Health Assessment Exam #2 - Neurological System

CN I

Olfactory

Type: Sensory

Assessment: Test patency of nostrils; present familiar, non-irritating smells to each nostril with eyes closed

Expected Findings: Bilateral identification of distinct smells

Abnormal Findings/Clinical Significance: Ansomia (loss of smell); indicates nasal obstruction, smoking, or olfactory tract trauma

CN II

Optic

Type: Sensory

Assessment: Snellen chart for distant visual acuity, Rosenbaum card for near vision; confrontation test of peripheral fields

Expected Findings: 20/20 vision; intact peripheral visual fields

Abnormal Findings/Clinical Significance: Deficits in visual acuity, filed cuts (hemianopia); indicates ON dysfunction, glaucoma, or stroke

CN III

Oculomotor

Type: Motor

Assessment: Assess pupillary response to light (direct/consensual) and accommodation; test extra-ocular movements (EOMs) via 6 cardinal fields of gaze

Expected Findings: Equal, round pupils reacting to light and accommodation (PERRLA); smooth conjugate eye movements

Abnormal Findings/Clinical Significance: Ptosis (drooping eyelid), dilated/non-reactive pupil strabismus; indicated CN III compression (aneurysm, increased ICP)

CN IV

Trochlear

Type: Motor

Assessment: Assess EOMs; ask patient to look downward and inward (towards nose)

Expected Findings: Smooth downward and inward eye movement without nystagmus

Abnormal Findings/Clinical Significance: Inability to turn eye downward/ward; vertical diplopia (double vision)

CN V

Trigeminal

Type: Both

Assessment: Motor - palpate temporal/masseter muscle while patient clenches teeth; Sensory - light touch with cotton wisp on ophthalmic (V1), maxillary (V2), and mandibular (V3) facial regions

Expected Findings: Equal masseter contraction strength; accurate, bilateral facial sensation detection

Abnormal Findings/Clinical Significance: Weakness in jaw clenching; absent facial sensation; absent corneal reflex - indicated brainstem or nerve pathology

CN VI

Abducens

Type: Motor

Assessment: Assess EOMs; ask patient to move eyes laterally toward temples

Expected Findings: Smooth lateral tracking of both eyes

Abnormal Findings/Clinical Significance: Strabismus; inability to abduct eye laterally (medical deviation)

CN VII

Facial

Type: Both

Assessment: Motor - request facial expressions (smile, frown, raise eyebrows, close eyes tightly against resistance, puff cheeks); Sensory - taste on anterior 2/3 of tongue (rarely tested routinely)

Expected Findings: Symmetric facial movements; equal strength, air retained in puffed cheeks

Abnormal Findings/Clinical Significance: Facial droop, asymmetry, flattening of nasolabial fold, inability to close eye (Bell’s Palsy vs. Stroke)

CN VIII

Vestibulocochlear

Type: Sensory

Assessment: Whispered voice test at 1-2 feet; Weber and Rinne tuning fork tests if hearing deficit noted

Expected Findings: Whispered words repeated correctly bilaterally; Air conduction > Bone Conduction

Abnormal Findings/Clinical Significance: Sensorineural or conductive hearing loss, vertigo, tinnitus, unsteady balance

CN IX

Glossopharyngeal

Type: Both

Assessment: Assess swallowing; observe symmetrical elevation of soft palate and uvula when patient says “Ah”; gag reflex (when indicated)

Expected Findings: Uvula rises midline; symmetrical soft palate elevation; intact gag reflex

Abnormal Findings/Clinical Significance: Asymmetric uvula deviation; dysphagia; increased risk of airway

CN XII

Hypoglossal

Type: Motor

Assessment: Inspect tongue in mouth; ask patient to protrude tongue; test lingual speech sounds (“light, tight, dynamite”)

Expected Findings: Tongue protrudes in midline without atrophy, tremors, or weakness

Abnormal Findings/Clinical Significance: Tongue deviates to affected side upon protrusion; dysarthia; indicates lower motor neuron lesion

PERRLA

Pupils Equal

Round

Reactive to Light (direct and consensual)

Accommodation

Direct Light Reflex

Constriction of pupil in eye directly exposed to light source

Consensual Light Reflex

Simultaneous constriction of contralateral pupil when light is shone in opposite

• Pathophysiology - Light stimulus travels via CN II (afferent/sensory route) to brainstem, causing bilateral motor output via CN III (efferent route)

Anisocoria

Unequal pupil size

• Expected - Normal variant present in ~5% of population if pupillary light reflexes are intact and bilateral equal baseline exists

• Unexpected - New-onset unequal pupils; unilateral dilated non-reactive pupil indicates optic nerve damage, brain herniation, or acute CN III compression

Cortical Sensory Test

Stereognosis - Ability to recognize small, familiar object placed in hand with eyes closed

• Loss = Tactile agnosia (parietal lobe lesion)

Graphethesia - Ability to read a number or letter traced on palm with eyes closed

• Loss = Parietal lobe damage

Primary Sensory Tests

• Light Touch - Soft touch using cotton wisp across distal dermatomes bilaterally

• Pain Perception - Test discrimination between sharp and dull ends of a clean object

• Vibration Sensation - Apply a vibrating 128 Hz tuning fork over bony prominences (great toe, malleolus, fingers); loss of vibration sense at ankle is an early sign of peripheral neuropathy (ex., diabetes mellitus, aging)

Monofilament Test (Diabetic Neuropathy Screening)

• Press a 10g Semmes-Weinstein monofilament perpendicularly against 10 designated plantar sites until it bends slightly, holding for 1-2 seconds

• Inability to perceive touch at 4 or more sites indicates loss of protective sensation, conferring high risk for foot ulceration

DTR Grade 0

Description: No response/Absent

Interpretation: Abnormal (lower motor neuron lesion, severe neuropathy)

Intervention: Assess motor strength; check thyroid function/metabolic state

DTR Grade 1+

Description: Sluggish, diminished, low normal

Interpretation: May be normal or indicate motor deficits

Intervention: Compare bilaterally; re-evaluate after reinforcement

DTR Grade 2+

Description: Expected/Active normal

Interpretation: Normal neurological finding

Intervention: Document baseline finding

DTR Grade 3+

Description: Slightly hyperactive, brisk

Interpretation: May be normal variant or mild upper motor neuron sign

Intervention: Assess for systemic signs of irritability (e.g., preeclampsia)

DTR Grade 4+

Description: Very brisk, hyperactive with clonus

Interpretation: Abnormal (upper motor neuron lesion, stroke, spinal cord injury)

Intervention: Assess of Clonus - rapidly dorsiflex foot and hold; observe for rhythmic involuntary muscular contractions; notify provider

Stroke Evaluation (FAST)

F - Face drooping: Ask patient to smile; look for unilateral facial droop or asymmetry

A - Arm weakness: Ask patient to extend both arms forward with palms up for 10 seconds; look for arm drift or weakness

S - Speech difficulty: Check for slurred speech dysarthria, or inappropriate word choice (“light, tight, dynamite”)

T - Time to call EMS/Emergency Escalation: Immediate notification of stroke team; note time last seen normal

Critical Neurological Red Flag Signs

Sudden Severe “Thunderclap” Headache: Max intensity reached within seconds (“worst headache of life”)

• Pathophysiology: Subarachnoid hemorrhage

Acute Drop in Level of Consciousness (LOC): Sudden lethargy, obtundation, or stupor

Glasgow Coma Scale (GCS): Indicated severe brain injury or coma (C + V + M score)

• Safety Rule: “GCS 8, Intubate!”; patient cannot maintain airway reflexes; prioritize immediate airway protection and notify emergency response team

Cerebellar Assessment

Gait: Observe normal walking across 10-20 ft

• Expected: Smooth, rhythmic, effortless gait with reciprocal arm swing

Tandem Walking: Ask patient to walk straight line heel-to-toe

• Expected: Ability to maintain balance & straight line

Romberg Test: Ask patient to stand with feet together, arms at side, and close eyes for 20 seconds

• Expected (Negative Romberg): Minimal or no swaying

• Abnormal (Positive Romberg): Loss of balance, stepping out of stance when eye are close

  • Pathophysiology: Sensory ataxia, vestibular loss, or posterior column disease; Prioritize fall precautions