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Appendix A Neurologic Examination

I. Mental Status ➤ o Ask the patient to say “Ahhh” and directly observe
• Level of Consciousness: Note whether the patient is: for symmetric palatal elevation.
➤ o Alert/responsive • Comatose patient:
➤ o Not alert but arouses to verbal stimulation ➤ o Check corneal reflexes; stimulation should trigger
➤ o Not alert but responds to painful stimulation eyelid closure.
➤ o Unresponsive ➤ o Observe for facial grimacing with painful stimuli.
• Orientation: Assess the patient’s ability to provide: Note symmetry and strength.
➤ o Name ➤ o Directly stimulate the back of the throat and look
➤ o Current location for a gag, tearing, and/or cough.
➤ o Current date III. Motor
➤ o Current situation (e.g., ask the patient what hap- • Tone: Note whether resting tone is increased (i.e.,
pened to him/her) spastic or rigid), normal, or decreased (flaccid).
• Language: Note the fluency and appropriateness of the • Strength: Observe for spontaneous movement of ex-
patient’s response to questions. Note patient’s ability to tremities and note any asymmetry of movement (i.e.,
follow commands when assessing other functions (e.g., patient moves left side more than right side). Lift
smiling, grip strength, wiggling toes). Ask the patient to arms and legs, and note whether the limbs fall im-
name a simple object (e.g., thumb, glove, watch). mediately, drift, or can be maintained against gravity.
• Speech: Observe for evidence of slurred speech. Push and pull against the upper and lower extremi-
II. Cranial Nerves ties and note any resistance given. Note any differ-
• All patients: ences in resistance provided between the left and
➤ o Assess the pupillary response to light. right sides.
➤ o Assess position of the eyes and note any movements (NOTE: it is often difficult to perform formal strength
(e.g., midline, gaze deviated left or right, nystagmus, testing in TBI patients. Unless the patient is awake and
eyes move together versus uncoupled movements). cooperative, reliable strength testing is difficult.)
• Noncomatose patient: • Involuntary movements: Note any involuntary move-
➤ o Test sensation to light touch on both sides of the face. ments (e.g., twitching, tremor, myoclonus) involving
➤ o Ask patient to smile and raise eyebrows, and observe the face, arms, legs, or trunk.
for symmetry. IV. Sensory

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