Neurological Assessment and Examination
Systematic Approach
Assessment begins with level of consciousness (alert, verbal, painful, unresponsive) and the Glasgow Coma Scale (eye, verbal, motor; maximum 15). Then assess pupils (size, symmetry, reactivity), cranial nerves I–XII, motor strength (0–5 scale), deep tendon reflexes, sensation, coordination (finger-to-nose, heel-to-shin), and gait. Document a baseline so trends can be tracked.
Cranial nerve testing: II (visual acuity, fields), III/IV/VI (extraocular movements, pupils), V (facial sensation, jaw strength), VII (facial movement), VIII (hearing), IX/X (swallow, gag), XI (shoulder shrug), XII (tongue). A dilated, unreactive pupil with declining consciousness suggests uncal herniation and is an emergency.
Traps
Questions often test the difference between upper and lower motor neuron signs. Upper motor neuron lesions show spasticity, hyperreflexia, and a positive Babinski sign; lower motor neuron lesions show flaccidity, atrophy, fasciculations, and hyporeflexia. Another common trap is confusing a positive Babinski (abnormal in adults, indicates UMN lesion) with a normal plantar response. Also watch for questions that ask the earliest sign of deterioration - often a change in level of consciousness, not pupil change.
Worked Example
A patient has right-sided weakness, increased reflexes on the right, and a positive Babinski on the right. This is an upper motor neuron pattern, suggesting a left cerebral lesion (contralateral because the corticospinal tract crosses in the medulla).
Rule of Thumb
"UMN = tight and hyper; LMN = loose and hypo." Trend the GCS and pupils; a falling GCS is the earliest red flag.