d. Neurological Assessment. There are two approaches to assessment of the
neurologic system, depending on the condition of the patient and his chief complaint. If
the patient is undergoing a routine health assessment, a screening level exam is
appropriate. If the patient's chief complaint relates to the neurologic system, a more
detailed assessment is required. A most important consideration is the cooperation and
participation of the patient. The following assessments should be made.
(1) Mental status. Assess the patients level of consciousness and
orientation to time, place, and person. Much of the mental status exam can be done
during the interview. The patient's orientation to person, place, and time are intact if he
knows who he is, where he is, and the time of day. Altered states of consciousness are:
Conscious--Alert, awake, aware of one's self and environment.
(b) Confusion--Disorientation in time. Irritability and/or drowsiness.
Misjudgment of sensory input. Shortened attention span. Decrease in memory.
(c) Delirium--Disorientation, fear. Misperception of sensory stimuli.
Visual and auditory hallucinations. Loss of contact with environment.
Stupor--Unresponsive, but can be aroused back to a near normal
Coma--Unresponsive to external stimuli.
Akinetic mutism--Alert-appearing, immobile. Mental activity absent.
(g) Locked-syndrome--No effective verbal or motor communication.
Consciousness may be intact. EEG indicates a preservation of cerebral activity.
(h) Chronic vegetative state - Vital functions preserved with no evidence
of active mental processes. EEG indicates absence of cerebral activity.
(2) Pupillary reaction. Examine the pupils for briskness, symmetry, and
accommodation. Pupils are normally round and can range in size from "pinpoint" to
occupying the entire space of the iris. Pupils normally constrict with increasing light and
accommodation (ability of the lens to adjust to objects at varying distances).
(3) Strength. Muscle strength is tested against the resistance of the examiner.
Strength will vary from person to person. Symmetrical responses are significant and
permit you to use the patient as his own control. Assess strength in all extremities, the
neck, and back.
(a) To assess strength in the upper extremities, have the patient squeeze
your first two fingers with both hands. The grip should be reasonably strong, but most
important; it should be equal in both hands. Apply resistance when the patient flexes the
wrist and elbow. Note any pain or weakness the patient has.