Neurological Exam in the Emergency Department – Study Notes

Why it matters

• Neuro exam is the most common exam in ED/urgent care.

• ~10 of the top 25 chief complaints are neurologic (headache, back pain, dizziness, weakness, vision changes, confusion, etc.).

• “Grandma’s not right” is a frequent vague complaint that requires a structured, reproducible exam.

General Principles

• Perform the exam the same way every time.

• Objective findings > subjective impressions.

• Document functional and safety-related deficits, not just symptoms.

• Always consider home safety (stairs, stove, fall risk).

Mental Status

• Three-object retention (banana, monkey, paper): recall after 15–120 seconds.

  • Normal = remembers all 3.

  • Abnormal = ≤2 → raises concerns about safety at home.

• Follow three-step commands (e.g., close eyes, touch right thumb to left ear, stick out tongue):

  • Tests attention, right-left orientation, and ability to follow sequential directions.

  • Inability suggests risk to self/others and documents confusion objectively.

• Orientation mapping: ask patient to point to the door they entered from → tests spatial memory and orientation.

Cranial Nerves

• Test selectively, not blindly “CN II–XII intact.”

• Speech and swallow → CN IX, X, XII grossly intact.

• Visual fields and pursuits → screen CN II, III, IV, VI.

• Smooth pursuit and cover/uncover test useful in dizziness/vertigo (basis for HINTS exam).

• Facial symmetry/smile → CN VII.

• Only document what you actually checked.

Motor Exam

• Pronator drift: arms outstretched, eyes closed.

  • Normal = arms remain steady.

  • Drift/pronation = corticospinal tract lesion.

  • Motor impersistence (inability to maintain position) = frontal lobe disease.

  • Searching movement of one limb = parietal lobe lesion.

• Romberg test: feet together, eyes closed.

  • Instability with foot out for balance → central balance system deficit.

• Watch gait, hallway navigation, and use of support rails → gives functional clues.

Reflexes

• Test bilaterally, top to bottom (jaw, arms, knees).

• Symmetry is key.

• Asymmetry → indicates lesion, often correlates with motor abnormalities.

Functional and Safety Assessment

• Can patient monitor limbs in space without vision?

• Can they maintain balance without external support?

• Do they show evidence of neglect, motor impersistence, or unsafe cognitive patterns?

• Answers guide admission vs. discharge decisions.

Key Takeaways

• Use structured, reproducible maneuvers:

  • Three-object recall.

  • Three-step commands.

  • Pronator drift.

  • Romberg and gait.

• Document objective findings (e.g., “2/3 object recall at 2 minutes,” “unable to cross midline in 3-step task”) rather than vague statements like “not right.”

• Neuro exam is the gateway to diagnosis and safety decisions—not just finding lesions but determining functional capacity.

Summary: A focused, reproducible neurological exam in the ED assesses cognition, cranial nerves, motor function, reflexes, and safety.