Neuro

Neurological Exam Dictation Reference Card

Mental Status

• Alertness & Orientation: Alert and oriented to person, place, time, and situation.
• Attention & Concentration: Able to perform serial 7s, spell “world” backwards.
• Memory: Immediate recall (3 words), recent (events of the day), remote (historical facts).
• Language: Fluent speech, comprehension, repetition, naming intact.
• Fund of Knowledge: Appropriate for age and education level.
• Abstract Thinking: Interprets proverbs correctly.
• Judgment & Insight: Recognizes deficits, makes appropriate decisions.

Cranial Nerves

Cranial Nerve I (Olfactory):

• Able to identify common odors bilaterally.

Cranial Nerve II (Optic):

• Visual Acuity: Snellen chart (e.g., 20/20).
• Visual Fields: Intact to confrontation.
• Fundoscopic Exam: Optic discs sharp, no papilledema, hemorrhages, or exudates.
• Pupillary Response: PERRLA, afferent pupillary defect absent.

Cranial Nerves III, IV, VI (Oculomotor, Trochlear, Abducens):

• EOM: Full in all directions, no nystagmus or diplopia.
• Ptosis: Absent.
• Pupils: Equal and reactive to light and accommodation.

Cranial Nerve V (Trigeminal):

• Sensation: Light touch, pinprick, temperature intact in ophthalmic, maxillary, and mandibular branches bilaterally.
• Motor: Masseter and temporalis muscles strong and symmetric with jaw clenching.
• Corneal Reflex: Present bilaterally.

Cranial Nerve VII (Facial):

• Facial Movements: Symmetric smile, frown, eyebrow raise, eyelid closure, puffed cheeks.
• Taste: Anterior 2/3 tongue intact.

Cranial Nerve VIII (Vestibulocochlear):

• Hearing: Intact to whispered voice, Weber midline, Rinne AC>BC bilaterally.
• Vestibular Function: No spontaneous nystagmus, no vertigo.

Cranial Nerve IX, X (Glossopharyngeal, Vagus):

• Palate Elevation: Symmetric with phonation.
• Gag Reflex: Present bilaterally.
• Swallowing: Normal, no aspiration.
• Speech: No hoarseness or dysarthria.

Cranial Nerve XI (Spinal Accessory):

• Shoulder Shrug: Strong bilaterally (trapezius).
• Head Rotation: Strong bilaterally against resistance (sternocleidomastoid).

Cranial Nerve XII (Hypoglossal):

• Tongue Position: Midline, no atrophy or fasciculations.
• Strength: Equal resistance against cheek.

Motor System

• Muscle Bulk & Tone: Normal, no atrophy, spasticity, rigidity.
• Strength Testing (0-5 scale):
  • Upper Extremity: Shoulder abduction (C5), elbow flexion (C5-C6), elbow extension (C7), wrist extension (C6), grip strength (C7-T1).
  • Lower Extremity: Hip flexion (L2), knee extension (L3-L4), ankle dorsiflexion (L4-L5), great toe extension (L5), ankle plantarflexion (S1).
• Involuntary Movements: No tremors, fasciculations, chorea, or dystonia.

Reflexes

• Deep Tendon Reflexes (0-4+ scale):
  • Biceps (C5-C6)
  • Brachioradialis (C5-C6)
  • Triceps (C7-C8)
  • Patellar (L2-L4)
  • Achilles (S1-S2)
  • Jaw Jerk (CN V, brainstem lesion indicator if hyperreflexic)
• Plantar Reflex (Babinski): Normal (down-going toes), abnormal (up-going toes).
• Clonus: Absent or present (sustained beats).

Sensory System

• Light Touch: Intact throughout dermatomes.
• Pinprick: Intact or decreased in specific dermatomes.
• Temperature: Intact.
• Vibration: Intact at great toe and fingers (assess peripheral neuropathy).
• Proprioception: Intact at fingers and toes.
• Cortical Sensory Function:
  • Graphesthesia: Identifies traced numbers on palm.
  • Stereognosis: Recognizes common objects by touch.
  • Two-Point Discrimination: Normal or impaired.

Coordination & Cerebellar Function

• Finger-to-Nose Test: No dysmetria.
• Heel-to-Shin Test: Smooth, no dysmetria.
• Rapid Alternating Movements: Normal, no dysdiadochokinesia.
• Romberg Test: Negative (no instability with eyes closed).
• Pronator Drift: Negative (no downward drift or pronation).

Gait & Station

• Posture: Upright, no abnormal posturing.
• Gait: Normal, steady, symmetric.
• Tandem Walking: No difficulty.
• Heel & Toe Walking: Intact (tests L4-5 and S1).
• Ataxia: Absent or present.

Upper Motor Neuron Lesion Tests

• Babinski Sign: Toes down (normal) or up (UMN lesion).
• Clonus: Sustained beats indicate hyperreflexia.
• Hoffmann’s Sign: Finger flick test, positive suggests corticospinal tract lesion.

Meningeal Signs

• Brudzinski’s Sign: Neck flexion causes knee/hip flexion (meningitis).
• Kernig’s Sign: Inability to straighten leg when hip is flexed (meningitis).

Peripheral Nerve Tests

• Tinel’s Sign: Tap over nerve for irritation (carpal tunnel, cubital tunnel).
• Phalen’s Test: Wrist flexion causes numbness (median nerve compression).
• Froment’s Sign: Ulnar nerve dysfunction.

Neuromuscular Fatigue Tests

• Ice Pack Test: Myasthenia gravis (ptosis improves with cooling).
• Tensilon Test: Temporary muscle strength improvement (historical MG test).