MIRANDA, FRITZ CORTEZ BSN – 3C

NCM 116 March 4, 2022

Neurologic System Assessment

A. Neurologic Assessment
➢ Indications of the Assessment
o A complete and thorough evaluation of a person's nervous system is important if there is
any reason to think there may be an underlying problem, or during a complete physical.
Damage to the nervous system can cause problems in daily functioning. Early
identification may help to find the cause and decrease long-term complications. A
complete neurological exam may be done:
✓ During a routine physical
✓ Following any type of trauma
✓ To follow the progression of a disease

o If the person has any of the following complaints:

✓ Headaches
✓ Blurry vision
✓ Change in behavior
✓ Fatigue
✓ Change in balance or coordination
✓ Numbness or tingling in the arms or legs
✓ Decrease in movement of the arms or legs
✓ Injury to the head, neck, or back
✓ Fever
✓ Seizures
✓ Slurred speech
✓ Weakness
✓ Tremor

➢ Criteria, Scoring System, and Interpretation

o Mental status. Mental status (the patient's level of awareness and interaction with the
environment) may be assessed by conversing with the patient and establishing his or her
awareness of person, place, and time. The person will also be observed for clear speech
and making sense while talking. This is usually done by the patient's healthcare provider
just by observing the patient during normal interactions. Seven areas of mental status
need to be considered:
✓ Level of awareness.
✓ Attentiveness: Is the patient paying attention to you and your questions or is he
distractible and requiring re-focusing?
✓ Orientation: to self, place, time. Disorientation to time typically occurs before
disorientation to place or person. Disorientation to self is typically a sign of
psychiatric disease.
✓ Speech & language: includes fluency, repetition, comprehension, reading,
writing, naming.
✓ Memory: includes registration and retention.
 ✓ Higher intellectual function: includes general knowledge, abstraction, judgment,
insight, reasoning.
✓ Mood and affect: The primary purpose of assessing mood and affect in the
neurological exam is to determine if psychiatric disease may be interfering with
the neurological assessment. We’re not looking for a DSM-IV psychiatric
diagnosis.

o Motor function and balance. This may be tested by having the patient push and pull
against the healthcare provider's hands with his or her arms and legs. Balance may be
checked by assessing how the person stands and walks or having the patient stand with
his or her eyes closed while being gently pushed to one side or the other. The patient's
joints may also be checked simply by passive (performed by the healthcare provider) and
active (performed by the patient) movement.
❖ Strength should be graded. The following scale, originally developed by The
Medical Research Council of the United Kingdom, is now used universally:
✓ 0: No visible muscle contraction
✓ 1: Visible muscle contraction with no or trace movement
✓ 2: Limb movement, but not against gravity
✓ 3: Movement against gravity but not resistance
✓ 4: Movement against at least some resistance supplied by the examiner
✓ 5: Full strength

o Sensory exam. The patient's healthcare provider may also do a sensory test that checks
his or her ability to feel. This may be done by using different instruments: dull needles,
tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the
patient's legs, arms, or other parts of the body and have him or her identify the sensation
(for example, hot or cold, sharp or dull).

o Reflexes in the older child and adult. Reflex testing is the most objective part of the
neurological exam and is the least dependent on cooperation (but note that reflexes can
be reinforced or decreased voluntarily to some extent, as occurs in guarding). The muscle
stretch reflexes (a.k.a. “deep tendon reflexes,” which is incorrect terminology since it is
the indirect stretching of the muscle that elicits the reflex; the tendon just happens to be
conveniently located to apply the stimulus to) are obtained by placing the muscle in a
state of slight tension and then quickly tapping either the tendon or the periosteum to
which the muscle is attached and observing the vigor and briskness of the response. The
muscle contraction should be seen and felt and compared side-to-side. If reflexes are
diminished or absent, try reinforcing the reflex by distracting the patient or having the
patient contract other muscles (e.g., clench teeth). Note, however, that symmetrically
brisk, diminished, or even absent reflexes may be found in normal people. The muscle
stretch reflexes that are the most clinically relevant and that you should know how to
obtain include the biceps, triceps, knee, and ankle. The superficial (cutaneous) reflexes
are elicited by applying a scratching stimulus to the skin. The only superficial reflex that
you need to know other than the corneal is the plantar reflex. An abnormal plantar reflex
(extension of the great toe with fanning out of the other toes upon stimulation of the
plantar surface of the foot) is a specific indicator of corticospinal tract dysfunction and
may be the only sign of ongoing disease or the only residual sign of previous disease.
 ❖ Deep Tendon Reflexes are graded as follows:
✓ 0 = no response; always abnormal
✓ 1+ = a slight but definitely present response; may or may not be normal
✓ 2+ = a brisk response; normal
✓ 3+ = a very brisk response; may or may not be normal
✓ 4+ = a tap elicits a repeating reflex (clonus); always abnormal

o Evaluation of the nerves of the brain. The cranial nerves consist of nerves that exit
through foramina in the skull, not necessarily nerves that originate in the brain (though
most do). The following table lists the various testable functions of each of the cranial
nerves. The functions in bold are those that should be tested in a screening exam. I cannot
stress enough the importance of the fundoscopic exam in all patients from the standpoint
of both the general physical exam and the neurological exam. Visual acuity is certainly a
vital part of the general exam, but I did not include it as vital in the screening neurological
exam because the vast majority of impairment in visual acuity is due to refractive errors
rather than optic nerve dysfunction. There are 12 main nerves of the brain, called the
cranial nerves. During a complete neurological exam, most of these nerves are evaluated
to help determine the functioning of the brain:
▪ Cranial nerve I (olfactory nerve). This is the nerve of smell. The patient may be
asked to identify different smells with his or her eyes closed.
▪ Cranial nerve II (optic nerve). This nerve carries vision to the brain. A visual test
may be given and the patient's eye may be examined with a special light.
▪ Cranial nerve III (oculomotor). This nerve is responsible for pupil size and certain
movements of the eye. The patient's healthcare provider may examine the pupil
(the black part of the eye) with a light and have the patient follow the light in
various directions.
▪ Cranial nerve IV (trochlear nerve). This nerve also helps with the movement of
the eyes.
▪ Cranial nerve V (trigeminal nerve). This nerve allows for many functions,
including the ability to feel the face, inside the mouth, and move the muscles
involved with chewing. The patient's healthcare provider may touch the face at
different areas and watch the patient as he or she bites down.
▪ Cranial nerve VI (abducens nerve). This nerve helps with the movement of the
eyes. The patient may be asked to follow a light or finger to move the eyes.
▪ Cranial nerve VII (facial nerve). This nerve is responsible for various functions,
including the movement of the face muscle and taste. The patient may be asked
to identify different tastes (sweet, sour, bitter), asked to smile, move the cheeks,
or show the teeth.
▪ Cranial nerve VIII (acoustic nerve). This nerve is the nerve of hearing. A hearing
test may be performed on the patient.
▪ Cranial nerve IX (glossopharyngeal nerve). This nerve is involved with taste and
swallowing. Once again, the patient may be asked to identify different tastes on
the back of the tongue. The gag reflex may be tested.
▪ Cranial nerve X (vagus nerve). This nerve is mainly responsible for the ability to
swallow, the gag reflex, some taste, and part of speech. The patient may be asked
to swallow and a tongue blade may be used to elicit the gag response.
 ▪ Cranial nerve XI (accessory nerve). This nerve is involved in the movement of the
shoulders and neck. The patient may be asked to turn his or her head from side
to side against mild resistance, or to shrug the shoulders.
▪ Cranial nerve XII (hypoglossal nerve). The final cranial nerve is mainly responsible
for movement of the tongue. The patient may be instructed to stick out his or her
tongue and speak.

o Coordination & Gait. Test coordination at rest and with action, in the trunk (e.g., ability
to maintain an erect posture), and in the limbs. Impairment of coordination may be
detected through simple observation of the patient performing routine acts such as
signing his name, reaching for objects, or getting onto the examination table. Specific
tests to look for impaired coordination in the limbs include finger-to-nose (patient
alternately touches your outstretched finger and his nose), heel-knee-shin (patient runs
the heel of one foot down the shin of the other), rapid alternating movements (patient
alternately taps the dorsal and plantar surface of one hand onto the other hand), and
finger or toe tapping. In all cases, you should be looking at rhythm, steadiness, speed, and
precision of movements. Loss of the ability to judge and control distance, speed, and
power of a motor act is termed dysmetria. Since walking requires proper functioning of
the cerebellum and motor, sensory, and vestibular systems as well as a whole host of
reflexes, assessment of gait can provide important information to guide the focus of the
rest of the neurological exam. It is for this reason that many physicians like to watch the
patient walk at the very beginning of the exam. The specific aspects of gait for you to pay
attention to include body and extremity posture; length, speed, and rhythm of steps; base
of gait (how far apart are the legs); arm swing; steadiness; and turning. Testing tandem
gait (walking heel to toe) can be helpful, though many otherwise normal elderly patients
cannot perform the task. The screening exam must include an assessment of gait.

B. Glasgow Coma Scale

➢ Indications of the Assessment
o The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired
consciousness in all types of acute medical and trauma patients.

➢ Criteria, Scoring System, and Interpretation

o There are three aspects of behavior that are independently measured as part of an
assessment of a patient’s GCS – motor responsiveness, verbal performance and eye-
opening. The highest response from each category elicited by the healthcare professional
is scored on the chart.
o The highest possible score is 15 (fully conscious) and the lowest possible score is 3 (coma
or dead).

I. Eye-opening (E) - A maximum possible score of 4 points

✓ Eyes opening spontaneously (4 points)
- If the patient is opening their eyes spontaneously, your assessment of this
behavior is complete, with the patient scoring 4 points. You would then move
on to assessing verbal response, as shown in the next section. If however, the
patient is not opening their eyes spontaneously, you need to work through
the following steps until a response is obtained.
✓ Eyes opening to sound (3 points)
 - If the patient doesn’t open their eyes spontaneously, you need to speak to
the patient “Hey Mrs. Smith, are you ok?”
- If the patient’s eyes open in response to the sound of your voice
✓ Eyes opening to pain (2 points)
- If the patient doesn’t open their eyes in response to sound, you need to move
on to assessing eye-opening to pain.
- There are different ways of assessing response to pain, but the most common
are:
❖ Applying pressure to one of the patient’s fingertips
❖ Squeezing one of the patient’s trapezius muscles (known as a
trapezius squeeze)
❖ Applying pressure to the patient’s supraorbital notch
❖ If the patient’s eyes open in response to a painful stimulus
✓ No response (1 point)
- If the patient does not open their eyes to a painful stimulus
✓ Not testable (NT)
- If the patient cannot open their eyes for some reason (e.g. oedema, trauma,
dressings), you should document that eye response could not be assessed
(NT).

II. Verbal response (V) - A maximum possible score of 5 points

✓ Orientated response (5 points)
- If the patient is able to answer your questions appropriately, the assessment
of verbal response is complete.
✓ Confused conversation (4 points)
- If the patient is able to reply, but their responses don’t seem quite right (e.g.
they don’t know where they are, or what the date is), this would be classed
as confused conversation.
✓ Inappropriate words (3 points)
- If the patient responds with seemingly random words that are completely
unrelated to the question you asked, this would be classed as inappropriate
words.
✓ Incomprehensible sounds (2 points)
- If the patient is making sounds, rather than speaking words (e.g. groans) then
this would be classed as incomprehensible sounds.
✓ No response (1 point)
 - If the patient has no response to your questions.
✓ Not testable (NT)
- If the patient is intubated or has other factors interfering with their ability to
communicate verbally, their response cannot be tested

III. Motor response (M) - A maximum possible score of 6 points

✓ Obeys commands (6 points)
- If they are able to follow this command correctly.
✓ Localizes to pain (5 points)
- If the patient makes attempts to reach towards the site at which you are
applying a painful stimulus (e.g. head, neck) and brings their hand above
their clavicle, this would be classed as localizing to pain.
✓ Withdraws to pain (4 points)
- This is another possible response to a painful stimulus, which involves the
patient trying to withdraw from the pain (e.g. the patient tries to pull their
arm away from you when applying a painful stimulus to their fingertip).
- This response is also referred to as a “normal flexion response” as the patient
typically flexes their arm rapidly at their elbow to move away from the painful
stimulus.
- It differs from the “abnormal flexion response to pain” shown below due to
the absence of the other features mentioned (e.g. internal rotation of the
shoulder, pronation of the forearm, wrist flexion).
✓ Abnormal flexion response to pain (3 points)
- Abnormal flexion to a painful stimulus typically involves adduction of the arm,
internal rotation of the shoulder, pronation of the forearm and wrist flexion
(known as decorticate posturing).
- Decorticate posturing indicates that there may be significant damage to areas
including the cerebral hemispheres, the internal capsule, and the thalamus.
✓ Abnormal extension response to pain (2 points)
- Abnormal extension to a painful stimulus is also known as decerebrate
posturing.
- In decerebrate posturing, the head is extended, with the arms and legs also
extended and internally rotated.
- The patient appears rigid with their teeth clenched.
 - The signs can be on just one side of the body or on both sides (the signs may
only be present in the upper limbs).
- Decerebrate posturing indicates brain stem damage. It is exhibited by people
with lesions or compression in the midbrain and lesions in the cerebellum.
- Progression from decorticate posturing to decerebrate posturing is often
indicative of uncal (transtentorial) or tonsillar brain herniation (often referred
to as coning).
✓ No response (1 point)
- The complete absence of a motor response to a painful stimulus.
✓ Not testable (NT)
- If the patient is unable to provide a motor response (e.g. paralysis), this
should be documented as not testable (NT).

• Every brain injury is different, but generally, brain injury is classified as:
▪ Severe: GCS (8 or less)
▪ Moderate: GCS (9-12)
▪ Mild: GCS (13-15)

C. NIH Stroke Scale

➢ Indications of the Assessment
o The NIHSS can be used as a clinical stroke assessment tool to evaluate and document
neurological status in acute stroke patients. The stroke scale is valid for predicting lesion
size and can serve as a measure of stroke severity.

➢ Criteria, Scoring System, and Interpretation

Instructions
1a. Level of consciousness: The investigator
must choose a response, even if a full
evaluation is prevented by such obstacles as
an endotracheal tube, language barrier, or
orotracheal trauma/bandages. A 3 is scored
only if the patient makes no movement (other
than reflexive posturing) in response to
noxious stimulation.
Scale Definition
• 0 = Alert; keenly responsive
• 1 = Not alert, but arousable by minor
stimulation to obey, answer, or
respond
• 2 = Not alert, requires repeated
stimulation to attend, or is obtunded
and requires strong or painful
stimulation to make movements (not
stereotyped)
 • 3 = Responds only with reflex motor or
autonomic effects or is totally
unresponsive, flaccid, or areflexic
1b. Level of consciousness questions: The • 0 = Answers both questions correctly
patient is asked the month and his/her age. • 1 = Answers one question correctly
The answer must be correct; no partial credit • 2 = Answers neither question correctly
is given for being close. Aphasic and
stuporous patients who do not comprehend
the questions are given a score of 2. Patients
unable to speak because of endotracheal
intubation, orotracheal trauma, severe
dysarthria from any cause, language barrier,
or any other problem not due to aphasia are
given a 1. It is important that only the initial
answer be graded and that the examiner not
"help" the patient with verbal or nonverbal
cues.
1c. Level of consciousness commands: The • 0 = Performs both tasks correctly
patient is asked to open and close the eyes • 1 = Performs one task correctly
and then to grip and release the nonparetic • 2 = Performs neither task correctly
hand. Substitute another one-step command
if the hands cannot be used. Credit is given if
an unequivocal attempt is made but not
completed because of weakness. If the
patient does not respond to command, the
task should be demonstrated to him/her
(pantomime) and the result scored (ie, follows
none, one, or two commands). Patients with
trauma, amputation, or other physical
impediments should be given suitable one-
step commands. Only the first attempt is
scored.
2. Best gaze: Only horizontal eye movements • 0 = Normal
are tested. Voluntary or reflexive • 1 = Partial gaze palsy; gaze is abnormal
(oculocephalic) eye movements are scored, in one or both eyes, but forced
but caloric testing is not performed. If the deviation or total gaze paresis is not
patient has a conjugate deviation of the eyes present
that can be overcome by voluntary or • 2 = Forced deviation, or total gaze
reflexive activity, the score will be 1. If a paresis not overcome is by the
patient has an isolated peripheral nerve oculocephalic maneuver
paresis (CN III, IV, or VI), score a 1. Gaze is
testable in all aphasic patients. Patients with
ocular trauma, bandages, or pre-existing
blindness or other disorder of visual acuity or
fields should be tested with reflexive
movements and a choice made by the
investigator. Establishing eye contact and
then moving about the patient from side to
side occasionally clarifies the presence of a
partial gaze palsy.
3. Visual: Visual fields (upper and lower
quadrants) are tested by confrontation, using
finger counting or visual threat as
appropriate. The patient must be
encouraged, but if he/she looks at the side of
the moving fingers appropriately, this can be
scored as normal. If is the patient has
unilateral blindness or enucleation, visual
fields in the remaining eye are scored. Score 1
only if a clear-cut asymmetry, including
quadrantanopia, is found. If the patient is
blind from any cause, score 3. Double
simultaneous stimulation is performed at this
point. If there is extinction, the patient
receives a 1 and the results are used to
answer question 11.
4. Facial palsy: Ask or use pantomime to
encourage the patient to show teeth or raise
eyebrows and close eyes. Score symmetry of
grimace in response to noxious stimuli in the
poorly responsive or noncomprehending
patient. If facial trauma/bandages,
orotracheal tube, tape, or other physical
barrier obscures the face, these should be
removed to the extent possible
5. Motor arm: The limb is placed in the
appropriate position: extend the arms (palms
down) 90° (if sitting) or 45° (if supine). Drift is
scored if the arm falls before 10 seconds. The
aphasic patient is encouraged using urgency
in the voice and pantomime, but not noxious
stimulation. Each limb is tested in turn,
beginning with the nonparetic arm. The
examiner should record the score as
untestable (UN) only in the case of
amputation or joint fusion at the shoulder and
clearly write the explanation for this choice.
6. Motor leg: The limb is placed in the
appropriate position: hold the leg at 30°
(always tested supine). Drift is scored if the leg
falls before 5 seconds. The aphasic patient is
encouraged using urgency in the voice and
pantomime, but not noxious stimulation.
• 0 = No visual loss
• 1 = Partial hemianopia
• 2 = Complete hemianopia
• 3 = Bilateral hemianopia (blind
including cortical blindness)
• 0 = Normal symmetrical movements
• 1 = Minor paralysis (flattened
nasolabial fold, asymmetry on smiling)
• 2 = Partial paralysis (total or near-total
paralysis of lower face)
• 3 = Complete paralysis of one or both
sides (absence of facial movement in
the upper and lower face)
• 0 = No drift; limb holds 90° (or 45°) for
full 10 seconds
• 1 = Drift; limb holds 90° (or 45°), but
drifts down before full 10 seconds;
does not hit bed or other support
• 2 = Some effort against gravity; limb
cannot get to or maintain (if cued) 90°
(or 45°), drifts down to bed, but has
some effort against gravity
• 3 = No effort against gravity; limb falls
• 4 = No movement
• UN = Amputation or joint fusion
5a. Left Arm
5b. Right Arm
• 0 = No drift; leg holds 30° position for
full 5 seconds
• 1 = Drift; leg falls by the end of the 5-
second period but does not hit bed
Each limb is tested in turn, beginning with the
nonparetic leg. The examiner should record
the score as untestable (UN) only in the case
of amputation or joint fusion at the shoulder
and clearly write the explanation for this
choice
7. Limb ataxia: This step is aimed at finding
evidence of a unilateral cerebellar lesion. Test
with the patient’s eyes open. In case of visual
defect, ensure testing is done in intact visual
field. The finger-nose-finger and heel-shin
tests are performed on both sides, and ataxia
is scored only if present out of proportion to
weakness. Ataxia is absent in the patient who
cannot understand or is paralyzed. Only in the
case of amputation or joint fusion may the
item be scored as untestable (UN), and the
examiner must clearly write the explanation
for not scoring. In case of blindness test by
touching nose from extended arm position.
8. Sensory: Sensation or grimace to pinprick
when tested or withdrawal from noxious
stimulus in the obtunded or aphasic patient.
Only sensory loss attributed to stroke is
scored as abnormal, and the examiner should
test as many body areas (arms [not hands],
legs, trunk, face) as needed to accurately
check for hemisensory loss. A score of 2,
"severe or total sensory loss," should be given
only when a severe or total loss of sensation
can be clearly demonstrated. Stuporous and
aphasic patients will therefore probably score
1 or 0. The patient with brain stem stroke who
has bilateral loss of sensation is scored 2. If
the patient does not respond and is
quadriplegic, score 2. Patients in coma (item
1a=3) are automatically given a 2 on this item.
9. Best language: A great deal of information
about comprehension is obtained during the
preceding sections of the examination. The
patient is asked to describe what is happening
in the given picture to name the items on the
given naming sheet, and to read from the
given list of sentences. Comprehension is
• 2 = Some effort against gravity; leg
falls to bed by 5 seconds, but has some
effort against gravity
• 3 = No effort against gravity, leg falls
to bed immediately
• 4 = No movement
• UN = Amputation, joint fusion
6a. Left Leg
6b. Right Leg
• 0 = Absent
• 1 = Present in one limb
• 2 = Present in two limbs
• UN = Amputation or joint fusion
• 0 = Normal; no sensory loss.
• 1 = Mild to moderate sensory loss;
patient feels pinprick is less sharp or is
dull on the affected side or there is a
loss of superficial pain with pinprick
but patient is aware he/she is being
touched
• 2 = Severe to total sensory loss;
patient is not aware of being touched
in the face, arm, and leg
• 0 = No aphasia; normal
• 1 = Mild to moderate aphasia; some
obvious loss of fluency or facility of
comprehension, without significant
limitation on ideas expressed or form
of expression; reduction of speech
and/or comprehension, however,
judged from responses here, as well as to all
of the commands in the preceding general
neurological examination. If visual loss
interferes with the tests, ask the patient to
identify objects placed in the hand, repeat,
and produce speech. The intubated patient
should be asked to write. The patient in coma
(question 1a=3) will automatically score 3 on
this item. The examiner must choose a score
in the patient with stupor or limited
cooperation, but a score of 3 should be used
only if the patient is mute and follows no one-
stepcommands.
10. Dysarthria: If patient is thought to be
normal, an adequate sample of speech must
be obtained by asking the patient to read or
repeat words from a given list. If the patient
has severe aphasia, the clarity of articulation
of spontaneous speech can be rated. Only if
the patient is intubated or has other physical
barrier to producing speech may the item be
scored as untestable (UN), and the examiner
must clearly write an explanation for not
scoring. Do not tell the patient why he/she is
being tested
11. Extinction and inattention (formerly
neglect): Sufficient information to identify
neglect may be obtained during the prior
testing. If the patient has a severe visual loss
preventing visual double simultaneous
stimulation and the cutaneous stimuli are
normal, the score is normal. If the patient has
aphasia but does appear to attend to both
sides, the score is normal. The presence of
visual spatial neglect or anosognosia may also
be taken as evidence of abnormality. Since
the abnormality is scored only if present, the
item is never untestable.
makes conversation about provided
material difficult or impossible. For
example, in conversation about
provided materials, examiner can
identify picture or naming card from
patient's response
• 2 = Severe aphasia; all communication
is through fragmentary expression;
great need for inference, questioning,
and guessing by the listener. Range of
information that can be exchanged is
limited; listener carries burden of
communication. Examiner cannot
identify materials provided from
patient response.
• 3 = Mute; global aphasia; no usable
speech or auditory comprehension
• 0 = Normal
• 1 = Mild to moderate; patient slurs at
least some words and, at worst, can be
understood with some difficulty
• 2 = Severe; patient's speech is so
slurred as to be unintelligible in the
absence of or out of proportion to any
dysphasia, or is mute/anarthric
• UN = Intubated or other physical
barrier
• 0 = No abnormality
• 1 = Visual, tactile, auditory, spatial, or
personal inattention or extinction to
bilateral simultaneous stimulation in
one of the sensory modalities.
• 2 = Profound hemi-inattention or
hemi-inattention to more than one
modality; does not recognize own
hand or orients to only one side of
space.
 NIH Stroke Scale Scoring and Interpretation

References:
Christensen, B. (2021, October 26). NIH Stroke Scale. https://emedicine.medscape.com/article/2172609-
overview
Glass, A., & Zazulia, A. (2011, May 2). Clinical Skills: Neurological Examination. https://neuro.wustl.edu/Po
rtals/Neurology/Education/PDFs/Neurological-Exam-Lecture-Notes.pdf
Johns Hopkins Medicine. (n.d.). Neurological Exam. https://www.hopkinsmedicine.org/health/conditions
-and-diseases/neurological-exam
Newman, G. (2020). How to Assess Muscle Strength. https://www.msdmanuals.com/professional/neurol
ogic-disorders/neurologic-examination/how-to-assess-muscle-strength
Walker, K. H. (n.d.). Clinical Methods: The History, Physical, and Laboratory Examinations. https://www.nc
bi.nlm.nih.gov/books/NBK396/#__NBK396_dtls__
Yousuf, K. (2021, November 12). Glasgow Coma Scale (GCS). https://geekymedics.com/glasgow-coma-sca
le-gcs/