1. Dr. Juan Ramón Meriño Smith. MSc Consultant Neurologist
ASSESSMENT OF THE NEUROLOGICAL SYSTEM
Dr. Juan Ramón Meriño Smith. MSc
Consultant Neurologist
The Gambia 2009

2. A complete Neurological assessment include:
Assessment of mental status and level of consciousness
Sensation
Cranial nerves
Motor and cerebellar function
Reflex

3. Assessment parameter
Assessment skill
Comments
Mental status.
Level of consciousness
Note general
appearance, affect,
speech content, logic,
memory, judgment and
speech patterns during
the history
If any abnormality or
Inconsistencies are evident, perform full mental status assessment
Perform GCS with
Motor and pupil
assessment
If GCS < 15 perform full assessment of mental status and consciousness
If motor assessment is abnormal or asymmetrical, perform complete motor and sensory assessment

4. Assessment parameter
Assessment skill
Comments
Sensation
Assess pain and vibration in
The hands and feet, light
Touch on the limbs
If deficits are identified, perform a complete sensory assessment
Cranial nerves
Assess CN II, III, IV, VI:
Visual acuity, gross visual fields, funduscopy examination, pupillary reaction and EOM
If any abnormalities exist, perform a complete assessment of all XII CN
Assess CN VII, VIII, IX, X, XII:
Facial expression, gross hearing, voice and tongue

5. Assessment parameter
Assessment skill
Comments
Motor system
Muscle tone and strength,
Abnormal movements, grasps
If deficits are noted, perform a complete motor system assessment
Cerebellar function
Observe the patient’s:
Gait on arrival
Ability to:
Walk heel-to-toe
Walk on toes
Walk on heels
Hop in place
3. Check Rhomberg’ s sign
If any abnormalities exist, perform a complete cerebellar assessment

6. Assessment parameter
Assessment skill
Comments
Reflexes
Assess the muscle stretch
reflex and the plantar
response
If an any abnormal response is elicited, perform a complete reflex assessment

7. GLASGOW COMA SCALE (GCS)
An international method for grading neurological response of the injured or severely ill patients. It is used for patients who have the potential for rapid deterioration.
The GCS assess three parameters of consciousness: eye opening, verbal response and motor response.
Verbal response
Eyes open
Motor response
Oriented
Confused
Inappropriate
Incomprehensible --- 2
None
Obey commands
Localize pain
Withdrawal
Flexion abnormal
Extension abnormal
None
Spontaneously
To speech
To pain
None

8. LEVEL OF CONSCIOUSNESS (LOC)
Response to stimuli
Pupil response
Pathophysiology
Prognosis
Confusion
GCS=14
Spontaneous but may be inappropriate. Memory faulty. Reflex intact
Normal
Metabolic derangement. Diffuse brain dysfunction
Good chance of recovery. Must treat primary cause
Lethargy GCS=13-14
Requires stimulus to respond (verbal, touch). Reflex intact
Normal to unequal
Metabolic derangement. Medications, Increased ICP
Superficial
Stupor
GCS=12-13
Requires vigorous continuous stimuli to respond
unequal or
sluggish

9. Responds to pain . No cognitive response. Reflexes abnormal Normal
LEVEL OF CONSCIOUSNESS (LOC)
LOC
Response to stimuli
Pupil response
Pathophysiology
Prognosis
Deep Stupor
GCS=8-10
(Permanent
Vegetative state)
Responds to pain . No cognitive response. Reflexes abnormal
Normal
Anoxic ischemic
insults
Irreversible
Superficial
Coma
GCS=6-8 Locked-in syndrome
Awake and aware respond with eyes only
Lesion in pons All four extremities and cranial nerves paralyzed. Myasthenia Gravis. Acute polyneuritis
Poor prognosis

10. LEVEL OF CONSCIOUSNESS (LOC)
Response to stimuli
Pupil response
Pathophysiology
Prognosis
Moderate coma
GCS=3-6
Abnormal.
Varied response to pain. Reflex abnormal or absent
Abnormal dilated or pinpoint
Anoxia. Traumatic injury. Space- occupying lesion. Cerebral edema
Prognosis depend on length of time in coma
Brain Death
GCS<3
No response
Reflexes abnormal or
absent
Anoxia.
Structural damage
Irreversible

11. Cranial Nerves Olfatory Optic Oculomotor Trochlear Trigeminal Abducens
VII. Facial
Acoustic
IX. Glossopharyngeal
X. Vagus
XI. Spinal accessory
XII. Hypoglossal
Cranial Nerves

12. REFLEXES Deep tendon reflexes Biceps Triceps Brachioradialis Patellar
Achilles
Superficial or cutaneous reflexes
Abdominal
Cremasteric
Plantar
Bulbocavernosus

13. C. Triceps
D. Patellar

16. CEREBELLAR FUNCTION Coordination: Gait Station: Rhomberg’s Test
Fingertip-to- Nose Touch
Rapid Alternating Hand
Movement
Heel Slide
Figure eight
Gait
Station:
Rhomberg’s Test

19. THANK YOU