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Observation

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  • Developmental stage, social interaction
  • Gross and fine motor movements, abnormal movements

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Vital Signs and Anthropometrics

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  • Growth charts, including FOC

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Mental Status

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  • LOC, ± GCS, ± Mini Mental Status Exam

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Cranial Nerves

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Cranial Nerve

Nerve

Exam

I

Olfactory

Test sense of smell

II

Optic

Perform funduscopic exam, visual acuity, visual fields, pupillary response

III

Oculomotor

Assess medial, superior, and inferior recti muscles, inferior oblique, and levator palpebra superioris muscles; cover/uncover test (Figure 22-1)

IV

Trochlear

Assess superior oblique muscle, cover/uncover test (Figure 22-1)

V

Trigeminal

Assess muscles of mastication, sensation to face and anterior scalp, corneal reflex

VI

Abducens

Assess lateral rectus muscle, cover uncover test (Figure 22-1)

VII

Facial

Assess facial muscles, taste (anterior 2/3 of tongue), parasympathetics to lacrimal and salivary gland

VIII

Auditory

Test hearing to finger rub, vestibular function

IX

Glossopharyngeal

Test gag and palate elevation

X

Vagus

Test gag and palate elevation

XI

Spinal accessory

Assess strength of trapezius and sternocleidomastoid

XII

Hypoglossal

Assess tongue bulk and atrophy, symmetry

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eFigure 22-1
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Innervation of the extraocular muscles. Cranial nerves are represented in parentheses next to the muscle of innervations (eg, R4 is right fourth cranial nerve). IO, inferior oblique; IR, inferior rectus; LR, lateral rectus; MR, medial rectus; SO, superior oblique; SR, superior rectus.

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Deep Tendon Reflexes

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  • 4+: Hyperreflexia with clonus
  • 3+: Hyperreflexia with spread across joint
  • 2+: Normal
  • 1+: Hyporeflexia
  • 0: No movement

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Motor

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  • Muscle bulk and tone
  • Assess pronator drift for subtle weakness
  • Muscle strength:
    • 5/5: Full strength
    • 4/5: Full ROM against light resistance
    • 3/5: Full ROM against gravity only
    • 2/5: Full ROM in horizontal plane (gravity eliminated)
    • 1/5: Trace (“flicker”) of movement
    • 0/5: No movement

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Coordination

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  • Cerebellum and basal ganglia testing
    • Finger to nose, heel to shin, rapid alternating movements
    • Assess for head tilt or tremor, fluidity of movement
    • Assess for abnormal movements
  • Assess gait in the forward and backward directions; heel, toe and tandem gait
  • Romberg test : Assess patient standing with feet together and eyes closed; if patient steps to the side or falls → positive test result (may indicate a disturbance in vestibular apparatus or proprioception)

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Sensory

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  • Test in all extremities (Figure 22-2)
    • Pin prick, temperature sensation (spinothalamic tract in anterior spinal cord)
    • Vibration, proprioception (posterior columns in posterior spinal cord)
    • Assess for sensory level on the trunk if concern for spinal cord lesion

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Miscellaneous Localizing Signs and Reflexes

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Maneuver

Description

Significance

Babinski ...

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