Neurological Examination Templates

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.

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.

•  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.

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)

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)

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)

• 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

MOCA: ***

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