The neurological examination evaluates several domains including mental status, cranial nerves, motor function, reflexes, sensation, and coordination. It begins with tests of orientation, attention, memory, and language to assess mental status. Cranial nerves are tested individually for strength and sensation. The motor exam evaluates strength, gait, muscle tone, and abnormal movements. Reflexes including deep tendon reflexes are graded. Coordination is assessed using tests like finger-to-nose. Sensation is tested for vibration, proprioception, temperature, and pain. Subtle signs can indicate conditions like stroke or multiple sclerosis.

1. THE NEUROLOGICAL EXAMINATION

2. NEUROLOGICAL EXAM
• Mental status
• Cranial nerves
• Motor exam
– Strength
– Gait
– Cerebellar
• Reflexes
• Sensation

3. MENTAL STATUS
“FOGS”
 Family story of memory loss
 Orientation
 General Information
 Spelling &/or numbers
 Recognition of objects

4. Level of Consciousness
• Awake and alert
• Agitated
• Lethargic
– Arousable with
• Voice
• Gentle stimulation
• Painful/vigorous stimulation
• Comatose

5. LANGUAGE
• Fluency
• Naming
• Repetition
• Reading
• Writing
• Comprehension
Aphasia vs. dysarthria

6. MEMORY
• Immediate
– Really a measure of attention rather than memory
• Remote
• 3 objects at 0/3/5 minutes
• Historical events
• Personal events
Orientation
• Person
– Not who they are but who you are
• Place
• Time

7. OTHER COGNITIVE FUNCTIONS
• Calculation
• Abstraction
• Similarities/differences
• Judgement
• Personality/behavior

8. CRANIAL NERVE EXAM
• I - olfactory
– Don’t use a noxious stimulus
– Coffee, lemon extract
• Ii - optic
– Visual acuity
– Visual fields
– Fundoscopic exam

9. CRANIAL NERVE EXAM
• Iii/iv/vi oculomotor, trochlear, abducens
– Pupillary response
– Eye movements
• 9 cardinal positions
– Observe lids for ptosis
• V - trigeminal
– Motor - jaw strength
– Sensory - all 3 divisions
– A lesion that effects C5 will usually effect all three segments
(ophthalmic, maxillary, & mandibular) so the exam light
touch on both cheeks. By cotton.

10. CRANIAL NERVES
• Vii - facial
– Observe for facial asymmetry
– Forehead wrinkling, eyelid closure, whistle/pucker
– Bell’s Palsy- Where the nerve is injured between pons &
face there is total facial paralysis i.e., weakness of a
corner of the mouth + closing the eye + wrinkling the
brow.
• Viii - vestibular
– Acuity
– Rinne, weber
– Rubbing your fingers together next to the patients ear.

11. CRANIAL NERVES
• Ix/x - glossopharyngeal, vagus
– GAG reflex check
• Xi - spinal accessory
– Sternocleidomastoid m.
– Trapezius muscle
• Xii - hypoglossal
– Tongue strength
– Right xii thrusts tongue to left
– stick out your tongue
– The tongue will deviate to the side of weakness.

12. MOTOR EXAMINATION

13. STRENGTH
• Strength
– Graded 0 - 5
– 0 - no movement
– 1 - flicker
– 2 - movement with gravity removed
– 3 - movement against gravity
– 4 - movement against resistance
– 5 - normal strength

14. STRENGTH EXAM
• Upper and lower extremities
• Distal and proximal muscles
• Grip strength is a poor screening tool for strength
• Subtle weakness
– Toe walk, heel walk
– Out of chair
– Deep knee bend

15. Motor exam, cont
• Subtle signs of weakness on a cortical/subcortical
basis
– Pronator drift
– Orbiting

16. Gait evaluation
• Include walking and turning
• Examples of abnormal gait
– High steppage
– Waddling
– Hemiparetic
– Shuffling
– Turns en bloc

17. MUSCLE OBSERVATION
• ATROPHY
• FASCIULATIONS

18. ABNORMAL MOVEMENTS
• TREMOR
– REST
– WITH ARMS OUTSTRETCHED
– INTENTION
• CHOREA
• ATHETOSIS
• ABNORMAL POSTURES

19. CEREBELLAR FUNCTION
• RAPID ALTERNATING MOVEMENTS
• FINGER TO FINGER TO NOSE TESTING
• HEEL TO SHIN
• GAIT
– TANDEM

20. Romberg Test
• Key test:
• Be sure to check orthostatic (B/P) for changes first
• Balance is maintained by vision, vestibular sense &
proprioception. These feed into the cerebellum either
directly or indirectly. If a patient sways with eyes open or
close it is considered +.

21. Coordination
• Key Test:
• Finger to nose & heel to shin motions
• Alternating rapid movements of hand & foot.
Examples of tapping thumb & index fingers
together, or heel on floor & tap toes on floor.
• Balance test- Tandem gait or Romberg test.

22. REFLEXES

23. MUSCLE STRETCH REFLEXES (DEEP
TENDON REFLEXES)
• GRADED 0 - 5
– 0 - ABSENT
– 1 - PRESENT WITH REINFORCEMENT
– 2 - NORMAL
– 3 - ENHANCED
– 4 - UNSUSTAINED CLONUS
– 5 - SUSTAINED CLONUS

24. MSR / DTR
• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE

25. Reflexes
• Key tests:
• Triceps, biceps, knee jerk, Achilles & Babinski are the major
reflexes.
• Asymmetry is usually a sign of major pathology.
• Babinski- This points to a upper motor neuron lesion. A
positive test is when the lateral aspect of the foot is
scratched & the big toe dorsiflexes & the other toes fan out

26. OTHER REFLEXES
• Upper motor neuron dysfunction
– BABINSKI
• present or absent
• toes downgoing/ flexor plantar response
– HOFMAN’S
– JAW JERK
• Frontal release signs
– GRASP
– SNOUT
– SUCK
– PALMOMENTAL

27. TONE
• INCREASED, DECREASED, NORMAL
• COGWHEELING
• CLASP KNIFE

28. SENSORY EXAM

29. SENSORY EXAM
• Vibration
– 128 hz tuning fork
• Joint position sense
• Pin prick
• Temperature
Start distally and move proximally

30. HIGHER CORTICAL SENSATIONS
• GRAPHESTHESIA
• STEREOGNOSIS
• DOUBLE SIMULTANEOUS STIMULATION
• BAROSTHESIA
• TEXTURES

31. Sensory Extremity Examination
• Key Test:
• Pain Sensation- Use simultaneous stimulation
(sharp, dull, etc.)
• Proprioception- Test big toe (position).
MS, neurosyphilis, & pernicious anemia may cause
loss of lower extremity proprioception.