Neuro Clinical Exam: Term 3 Midterm Skills

Olfaction: Cranial Nerve(s)

CN I (olfactory)

Olfaction: How do you test it?

Ask pt to identify a familiar scent with each nostril separately

Olfaction: Negative Test (Normal)

Correctly identifies scent

Olfaction: Positive Test (Abnormal)

Inability to smell or asymmetry in detection

Pupillary Response: Cranial Nerve(s)

CN II (sensory) & CN III (motor)

Pupillary Response: How do you test it?

Shine light in each eye; observe both pupils.

Pupillary Response: Negative (Normal)

Equal and brisk constriction in both eyes

Pupillary Response: Positive (Abnormal)

No constriction or asymmetry (e.g., fixed/dilated pupil)

Visual Acuity: Cranial Nerve(s)

CN II (optic)

Visual Acuity: How do you test it?

Use Snellen chart; one eye at a time.

Visual Acuity: Negative (Normal)

Normal vision for age

Visual Acuity: Positive (Abnormal)

Blurred or reduced acuity

Visual Fields: Cranial Nerve(s)

CN II - Optic

Visual Fields: How do you test it?

Wiggle fingers in each quadrant while pt looks straight ahead.

Visual Fields: Negative (Normal)

Detects movement in all quadrants

Visual Fields: Positive (Abnormal)

Loss of peripheral vision in any quadrant

Visual Extinction: Cranial Nerve(s)

CN II - Optic & Parietal lobe

Visual Extinction: How do you test it?

Present stimuli on both sides at once.

Visual Extinction: Negative (Normal)

Detects both sides

Visual Extinction: Positive (Abnormal)

Ignores one side (usually left) when both are presented

Smooth Pursuit: Cranial Nerve(s)

CN III, IV, VI

Smooth Pursuit: How do you test it?

Ask pt to follow your finger in an "H" pattern.

Smooth Pursuit: Negative (Normal)

Smooth, full eye movement

Smooth Pursuit: Positive (Abnormal)

Jerky or limited movement in one or more directions

Saccades: Cranial Nerve(s)

CN III, IV, VI

Saccades: How do you test it?

Ask patient to look rapidly between two targets

Saccades: Negative (Normal)

Quick, accurate movements

Saccades: Positive (Abnormal)

Overshooting, delayed, or inaccurate saccades

Convergence: Cranial Nerve(s)

CN III - Oculomotor

Convergence: How do you test it?

Move object toward pt's nose.

Convergence: Negative (Normal)

Eyes converge symmetrically

Convergence: Positive (Abnormal)

One eye lags or drifts outward

Facial Sensation: Cranial Nerve(s)

CN V - Trigeminal

Facial Sensation: How do you test it?

Lightly touch forehead, cheek, and jaw.

Facial Sensation: Positive (Abnormal)

Numbness or asymmetry

Facial Sensation: Negative (Normal)

Equal sensation bilaterally

Masseter Strength: Cranial Nerve(s)

CN V - Trigeminal

Masseter Strength: How do you test it?

Ask pt to clench teeth; palpate masseter and temporalis.

Masseter Strength: Negative (Normal)

Strong and symmetrical contraction

Masseter Strength: Positive (Abnormal)

Weakness or asymmetrical contraction

Facial Expression: Cranial Nerve(s)

CN VII - Facial

Facial Expression: How do you test it?

Ask pt to smile, raise eyebrows, puff cheeks, close eyes tightly.

Facial Expression: Negative (Normal)

Symmetrical facial movement

Facial Expression: Positive (Abnormal)

Facial drooping, asymmetry, or inability to perform actions

Hearing: Cranial Nerve(s)

CN VIII - Vestibulocochlear

Hearing: How do you test it?

Rub fingers or use a tuning fork near each ear.

Hearing: Negative (Normal)

Equal hearing bilaterally

Hearing: Positive (Abnormal)

Reduced hearing on one side

Palate Elevation/Speech: Cranial Nerve(s)

CN IX & X - Glossopharyngeal & Vagus

Palate Elevation/Speech: How do you test it?

Say "ah" and observe uvula; listen to the voice.

Palate Elevation/Speech: Negative (Normal)

Uvula rises symmetrically, clear speech

Palate Elevation/Speech: Positive (Abnormal)

Uvula deviates, nasal/hoarse speech

SCM Strength: Cranial Nerve(s)

CN XI - Spinal Accessory

SCM Strength: How do you perform it?

Ask the patient to turn their head against your hand (resistance applied on the side of the face).

SCM Strength: Negative (Normal)

Strong and equal resistance

SCM Strength: Positive (Abnormal)

Weakness on one side

Tongue Movement: Cranial Nerve(s)

CN XII - Hypoglossal

Tongue Movement: How do you test it?

Ask pt to stick out tongue and move it side to side.

Tongue Movement: Negative (Normal)

Midline position, full ROM

Tongue Movement: Positive (Abnormal)

Tongue deviates or appears atrophic on one side

Biceps Reflex: How do you test it?

Tap the biceps tendon with the arm partially flexed.

Biceps Reflex: Negative (Normal)

Visible biceps contraction and slight forearm flexion

Biceps Reflex: Positive (Abnormal)

Hyperreflexia, hyporeflexia, or no response

Triceps Reflex: How do you test it?

Tap the triceps tendon just above the elbow with arm 90 abd, and full IR

Triceps Reflex: Negative (Normal)

Elbow extends slightly

Triceps Reflex: Positive (Abnormal)

Exaggerated or absent extension

Brachioradialis Reflex: How do you test it?

Tap tendon near the wrist (thumb side) with forearm relaxed w/ elbow at 90

Brachioradialis Reflex: Negative (Normal)

Elbow flexion and/or forearm supination

Brachioradialis Reflex: Positive (Abnormal)

Absent or exaggerated response

Patellar Reflex: How do you test it?

Tap patellar tendon (just below patella) with patient seated and legs dangling

Patellar Reflex: Negative (Normal)

Leg extends briefly

Patellar Reflex: Positive (Abnormal)

Hypo/hyperreflexia or no movement

Achilles Reflex: How do you test it?

With foot relaxed in neutral, tap the Achilles tendon.

Achilles Reflex: Negative (Normal)

Plantarflexion of the foot

Achilles Reflex: Positive (Abnormal)

No movement or clonus (sustained contractions)

Babinski Sign: How do you test it?

Stroke the lateral aspect of the foot upward and medially.

Babinski Sign: Negative (Normal)

Toes curl downward (flexion)

Babinski Sign: Positive (Abnormal)

Big toe extends, toes fan out (positive Babinski – UMN lesion in adults)

Rapid Alternating Movements (RAMs): How do you test it?

Ask pt to rapidly flip palms up/down on thighs.

Rapid Alternating Movements (RAMs): Negative (Normal)

Smooth, fast, coordinated motion

Rapid Alternating Movements (RAMs): Positive (Abnormal)

Slow, clumsy, irregular movement (dysdiadochokinesia)

Finger-Nose-Finger: How do you test it?

Pt touches their nose, then the PT's finger repeatedly.

Finger-Nose-Finger: Negative (Normal)

Accurate and smooth

Finger-Nose-Finger: Positive (Abnormal)

Intention tremor, past-pointing, dysmetria

Heel to Shin: How do you test it?

Ask pt to run one heel down the opposite shin.

Heel to Shin: Negative (Normal)

Smooth, straight movement

Heel to Shin: Positive (Abnormal)

Jerky, inaccurate, or missed contact with shin (ataxia)

Joint Position Sense (Proprioception): How do you test it?

With pt's eyes closed, move a finger or toe slightly up or down and ask them to identify the direction. Test bilaterally.

Joint Position Sense (Proprioception): Negative (Normal)

Pt accurately identifies movement direction

Joint Position Sense (Proprioception): Positive (Abnormal)

Inaccurate or delayed response indicates impaired proprioception (e.g., dorsal column lesion, peripheral neuropathy)

Vibration Sense: How do you test it?

Strike a tuning fork and place it on a bony prominence (e.g., distal phalanx). Ask the pt to report when vibration starts and stops.

Vibration Sense: Negative (Normal)

Pt senses vibration and can tell when it stops

Vibration Sense: Positive (Abnormal)

Reduced or absent vibration sense (often seen in peripheral neuropathy or posterior column damage)

Tactile Extinction: How do you test it?

Lightly touch the same area on both sides of the body simultaneously (e.g., cheeks, hands) with the patient’s eyes closed.

Tactile Extinction: Negative (Normal)

Pt feels both touches equally

Tactile Extinction: Positive (Abnormal)

Pt reports feeling only one side (usually the side opposite a brain lesion—parietal lobe dysfunction)