NEUROLOGICAL EXAM

Guide to Neurological Examination

This systematic guide will walk you through a complete neurological exam—from general inspection to specialized tests. Follow each step methodically to ensure you capture all necessary clinical information, and feel free to adapt the techniques as you gain more experience.

1. General Inspection

Before Starting the Exam:

  • Patient Positioning:

    • Ensure the patient is comfortably seated or lying down in a quiet, well-lit environment.

    • Introduce yourself and explain the procedure to ease any anxiety.

Observation:

  • General Appearance:

    • Note the patient's overall demeanor, grooming, and level of alertness.

    • Assess for any signs of distress, confusion, or abnormal movements.

  • Behavior and Posture:

    • Observe facial expressions, posture, and any involuntary movements (tremors, tics, or chorea).

  • Gait (if ambulatory):

    • Ask the patient to walk a few steps, turn, and walk back. Look for asymmetry, dragging, or unsteady gait.

2. Mental Status Examination

Assessment Areas:

  • Level of Consciousness:

    • Check if the patient is alert and responsive.

  • Orientation:

    • Ask questions about time, place, and person.

  • Attention and Concentration:

    • Ask the patient to perform simple tasks (e.g., counting backwards from 20).

  • Memory:

    • Evaluate short-term memory (recall of a list of words) and long-term memory.

  • Language:

    • Assess fluency, comprehension, and naming.

  • Mood and Affect:

    • Observe if the patient's mood is appropriate for the situation.

  • Higher Cognitive Functions:

    • If appropriate, include tasks such as drawing a clock or solving simple puzzles.

3. Cranial Nerve Examination

Cranial Nerve I (Olfactory):

  • Test:

    • If indicated, use non-irritating substances (e.g., coffee, vanilla) to check smell in each nostril separately.

Cranial Nerve II (Optic):

  • Visual Acuity:

    • Use a Snellen chart to assess each eye individually.

  • Visual Fields:

    • Perform confrontation testing to evaluate peripheral vision.

  • Fundoscopy:

    • Inspect the optic disc, retinal vessels, and look for signs of papilledema or hemorrhage.

Cranial Nerves III, IV, VI (Oculomotor, Trochlear, Abducens):

  • Pupillary Response:

    • Check for direct and consensual light reflex.

  • Extraocular Movements:

    • Ask the patient to follow your finger in an “H” pattern. Look for nystagmus, diplopia, or restricted movement.

Cranial Nerve V (Trigeminal):

  • Facial Sensation:

    • Test light touch and pinprick in all three divisions (ophthalmic, maxillary, mandibular).

  • Muscles of Mastication:

    • Ask the patient to clench their teeth and palpate the masseter and temporalis muscles for symmetry and tenderness.

Cranial Nerve VII (Facial):

  • Motor Function:

    • Ask the patient to raise their eyebrows, close eyes tightly, smile, and puff out their cheeks.

  • Sensory and Taste:

    • Evaluate taste on the anterior two-thirds of the tongue if needed.

Cranial Nerve VIII (Vestibulocochlear):

  • Hearing:

    • Perform the whisper test and, if available, Rinne and Weber tests.

  • Balance:

    • Ask about any dizziness or vertigo.

Cranial Nerves IX & X (Glossopharyngeal and Vagus):

  • Pharyngeal Examination:

    • Ask the patient to open their mouth and say “ahh” while you observe the palate for symmetry and elevation.

  • Gag Reflex:

    • Gently stimulate the posterior pharyngeal wall to assess the gag response.

Cranial Nerve XI (Accessory):

  • Motor Strength:

    • Ask the patient to shrug their shoulders against resistance.

  • Observation:

    • Note any asymmetry or weakness.

Cranial Nerve XII (Hypoglossal):

  • Tongue Movement:

    • Ask the patient to stick out their tongue.

    • Observe for deviation, atrophy, or fasciculations.

4. Motor System Examination

Inspection:

  • Observe muscle bulk and symmetry.

  • Look for involuntary movements or fasciculations.

Strength Testing:

  • Technique:

    • Ask the patient to perform specific movements against resistance.

  • Areas to Test:

    • Upper Limbs: Shoulder abduction/adduction, elbow flexion/extension, wrist and finger movements.

    • Lower Limbs: Hip flexion/extension, knee flexion/extension, foot dorsiflexion/plantarflexion.

  • Grading:

    • Use the standard Medical Research Council (MRC) scale (0–5).

Tone and Bulk:

  • Assess Muscle Tone:

    • Move the limbs passively to feel for rigidity or spasticity.

  • Examine Muscle Bulk:

    • Look for signs of atrophy or hypertrophy.

5. Sensory System Examination

Testing Modalities:

  • Light Touch:

    • Use a cotton wisp to test all dermatomes.

  • Pain (Pinprick):

    • Use a disposable pin or neurotip to assess for sharp/dull discrimination.

  • Temperature:

    • Compare using test tubes with warm and cool water if available.

  • Vibration and Proprioception:

    • Use a 128 Hz tuning fork on bony prominences (e.g., ankles, wrists).

  • Cortical Sensory Function:

    • Assess for stereognosis (ability to recognize objects by touch) and graphesthesia (recognition of writing on the skin).

6. Reflex Examination

Deep Tendon Reflexes:

  • Upper Extremities:

    • Biceps, triceps, brachioradialis.

  • Lower Extremities:

    • Patellar and Achilles reflexes.

  • Grading:

    • Scale the responses from 0 (absent) to 4+ (hyperactive with clonus).

Pathological Reflexes:

  • Babinski’s Sign:

    • Stroke or upper motor neuron lesion? Stroke: Positive if big toe extends upward.

  • Other Signs:

    • Check for Hoffmann’s sign in the upper extremity.

7. Coordination and Cerebellar Examination

Tests to Perform:

  • Finger-to-Nose Test:

    • Ask the patient to alternate touching their nose and your finger. Look for dysmetria.

  • Heel-to-Shin Test:

    • Ask the patient to slide their heel down the opposite shin. Look for smooth coordination.

  • Rapid Alternating Movements (Dysdiadochokinesia):

    • Ask the patient to rapidly alternate hand movements (e.g., palm up/down).

Observation:

  • Note any tremors, clumsiness, or slowness in movement.

8. Gait and Balance Examination

Assessment of Gait:

  • Observation:

    • Ask the patient to walk normally, then on their toes and heels.

  • Tandem Gait:

    • Ask the patient to walk in a straight line, heel-to-toe.

  • Romberg Test:

    • With feet together and eyes closed, check for increased sway or loss of balance.

Additional Balance Tests:

  • Assess for Fall Risk:

    • Observe if the patient requires assistance or shows signs of instability.

9. Pro-Tips to Stand Out

  • Explain Every Step:

    • Clear communication helps build patient trust and reduces anxiety.

  • Be Systematic:

    • Follow the same order each time so that no component is missed.

  • Record Observations:

    • Document both normal and abnormal findings meticulously.

  • Maintain Professionalism:

    • Demonstrate confidence, empathy, and respect at all times.

  • Adapt and Engage:

    • Tailor your approach to the patient's specific conditions and needs.

  • Self-Evaluation:

    • Reflect on each examination session to continuously improve your technique.

10. Final Steps

  • Summarize Findings:

    • Share a brief overview of your observations with the patient if appropriate.

  • Patient Comfort:

    • Ensure the patient is comfortable and provide them with time to ask questions.

  • Hygiene:

    • Wash your hands and clean any equipment used.