: Sensation intact to pinprick in all three divisions bilaterally
CN VII: Face symmetric with normal eye closure and smile
CN VIII: Hearing intact to finger rub
CN IX, X: Palate elevates symmetrically; phonation normal
CN XI: Intact shoulder shrug and head rotation
CN XII: Tongue midline, full range of motion, no atrophy or fasciculations
Motor: No pronator drift; muscle bulk normal; strength 5/5 throughout. Increased tone (rigidity) in bilateral upper and lower extremities and neck
Tested muscle groups: Deltoids, biceps, triceps, wrist extensors, finger abductors, hip flexors/extensors, knee flexors/extensors, ankle dorsiflexors/plantarflexors
Reflexes: 2+ and symmetric at biceps, triceps, knees, and ankles; plantar responses flexor bilaterally
Sensory: Intact to light touch, pinprick, vibration, and proprioception in fingers and toes
Coordination: No dysmetria on finger-to-nose and heel-to-shin; rapid alternating movements and fine motor movements intact; Romberg negative; no tremor or choreiform movements observed
Gait/Stance: Stooped posture; short-stepped gait with decreased arm swing bilaterally; turns in block; no freezing or festination observed
UPDRS Part III (Motor Exam):
Scored 0 (normal) to 4 (severe impairment):
- Speech:
- Facial expression:
- Resting tremor:
- Postural/action tremor:
- Rigidity:
- Finger taps:
- Hand movements:
- Rapid alternating movements:
- Leg agility:
- Arising from chair:
- Posture:
- Gait:
- Postural stability:
- Body bradykinesia/hypokinesia:
Total Score: ___
Gen: Laying in bed, no apparent distress
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft,non-tender, non-distended.
Neuro:
Mental status:
- Alertness: Alert
- Attention: Normal span; able to spell "WORLD" backward; able to perform serial 7s
- Orientation: Oriented to person, place, and time
- Psychomotor activity: Normal
- Affect: Normal
- Judgment: Fair
- Insight: Fair
- Memory: Impaired delayed recall (1/3 objects at 5 minutes); intact long-term memory
- Executive Function: Able to replicate a cube and draw a clock face
- Abstraction: Intact (e.g., relates fruit, tools appropriately)
- Language: Fluent, no paraphasias
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 plantar response, no Hoffman's, no clonus
Coordination no observed nystagmus or appendicular ataxia on spontaneous movements
MOCA: ***
General: Patient lying in bed, alert, no acute distress.
CVS: Regular rate and rhythm, no carotid bruits.
Chest: No signs of respiratory distress, breathing comfortably on room air.
Abdomen: Soft, non-tender, non-distended.
Neurologic Examination:
Mental Status:
- Level of alertness: Awake, maintains eye contact
- Psychomotor activity: Normal
- Speech: Fluent, normal articulation, no paraphasias
- Mood/Affect: Mood stable; affect appropriate and congruent
- Insight and Judgment: Insight limited; judgment fair
- Orientation: Oriented to person and place; disoriented to date and day
- Attention/Concentration: Spelled “WORLD” backward with 2 errors; performed serial 7s to 86 with one error
- Memory: Immediate recall 3/3; delayed recall 1/3 at 5 minutes; remote memory intact
- Executive Function: Drew a clock accurately; replicated a cube with minor distortion
- Abstraction: Identified similarities between paired items (e.g., apple/orange, car/train)
- Language: Naming intact; repetition accurate; followed two-step commands; able to read and write a sentence
Cranial Nerves:
- CN II: Pupils equal, 3 mm, reactive to light; no APD
- CN III, IV, VI: EOMI, no nystagmus
- CN V: Sensation intact to light touch and pinprick
- CN VII: Facial movements symmetric
- CN VIII: Responds to conversational speech
- CN IX, X: Palate elevates symmetrically; gag reflex present
- CN XI: Shoulder shrug symmetric
- CN XII: Tongue midline, no atrophy or fasciculations
Motor:
- Tone and bulk normal
- Strength: Moves all limbs spontaneously; estimated 4+/5 throughout; followed simple commands inconsistently
Sensory: Pinprick and light touch intact in all extremities and face bilaterally
Reflexes: 2+ throughout; plantar responses flexor bilaterally; no Hoffman's, no clonus
Coordination: No spontaneous or intention tremor. No dysmetria on available movement
Gait: Normal
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