Immersion Neurologic Exam
After Immersion, you should be able to perform the following:
Assess mental status
- Level of consciousness
- Orientation
Assess cranial nerves II-XII
- Test visual acuity and visual fields for each eye alone (CN II)
- Test pupillary reaction (CN II and III)
- Test eyelid opening (CN III)
- Test extra-ocular movements (CN III, IV, VI), observing for nystagmus (CN VIII)
- Test facial sensation & muscles of mastication (CN V)
- Test muscles of facial expression (CN VII)
- Test hearing (CN VIII)
- Test palatal rise to phonation (CN IX and X)
- Test sternocleidomastoid & upper trapezius muscle strength (CN XI)
- Test tongue protrusion (CN XII)
Assess motor function
- Evaluate strength and bulk of:
- Upper extremity muscle groups: Shoulder abductors, arm flexors and extensors, wrist flexors and extensors, finger flexors, finger abductors
- Lower extremity muscle groups: Hip flexors, extensors, abductors and adductors; knee flexors and extensors, foot dorsiflexors and plantar flexors
- Assess for pronator drift
Assess reflexes
- Upper extremity: Biceps, triceps, and brachioradialis
- Lower extremity: Patellar, Achilles and plantar
Assess sensation
- Compare light touch on the bilateral arms and legs
Assess cerebellar function
- Finger to nose test
- Heel to shin test
- Gait
- Romberg test (tests sensation and cerebellar function)
A comprehensive neurologic exam assesses six domains.
- Mental status
- Cranial nerves
- Motor function
- Reflexes
- Sensation
- Cerebellar function
You can think of the neurologic exam as ‘head to toe’. Mental status is all about the brain, the cranial nerves assess head and shoulders, and the motor, reflex and sensory exams assess the rest of the body, usually from superior (upper extremities) to inferior (legs and feet).
In Immersion, focus on repetition, developing the muscle memory to perform the exam smoothly. Understanding your findings requires more knowledge of neuroanatomy and physiology than can be covered here. We’ll spend another afternoon on this in your Mind, Brain and Behavior block.
Demonstration Exam
Dr. Breana Taylor, a neurologist and Cascade College faculty, demonstrates a complete neurologic exam assessing all 6 domains, including visual acuity, visual fields, and hearing, which you also saw demonstrated in the Head and Neck exam. These can be performed in either section depending on the patient’s chief concern but you only need to do them once.
Each section of the neurologic exam is discussed in more detail in the next six chapters – navigate through them using the arrows at the bottom or the menu at left.
Sample documentation of a detailed neurologic exam
Mental Status: Alert and appropriate, oriented to person, place, and time.
Cranial nerves:
II: Visual acuity 20/30 (tested with pocket visual screener)
III,IV,VI: Full extraocular movements
V: Masseter strength intact, sensation intact to light touch
VII: Symmetric facial expressions
VIII: Hearing intact to rubbed fingers bilaterally
IX,X: Palate elevates symmetrically with phonation
XI: Strong head turn and shoulder shrug bilaterally
XII: Tongue protrudes symmetrically
Motor Function: 5/5 strength in distal and proximal muscle groups in both upper and lower extremities. No pronator drift.
Deep Tendon Reflexes: Reflexes 2+ and symmetric at biceps, triceps, brachioradialis, patellar, Achilles. Toes downgoing bilaterally.
Sensation: Intact to light touch sense in upper and lower extremities.
Cerebellar Function: Finger to nose and heel to shin intact bilaterally without dysmetria.
Gait: Stable
Adaptations in the hospital
Many of your hospital patients will not be able to sit or stand. Here Dr. Taylor recommends adaptations to the motor and reflex exam for patients who are supine in bed.
