Section 1 of 8

Mental Status

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Level of consciousness

Orientation

Attention

Memory

Behavior

Affect

Cognitive screening

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Score/30

Additional finding

Live output

Neurological examination

Headings

Mental Status: Alert and oriented to person, place, and time. Attention and concentration are intact. Immediate, delayed, and remote memory are grossly intact. Behavior and affect are appropriate.
Speech & Language: Speech is fluent with normal verbal output. Articulation is clear without dysarthria. Comprehension, naming, and repetition are intact. No paraphasic errors or neologisms are observed.
Cranial Nerves: Visual fields are full to confrontation. Pupils are equal, round, and reactive to light without a relative afferent pupillary defect. Extraocular movements are full without nystagmus or ptosis. Facial sensation is intact throughout V1–V3 bilaterally, and muscles of mastication are full. The face is symmetric at rest and with activation, with strong eye closure bilaterally. Hearing is intact to conversation bilaterally. Palate elevates symmetrically and voice is normal. Strength is full in the sternocleidomastoid and trapezius muscles bilaterally. The tongue protrudes midline without atrophy or fasciculations.
Motor: Muscle bulk is normal without focal atrophy or fasciculations. Tone is normal throughout. No pronator drift is present. Strength is 5/5 throughout proximally and distally. Fine finger movements are intact bilaterally. No abnormal involuntary movements are observed.
Reflexes: Deep tendon reflexes are 2+ and symmetric at the biceps, brachioradialis, triceps, patellae, and Achilles. No clonus is present. Plantar responses are flexor bilaterally.
Sensory: Sensation is intact to light touch, pinprick, vibration, and proprioception throughout. No sensory level is identified. Romberg is negative.
Coordination: Finger–nose–finger testing is intact bilaterally without dysmetria. Heel–knee–shin testing is intact bilaterally. Rapid alternating movements are intact bilaterally. No truncal ataxia is present.
Gait: Gait is narrow-based with normal stride length, speed, and symmetric arm swing. Turns are normal. Heel, toe, and tandem walking are intact.

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