Neurological Examination Templates - NeurologyResidents (2024)

Normal Adult ExamExpand

GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of resp distress, on room air
ABD: Soft, NTTP
NEURO
MENTAL STATUS: AAOx3, memory intact, fund of knowledge appropriate
LANG/SPEECH: Naming and repetition intact, fluent, follows 3-step commands
CRANIAL NERVES:
II: Pupils equal and reactive, no RAPD, no VF deficits, normal fundus
III, IV, VI: EOM intact, no gaze preference or deviation, no nystagmus.
V: normal sensation in V1, V2, and V3 segments bilaterally
VII: no asymmetry, no nasolabial fold flattening
VIII: normal hearing to speech
IX, X: normal palatal elevation, no uvular deviation
XI: 5/5 head turn and 5/5 shoulder shrug bilaterally
XII: midline tongue protrusion
MOTOR:
5/5 muscle power in Rt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors. 5/5 in Rt hipflexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.

5/5 muscle power in Lt shoulder abductors/adductors, elbow flexors/extensors, wrist flexors/extensors, finger abductors/adductors. 5/5 in Lt hipflexors/extensors, knee flexors/extensors, ankle dorsiflexors and planter flexors.

REFLEXES: 2/4 throughout, bilateral flexor plantar response, no Hoffman's, no clonus
SENSORY:
Normal to touch, pinprick, vibration, temp all limbs
No hemineglect, no extinction to double sided stimulation (visual & tactile)
Romberg absent
COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria
STATION: normal stance, no truncal ataxia
GAIT: Normal; patient able to tip-toe, heel-walk.

Normal Adult Exma - Paragraph format Expand

GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP

NEURO:

Mental Status:Alert and oriented x3. Language is fluent with good comprehension.

Cranial Nerve:Pupils are equal, round, and reactive to light. Visual fields are intact to confrontation. Normal fundi. Ocular movements are intact. Face is symmetric at rest and with activation with intact sensation throughout. Hearing intact to finger rub bilaterally. Muscles of tongue and palate activate symmetrically. No dysarthria. Strength is full in sternocleidomastoid and trapezius bilaterally.

Motor:Muscle bulk and tone are normal. Strength is 5/5 in all four extremities both proximally and distally. Intact fine motor movements bilaterally. There is no pronator drift or satelliting on arm roll.

Sensory:Sensation is intact to light touch, pinprick, vibration, and proprioception throughout. Romberg is negative.

Reflexes:2+ and symmetric at the biceps, triceps, brachioradialis, patella, and Achilles bilaterally. Plantar response is flexor bilaterally.

Coordination:No dysmetria on finger-nose-finger or heel-knee-shin. Normal rapid alternating movements. Fast finger tapping with normal amplitude and speed.

Gait:Narrow based with normal stride length and good arm swing bilaterally. Able to walk on heels, toes, and in tandem.

Normal Adult Exam - Brief Expand

GEN: NAD, pleasant, cooperative
CVS: RRR, no carotid bruit
CHEST: No signs of distress, on room air
ABD: Soft, NTTP
NEURO:

MENTAL STATUS:AAOx3

LANG/SPEECH: Fluent, intact naming, repetition & comprehension

CRANIAL NERVES:

II: Pupils equal and reactive, no RAPD,normal visual field and fundus

III, IV, VI: EOM intact, no gaze preference or deviation

V: normal

VII: no facial asymmetry

VIII: normal hearing to speech

MOTOR: 5/5 in both upper and lower extremities

REFLEXES: 2/4 throughout,bilateral flexor plantars

SENSORY: Normal to touch, temperature & pin prick in all extremiteis

COORD: Normal finger to nose and heel to shin, no tremor, no dysmetria

Normal Adult Exam - Neuromuscular Expand

GEN: NAD, pleasant, cooperative

CVS: RRR, no carotid bruit

CHEST: No signs of resp distress, on room air

ABD: Soft, NTTP

NEURO:

• Mental status:The patient is alert, attentive, and oriented.
• Speech: clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes.
• Cranial nerves:
  CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
  CN III, IV, VI: EOMI, no nystagmus, no ptosis
  CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally.
  CN VII: Face is symmetric with normal eye closure and smile.
  CN VII: Hearing is normal to rubbing fingers
  CN IX, X: Palate elevates symmetrically. Phonation is normal.
  CN XI: Head turning and shoulder shrug are intact
  CN XII: Tongue is midline with normal movements and no atrophy.
• Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.

• Reflexes: Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.

Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.

Coordination:
Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent.

Gait/Stance:
Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes.

Normal Infact ExamExpand

Normal Toddler ExamExpand