How to Write Up a Neurological Physical Exam

Exam Introduction and Vital Signs

• 1

  Record your name and title as the person obtaining the history.

• 2

  Record the date, time and place the examination occurred.

• 3

  Record the patient's name, age, race and gender.

• 4

  Obtain and record the patient's vital signs including temperature (note if oral, axillary, ear, or rectal), pulse, respiratory rate, pulse oximetry, blood pressure, height, weight, BMI (body mass index) and pain score (if appropriate).

General Examination

• 5

  Record in one sentence the patient's name, age, race and gender.

• 6

  Observe and record the patient's level of consciousness (full consciousness, lethargy, obtundation, stupor or coma).

• 7

  Observe and record the patient's mental status including mood (relaxed or distressed), speech (slurred or coherent), thought process (evasion or oriented to place and time), overall health (good or poor) and hygiene (excellent or fair).

Neurological Examination

• 8

  Assess and record the function of each of the cranial nerves that control facial movement (V and VII).

• 9

  Assess and record the function of each of the cranial nerves that control hearing and smell (VIII and I).

• 10

  Assess and record the function of each of the cranial nerves that control swallowing and palatal elevation (IX and X).

• 11

  Assess and record the function of each of the cranial nerves that control tongue extrusion (XII).

• 12

  Assess and record the function of each of the cranial nerves that control vision, extra-ocular muscle function and papillary light response (II, III, IV and VI).

• 13

  Assess and record the function of each of the cranial nerves that control shoulder shrug (XI).

Sensory and Reflex Examination

• 14

  Assess and record the deep tendon reflexes (biceps, brachioradialis, triceps, patellar and Achilles).

• 15

  Assess and record the plantar reflex.

• 16

  Assess and record vibratory sense in all four extremities.

• 17

  Assess and record sensation to pain and light touch in all four extremities.

• 18

  Assess and record proprioception in toes.

Motor Function Examination

• 19

  Assess and record strength in muscles such as deltoids, biceps, triceps, quadriceps and hamstrings.

• 20

  Assess and record cerebellar function for both upper and lower extremities by testing rapid, alternating movements.

• 21

  Perform assessments on balance and drift using the Romberg test and watching for pronation and drift at the same time.

• 22

  Observe and record the barefoot gait and natural stance of the patient.

• 23

  Observe and record the patient's ability to walk on his or her heels, toes and in a heel-to-toe manner.