Neurological Assessment 🧠
Bedside neurological assessment for NCHDs: screening vs focused exam, GCS, cranial nerves, MRC power grading, sensation, reflexes, coordination, gait, documentation, and escalation.
🧭 Clinical workflow
- 1. Triage urgency first: ABC, capillary glucose, GCS, and sudden focal signs (FAST). Treat time-critical stroke or seizure pathways before a leisurely full exam.
- 2. Decide screen vs focused exam. If the history suggests no neurology, a brief screen is enough. If symptoms or screening findings are abnormal, examine the relevant systems in detail.
- 3. Work systematically: mental status / GCS → cranial nerves → motor (MRC) → tone and reflexes → sensation → coordination → gait.
- 4. Localise the pattern (UMN vs LMN, hemispheric, brainstem, cord, root, nerve, muscle) and document clearly.
- 5. Escalate per red flags below and local stroke / neurology pathways. See NICE NG127 for recognition and referral of suspected neurological conditions.
🚨 Red flags / escalate
- Sudden focal neurology (face, arm, speech, vision, neglect): treat as stroke / TIA per local pathway until proven otherwise.
- Rapidly progressive symmetrical limb weakness (hours to days): immediate senior review; assess bulbar and respiratory function (?Guillain–Barré).
- Rapidly progressive gait ataxia (days to weeks): urgent neurology / suspected cancer pathway referral (NICE NG127).
- New seizure features with blackout, meningism, declining GCS, or suspected raised ICP: ABC, senior, imaging as indicated.
- Suspected cauda equina (saddle anaesthesia, new urinary retention / incontinence, bilateral leg signs): urgent MRI and spinal team per local protocol.
- Fever with neck stiffness, photophobia, or rash: meningitis / encephalitis pathway.
- GCS falling or fluctuating: senior review; do not attribute to “sleep” without a documented neuro exam.
🧰 Before you start
- Explain what you are doing and obtain verbal consent. Offer a chaperone for intimate elements if needed.
- Position: ideally sitting or supine with enough space to assess gait. Expose limbs adequately; compare sides.
- Have: tendon hammer, Neurotip or similar, 128 Hz tuning fork if available, pen torch, cotton wool / fingertip.
- Check capillary glucose early if altered consciousness, stroke-like symptoms, or unknown history.
- Tailor depth to the question. Purpose beats ritual (MRCP PACES principle): know why each manoeuvre is included.
🧠 Mental status & consciousness
- Alertness and orientation to person, place, and time during history-taking.
- Language: fluency, comprehension, naming, repetition. Note dysarthria vs dysphasia.
- GCS if reduced consciousness or head injury: Eyes / Verbal / Motor. Record the three numbers, not only the total. Use the GCS calculator topic.
- If drowsy or confused, also document attention, following commands, and any fluctuation (delirium).
👁️ Cranial nerves (screen)
- II: visual acuity (each eye), confrontation fields, pupils (size, reactivity, RAPD), fundoscopy if headache / raised ICP concern.
- III, IV, VI: eye movements in H pattern; nystagmus; ptosis; diplopia.
- V: facial sensation (V1–V3), corneal reflex if indicated, jaw power if needed.
- VII: raise eyebrows, close eyes tightly, show teeth / smile. Upper face spared in UMN facial weakness.
- VIII: hearing (finger rub); Dix–Hallpike / HINTS only if trained and clinically indicated for vertigo.
- IX, X: palate elevation, voice, cough; gag only if indicated.
- XI: shoulder shrug / head turn against resistance.
- XII: tongue protrusion and fasciculations. Lower cranial nerves matter most when there is dysarthria or dysphagia.
💪 Motor system
- Inspection: wasting, fasciculations, posture, adventitious movements (tremor, myoclonus, chorea).
- Tone: passive movement at elbow, wrist, knee, ankle. Spasticity (clasp-knife) vs rigidity (lead-pipe / cogwheel).
- Pronator drift: arms outstretched, palms up, eyes closed. Drift or pronation suggests UMN lesion.
- Power: grade with MRC scale (table). Test key myotomes side-to-side. Fix the joint and feel the contraction.
- Key upper limb: shoulder abduction (C5), elbow flexion (C5–6), elbow extension (C7), wrist extension (C6–7), finger abduction (T1).
- Key lower limb: hip flexion (L2–3), knee extension (L3–4), ankle dorsiflexion (L4–5), great toe extension (L5), ankle plantarflexion (S1).
- Functional screens: heel and toe walking, deep knee bend, rising from a chair without hands.
0
- Finding
- No contraction
1
- Finding
- Flicker or trace of contraction
2
- Finding
- Active movement with gravity eliminated
3
- Finding
- Active movement against gravity
4
- Finding
- Active movement against gravity and resistance (use 4− / 4 / 4+ if helpful)
5
- Finding
- Normal power
| MRC grade | Finding |
|---|---|
| 0 | No contraction |
| 1 | Flicker or trace of contraction |
| 2 | Active movement with gravity eliminated |
| 3 | Active movement against gravity |
| 4 | Active movement against gravity and resistance (use 4− / 4 / 4+ if helpful) |
| 5 | Normal power |
🔨 Reflexes
- Biceps (C5–6), triceps (C7), brachioradialis (C6), knee (L3–4), ankle (S1). Compare sides.
- Plantars: stroke lateral sole. Extensor (Babinski) suggests UMN lesion after infancy.
- Grade roughly: 0 absent, 1+ reduced, 2+ normal, 3+ brisk, 4+ clonus. Clonus at ankle is abnormal.
- Absent reflexes with weakness: think LMN, neuropathy, or root. Brisk reflexes with weakness: think UMN / cord / brain.
✋ Sensation
- Modalities: light touch, pinprick (pain), temperature if available, vibration (128 Hz on bony prominence), proprioception.
- Demonstrate each modality on the sternum first. Ask whether sides feel the same, not “is this sharp?”
- Screen fingertips and toes. If abnormal or symptoms suggest a pattern, map dermatomes and major nerve territories.
- Look for patterns: hemisensory, sensory level (cord), glove-and-stocking, single root or peripheral nerve.
- Romberg: stand feet together, then close eyes. Sway or fall with eyes closed suggests proprioceptive (dorsal column / neuropathy) loss, not primary cerebellar disease.
🎯 Coordination & gait
- Finger–nose and heel–shin: look for intention tremor and past-pointing.
- Rapid alternating movements (dysdiadochokinesia).
- Gait: casual walk, tandem (heel–toe), turn. Note base width, arm swing, steppage, festination, circumduction.
- Cerebellar pattern reminder (DANISH): Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Speech, Heel–shin.
📝 Documentation
- Record GCS as E_ V_ M_ (and total). Note if a component is non-testable (e.g. intubated).
- Cranial nerves: state which were tested and any asymmetry.
- Power: MRC grades by muscle group or myotome, left and right. “Power 5/5 globally” is acceptable only after an adequate screen.
- Sensation: modalities tested and the pattern of any loss (do not invent precision you did not map).
- Reflexes: grade and plantars. Coordination and gait in plain language.
- Impression: localisation and urgency, then plan (imaging, stroke pathway, senior / neurology).
Related NICE guidance
NICENICE NG127 — Suspected neurological conditions: recognition and referral (2019)
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:11 ATRP / examination note: neurological assessment Patient: [age] [sex] Indication: [focal weakness / sensory change / headache / altered consciousness / gait / tremor / other] Capillary glucose: __ mmol/L 🧠 Consciousness / mental status: • GCS: E__ V__ M__ (total __) • Orientation: [person / place / time] • Speech: [normal / dysarthria / dysphasia — fluent / non-fluent / comprehension] 👁️ Cranial nerves: • Pupils: R __ mm [reactive/not] L __ mm [reactive/not] RAPD [Y/N] • Visual fields: [full / defect — describe] • Eye movements: [full / restriction / nystagmus / diplopia] • Face: [symmetric / UMN / LMN weakness — side] • Lower CNs (IX–XII): [NAD / abnormal — describe] 💪 Motor: • Tone: [normal / spastic / rigid / reduced] — side / limbs • Drift: [absent / present — side] • Power (MRC /5): UL: shoulder abd __/__ elbow flex __/__ elbow ext __/__ wrist ext __/__ finger abd __/__ LL: hip flex __/__ knee ext __/__ ankle DF __/__ EHL __/__ ankle PF __/__ • Plantars: R [↓/↑/mute] L [↓/↑/mute] 🔨 Reflexes: biceps __ triceps __ BR __ knee __ ankle __ (L/R) ✋ Sensation: [modalities tested] — pattern [NAD / hemisensory / level / glove-stocking / root / nerve] 🎯 Coordination / gait: • Finger–nose / heel–shin: [NAD / ataxia — side] • Gait / Romberg: [normal / abnormal — describe] 📋 Impression / localisation: [e.g. left hemispheric UMN / L5 root / length-dependent neuropathy / non-focal] 📌 Plan: • [CT / MRI / stroke pathway / senior / neurology / monitoring] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer