Guidance for the Neurologic Examination

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Headshot of Kimberly Beine, MD · Pre-clerkship Curriculum, Co-Director
Kimberly Beine
MD · Pre-clerkship Curriculum, Co-Director
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There are 9 parts of the neurologic exam. Click on the icons below for more details about each part.

There are 9 parts of the neurologic exam. Click on the icons below for more details about each part.

9 parts of the neurologic exam

Mental status

  • Level of consciousness
    • Alert
    • Lethargic
    • Somnolent
    • Unconscious
  • Orientation
    • Person
    • Place
    • Time
  • Thought processes
    • Linear, logical
    • Tangential
    • Hallucinations, delusions

Station and gait

  • Station
    • Romberg: Position sense (proprioception)
      • Stand feet together, eyes open, then eyes closed
    • Pronator drift: Close eyes, arms out in front, palms up, then tap each arm and watch return
  • Gait
    • Walk up and down hall (arm swing, balance, leg movements, balance [in turns])
    • Heel walk: Tests balance, dorsiflexion strength and accentuates arm swing
    • Toe walk: Tests plantar flexion and balance
    • Tandem walk (heel-toe-heel walk): Cerebellar function, position sense
    • Hop in place, 1 leg at a time
    • Shallow knee bend, 1 leg at a time

Skull and spine

(often in trauma)

  • Palpation for:
    • Defects
    • Deformity
    • Tenderness

Meninges

(Meningeal irritation)

  • Brudzinski’s: Flex neck; if hips and knees flex, it is positive
  • Kernig’s (knee): Flex knee and hip, then extend knee; positive if extension is resisted
  • I: Olfactory—each nostril separately
  • II: Optic (vision)
    • Visual acuity
    • Visual fields
    • Funduscopic
    • Pupillary response (afferent)
  • III, IV, VI: (Oculomotor—pupils and med & inf rectus & med & inf oblique, trochlear—sup oblique, abducens—lat rectus)—EOMs “H”—6 cardinal directions of gaze
    • Pupillary response (efferent—III)
    • Diplopia
    • Accommodation
    • Nystagmus (horizontal, vertical or rotary): Described by direction of quick phase
    • Ptosis (III)
  • V: Trigeminal
    • Motor: Muscles of mastication
    • Sensory: 3 divisions—ophthalmic, maxillary, mandibular
      • Sharp/dull
      • Light touch
      • Can augment with hot/cold if abnormality suspected
      • Corneal reflex (sensory: V, motor: VII)
  • VII: Facial
    • Motor: Facial movements and expressions
      • Look for asymmetry or involuntary movements
        • Eyebrows, eyelid closure, grimace (show teeth), puff cheeks
    • Sensory: Taste sensation in ant 2/3 of tongue
  • VIII: Acoustic—hearing and vestibular function
    • Whispered voice, if decreased in one
    • Conductive
      • Rinne (fork over mastoid and then ear): air vs bone conduction (normally AC>BC)
    • Sensineural
      • Weber (fork top of head): Lateralization to ear if conductive hearing loss (BC>AC) and to opposite ear if SNHL (not heard in ear with SNHL)
  • IX, X: Glossopharyngeal and vagus—palate, pharynx and larynx
    • Say ah: Uvula midline, soft palate rises symmetrically
    • Gag reflex
  • XI: Spinal accessory—upper trap and SCM
    • Shrug shoulders
    • Rotate head to either side against resistance
  • XII: Hypoglossal—tongue
    • Inspect for symmetry, fasciculations
    • Protrude tongue; look for deviation (can test motor through each cheek)

Motor

  • Inspection: body position, involuntary movements, tone (passive ROM) and bulk of muscles
  • Strength: Dominant usually stronger
    • Grading strength
      • 5: Normal—active movement against resistance with no fatigue
      • 4: Active movement against gravity with some resistance
      • 3: Active movement against gravity
      • 2: Active movement with gravity eliminated
      • 1: Barely detectable flicker or trace of contraction
      • 0: No muscular contraction detected

Sensory

  • Pain: Sharp/dull (swab)
  • Light touch (cotton wisp)
  • Temperature
  • Vibration: Largest tuning fork stem over bony prominences
  • Position sense (proprioception)
  • Stereognosis (identify objects)
  • Graphesthesia (draw numbers in palm)
  • 2 point discrimination
  • Point localization
  • Extinction (one or both sides)

coordination

(Motor, cerebellar, vestibular, sensory)

  • Rapid alternating movements
  • Fingers to thumb sequentially
  • Palms on thighs
  • Hands on thighs, palms-dorsum-palms
  • Point-to-point movements
  • Finger-nose-finger
  • Heel-knee-shin

Reflexes

  • Biceps: C5, C6
  • Brachioradialis: C5, C6
  • Triceps: C6, C7
  • Knee: L2-L4
  • Ankle: L5, S1
  • Graded
    • 0: No response
    • 1+: Diminished
    • 2+: Average, normal
    • 3+: Brisk
    • 4+: Very brisk, hyperactive response, with clonus
  • Babinski (upgoing is abnormal)