Inquire about: convulsions, loss of consciousness, headache, vertigo, vision loss, difficulty hearing, tinnitus, swallowing, weakness, difficulty moving, abnormal movements, numbness and tingling, tremor, trouble walking and balance, control of sphincters and sexual activity, memory, thinking, sleep, and depressive symptoms.
Brief Examination
Mental state, eye movements, pupils, visual fields, facial movements and speech, strength in the upper and lower limbs, reflexes, painful and touch sensitivity of the hands and feet, static and dynamic balance.
Mental Status
Level of consciousness: alertness, drowsiness, coma.
Orientation: to time, place, name, date, etc.
Attention and concentration: repeats numbers, spells words.
Memory: immediate (repeats digits), recent (recalls words previously spoken by the examiner), remote.
Language and speech: fluency, coherence, reading, written comprehension, repetition (ask for sequential numbers, increasing until error).
Gnosis and praxis: distinguishing right and left, identifying objects by touch, imitating movements.
Mini-Mental State Examination
Gait and Balance
Gait types
Romberg test
Inspection
Palpation and Auscultation
Carotid arteries
Heart
Pulses
Orbits
Cranial Nerves
I (Olfactory): test each nostril separately.
II (Optic): visual fields, fundoscopy, and visual acuity.
III, IV and VI (Oculomotor, Trochlear, Abducens): eye movements and pupils (direct, indirect and convergence reflexes), palpebral fissure.
V (Trigeminal): sensation of the ophthalmic, maxillary and mandibular branches. Motor: masseter, pterygoid and temporal muscles (ask the patient to open the mouth). Corneal reflex.
VII (Facial): eyelid closure, whistling and smiling, forehead wrinkling, trapezius and platysma. Taste on the anterior tongue, tear production.
VIII (Vestibulocochlear): cochlear function: whisper test, Rinne and Weber tests. Vestibular function: caloric nystagmus or Romberg test.
IX and X (Glossopharyngeal and Vagus): palate and uvula symmetry, palatal reflex, cough, then swallowing, phonation, taste as above.
XI (Accessory): strength of the trapezius and sternocleidomastoid.
XII (Hypoglossal): tongue volume, symmetry and mobility.
Motor Function
Involuntary movements
Strength: flexion and extension, abduction and adduction. Graded from 0 to 5. Maneuvers: outstretched arms (pronator drift, Barré). Simulation tests (Hoover, Souque and Hait).
Tone: passive resistance of the limb during mobilization while the patient is relaxed. Spasticity (upper motor neuron lesion), rigidity (extrapyramidal), paratonia (frontal lobe lesions and thalamus).
Coordination: finger-to-nose test, diadochokinesis and rebound test. Heel-to-knee test. Sitting without support.
Reflexes: response speed, amplitude and relaxation. Grading: 0 = absent, 1+ hypoactive, 2+ normal, 3+ brisk, 4+ hyperactive with clonus, 5+ hyperactive with sustained clonus. Symmetry. Tested reflexes: masseter, triceps, biceps, quadriceps, Achilles, Hoffmann sign and clonus (e.g., patellar and ankle). Babinski sign and equivalents.
Sensation
Close the eyes and test contralateral areas.
Superficial (touch, pain and temperature): shoulders C4, forearm C6, T1; anterior thigh L2; calf L4; toe S1.
Deep (proprioception): tuning fork on bony extremities.
