This document contains guidelines for performing a neurological examination. It begins with an overview of the developmental, psychosocial and cultural factors to consider. It then provides details on assessing various aspects of the neurological exam including mental status, cranial nerves, motor function, sensation and reflexes. Questions are provided to gather relevant history. The document comprehensively covers the steps and

11.  Developmental
 Psychosocial
 Cultural & Environmental

12.  COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors

13.  Do you experience any numbness or
tingling? When & where does this occur?
 Do you experience seizure? How often?
 Does anything seem to initiate a seizure?
 Do you experience headaches/ When
do they occur & what do they feel like?
 Do you have muscle weakness?
 Do you have slurring of speech?

14.  Any head injury with or w/o loss of
consciousness? What treatment did you
receive?
 Have you ever had meningitis,
encephalitis, injury to spinal cord, stroke?
 Family history of HPN, stroke, Alzhiemer’s?

15.  Do you smoke?
 Describe your usual diet?
 Do you lift heavy objects?

16.  Mental Status
 Cranial Nerves
 Motor & Cerebellar System
 Sensory System
 Reflexes

17.  Provide information about cerebral
cortex function
 4 major component:
(a) Appearance
(b) Behavior
(c) Cognition
(d) Thought process

18.  Posture
 Body Movements
 Dress
 Grooming & Hygiene

19. LEVEL OF
CONSCIOUSNESS
LEVEL Response
Alert Responds fully & appropriately to
stimuli
Lethargic Drowsy, responds to questions then
fall asleep
Obtunded Open eyes, responds slowly,
confused
Stuporous Arouses from sleep only from painful
stimuli
Comatose Unarousable with eyes closed

20. Score
Eye Opening Response Spontaneous opening 4
To verbal command 3
To pain 2
No response 1
Most integral motor response Obeys verbal commands 6
Localizes pain 5
Withdraws from pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
Most appropriate verbal response Oriented 5
Confused 4
Inappropriate words 3
Incoherent 2
No response 1
TOTAL SCORE 3-15

22.  Facial Expression
 Speech
› Quantity
› Rate
› Volume
› Fluency & rhythm
 Mood & Affect
› Mood – a sustained state of inner feeling
› Affect – how do the patient appear to you
(labile, blunted or flat)

23.  Orientation – Person, place & time
 Attention Span
 Recent Memory
 Remote Memory
 New Learning
 Judgment

24.  Thought Processes
 Thought Content
 Perceptions
 Screen for Suicidal Thoughts

25.  Provide information regarding
transmission of motor & sensory
messages (head & neck)
 Are evaluated during the head, neck,
eye & ear examinations

26. No. Cranial Nerve Function
I Olfactory Sense of smell
II Optic Vision
III Oculomotor Pupillary constriction, opening the eye & most
extraocular movements
IV Trochlear Downward, inward movement of the eye
V Trigeminal Motor – temporal & masseter muscles (jaw
clenching), lateral movement of the jaw
Sensory – facial. 3 divisions: (1) ophthalmic (2)
maxillary (3) mandibular
VI Abducens Lateral deviation of the eye
VII Facial Motor – facial movements: facial expressions,
closing the eye, closing the mouth
VIII Vestibulochoclear Hearing (cochlear division) & balance
(Acoustic) (vestibular division)

27. No. Cranial Nerve Function
IX Glossophrayngeal Motor – phraynx
Sensory – posterior portions of the eardrum
& ear canal, the phraynx, posterior tongue,
including taste
X Vagus Motor – palate, pharynx, larynx
Sensory – pharynx & larynx
XI Accessory Motor – sternocledomastoid & upper
portion of the trapezius
XII Hypoglossal Motor - tongue

28. Cranial Test
Nerve
I Smell
II Visual acuity, visual fields & ocular fundi
III, IV, VI Pupillary reactions, Extraocular movements
V Corneal reflexes, facial sensation & jaw movements
VII Facial movements
VIII Hearing
IX, X Swallowing & rise of the palate, gag reflex
V, VII, X, XII Voice & speech
XI Trapezius & Sternocleidomastoid contraction
XII Inspection of the tongue

29. - check for
smell
“ANOSMIA”
– absence of
smell

30. Visual Acuity
-Test for near vision
 Presbyopia –
impaired near
vision
-Test for distant
vision (Snellen’s Chart)
 Myopia –
“nearsightedness”
 Hyperopia –
“farsightedness”

31. Optic Fundi
Abnormalities :
 Retrobulbar neuritis –
inflammatory process of
the optic nerve behind
the eyeball (MS)
Papilledema (choked
disk) swelling of the optic
nerve as it enters the
retina (tumors of
hemorrhage)
Optic atrophy – change
in color of the disc &
decreased visual acuity
(MS, tumor)

33. Visual Fields by
Confrontation
Normal Findings:
 Inferior: 70
degrees
 Superior: 50
degrees
 Temporal: 90
degrees
 Nasal: 60
degrees

34. CN III, IV and VI
 inspect margins of
eyelids – eyelid covers
2mm of iris
* Ptosis = weak eye
muscles
 assess for extraocular
movements
> six cardinal fields:
H method or wheel
methods
Test for convergence

35. Muscle Cranial Nerve Function
Lateral Rectus VI Moves eye laterally
Medial Rectus III Moves eye medially
Superior Rectus III Elevates eye
Inferior Rectus III Depresses eye
Inferior Oblique III Elevates eye ; turns it laterally
Superior Oblique IV Depresses eye, turns it laterally

36. * Abnormal: strabismus ptosis
Nystagmus -
rythmic oscillation
of the eyes
Strabismus –
lack of muscle
coordination
diplopia
Diplopia –
double vision

37. Pupillary Reaction to Light
& Accomodation (PERRLA)
 round, equal in size &
shape in the center of the
eye
 Pupil inequality of <
0.5mm = ANISOCORIA
 Direct light reflex =
pupillary constriction in the
same eye
Consensual light reflex =
pupillary constriction in the
opposite eye
* both pupils should
constrict briskly

44.  Motor function
 Temporal & masseter
mucsles contract bilaterally
 Abnormal:
 PNS or CNS dysfunction
(bilateral)
 Lesion of CN V
(unilateral)
 Sensory function
 3 division: ophthalmic,
maxillary & mandibular
 absence: lesion in the:
 Trigeminal nerve
 Spinothalamic tract
 Posterior columns
 Corneal Reflex
 absence: lesions in the:
 Trigemeinal nerve
 Motor part of CN VII

46. Motor Function:
Facial expressions
Movements –
symmetrical
Abnormal:
 Bell’s Palsy
 Paralysis
lower part of
the face
Sensory Function:
 identify different
flavors
Abnormal: inability
to identify correct
flavor = CN VII
impairment
Corneal Reflex
 regulates the
motor response

47. Bell’s Palsy

48. Weber’s Test
Evaluate conduction of sound
waves through bones
Helps distinguish between
conductive hearing & sensorineural
hearing
 conductive hearing – sound
waves transmitted by the
external & middle ear
 sensorineural hearing –
sound waves transmitted by
the inner ear
Normal:
vibrations heard equally
in both ears
Abnormal:
 Tinnitus
 deafness
 Conduction hearing loss
 Sensorineural hearing loss

49.  Rinne Test
 Compares air & bone conduction sounds
 Normal:
 Air conduction heard longer than bone
conduction
 Abnormal:
 Conductive hearing loss – BC > AC
 Sensorineural hearing loss – AC > BC

50. Caloric Test
Test the vestibular
portion of the nerve
Performed only
when client is
experiencing
dizziness or vertigo.

51. Motor function: Sensory Function:
Normal: soft palate  Gag Reflex
rises, uvula remains in Normal:
midline  intact gag reflex
 symmetrically diminished
Abnormal: or absent in some normal
> soft palate does people
not rise – bilateral lesion Abnormal:
of CN X risk for aspiration
> unilateral rising of
soft palate & deviation Motor activity of pharynx
of uvula to the normal Normal:
side – unilateral lesion  swallows w/o difficulty
CN X  no hoarseness noted
Abnormal:
 Dysphagia
 vocal changes

52. Trapezius Muscle
Normal:
> symmetric,
strong contractions
Abnormal:
> asymmetric
muscle contraction
> drooping of the
shoulder

53. Sternocleidomastoid
Muscle
Normal:
> ease of movement
> wide range of
motion
Abnormal:
> muscle weakness
> muscle atrophy
> uneven shoulders

54. Movement &
strength of tongue
Note atrophy,
tremors & paralysis
Normal:
> Movement is
symmetrical &
smooth
> Bilateral strength is
apparent
> tongue at midline
Abnormal:
> Fasciculation –
PNS disease

55.  To determine functioning of the
pyramidal & extrapyramidal tracts
 To determine balance & coordination
Focus on:
 Body position
 Involuntary movements
 Characteristics of the muscles
 Coordination

56.  Natural walk
› Note posture, freedom of movement,
symmetry, rhythm & balance
› Normal: Steady; opposite arm swings

57. observe for:
stiffness or relaxation
equality of steps
pace of walking
position & coordination of arms
ability to maintain balance

58. Heel to toe walk on toes walk on heels
› Abnormal: Affected by disorder of the motor,
sensory, vestibular & cerebellar systems
: drug or alcohol intoxication, motor neuron
weakness or muscle weakness

59. Romberg’s Test
 assesses coordination &
equilibrium (CN VIII)
 note any unsteadiness or
swaying
Normal: stands erect with
minimal swaying with eyes
open or closed
 Abnormal: swaying greatly
increases, moving feet apart =
disease of posterior columns ,
vestibular dysfunctions or
cerebellar disorders

60. Cerebellar Ataxia
wide-based,
staggering, unsteady
gait
(+) Romberg’s test
Cerebellar diseases
or alcohol & drug
intoxication

61. Parkinsonian Gait
Shuffling gait, turns in
very stiff manner
Stooped-over posture
with flexed hips & knee
Seen in Parkinson's
disease

62. Scissors Gait
stiff, short gait
Thighs overrlap each
other with each step
Seen in partial
paralysis of the leg

63. Spastic Hemiparesis
Flexed arm held
close to body
while client drags
toe of legs or
circles it stiffly
outward & forward
lesions of UMN =
CVA

64. Footdrop (steppage
gait)
Liftsfoot & knee high
with each step, then
slaps the foot down hard
on the ground
Cannot walk on heels
LMN disease

65.  Finger – to – nose Test
› Pass – point test
› Assesses coordination & equilibrium
› Observe for movement of arms
 Smoothness of movement
 Point of contact of finger
› Normal: able to touch fingers to nose with
smooth, accurate movements with little
hesitation
› Abnormal: cerebellar disease

66. Finger – to –
nose – test
a.Normal
b.Ataxia
c.Intention
Tremor

67. Test for Pronator Drift
Normal:
Able to hold arm in
this position well
Abnormal:
Downward
movement of arm w/
flexion of fingers &
elbow

68. Rapid alternating movements
 observe rhythm, rate &
smoothness of the movements
 Normal:
 able to touch finger to
thumb rapidly
 rapidly turns palms up &
down
Abnormal:
 Unable to perform rapid
alternating movementrs =
cerebellar disease, upper motor
neuron weakness
Uncoordinated movements or
tremors ( dysdiadochokinesia –
impairment of the power to
perform alternating movements
in rapid, smooth & rhythmic
succession)

69. Heel to shin Test
Normal:
able to run each
heel smoothly
down each shin
Abnormal:
Deviation of heel
to one side =
cerebellar disease

70.  Test several kinds of sensation:
› Pain & temperature (spinothalamic
tracts)
› Position & vibration (posterior columns)
› Light touch ( both of these pathways)
› Discriminative sensations

71.  Pay special attention to:
› Where there are symptoms such as
numbness or pain
› Where there are motor or reflex
abnormalities that suggest a lesion of the
spinal cord or PNS
› Where there are trophic changes

72. Sensory Function
Test for senses and stimulus response
General Approach:
 Instruct the patient to identify the
sensations as you change stimulus and
respond to your questions as needed
 Keep the patient’s eyes closed
 Do the procedures in random, letting the
patient assess location of the area tested

73.  Test for spinothalamic tract
› Light touch
Abnormal:
 Anesthesia - absence of touch sensation
 Hypoesthesia – decreased sensitivity to touch
 Hyperesthesia – increased sensitivity to touch
› Sharp and Dull test
Abnormal:
 Analgesia –absence of pain sensation
 Hypoalgesia – decreased sensitivity to pain
 Hyperalgesia – increased sensitivity to pain
› Temperature testing

74.  Test for Posterior Column Tract
A. Vibration
› Tuning fork over bony prominences (toes,
ankle, knee, iliac crest, spinal process,
fingers, sternum, wrist, elbow)
› Inability = posterior column disease or
peripheral neuropathy (DM, chronic alcohol
abuse)

75. Test Stereognosis
 ability to identify
object without
seeing it
 astereognosis –
inability to identify
object correctly

76. Test Graphesthesia
 ability to
perceive
writing on the
skin

77. Test for Two point
Discrimination
 ability to identify the
smallest distance
between two points
Distances & locations:
 Fingertips - 0.3 to 0.6cm
 Hands & feet 1.5 – 2cm
 Lower leg 4cm
Abnormal: cortical disease

78.  Test Topognosis
- ability to identify an area that has been
touched
Abnormal: sensory or cortical disease
 Test position sense of joint movement
- great toe is dorsiflexed, plantar flexed
or abducted

79.  Reflect integrity of the reflex at specific
spinal levels and cerebral cortex function
 Approach
› Done last
› Patient in sitting position
› Limbs to be tested should be relaxed,
partially stretched
 Clenching teeth, humming, counting
ceiling blocks, interlocking of hands

80.  Reflex hammer
 Hold handle of the reflex
hammer between
thumb & index finger so
it swings freely
 Palpate the tendon that
you will need to strike
 Tap the tendon, not the
muscle or bone!
 With a relaxed hold,
Apply a short, quick &
direct blow using the
reflex hammer onto the
muscle’s insertion
tendon
• Pointed end - smaller
target (finger)
• Flat end – wider
target, produce
diffuse impact

81. Evaluation
0 NR
1+ Diminished
2+ Normal
3+ Brisk, above normal
4+ Hyperactive

82. Biceps Reflex
 Evaluates function of spinal
levels C5 & C6
 Approach:
 Partially bend patient’s
arm with elbow with palm
up
 Place your thumb over
the biceps tendon
 Strike your thumb with the
reflex hammer
Normal: 1+ to 3+ flexion &
contraction of biceps muscle
Abnormal: NR or exaggerated

83. Triceps Reflex
 Evaluates function of spinal
levels (C6 & C7)
 Approach:
 Ask patient to hang his
arm freely while
supported with your
nondominant hand
 With elbow flexed, tap
the tendon above the
olecranon process
Normal:
 1+ to 3+ elbow extends,
triceps contracts
Abnormal:
 NR or exaggerated

84. Brachioradialis Reflex
 Evaluates function of
spinal levels C5 & C6
Approach:
 Ask patient to flex elbow
with palm down
 Hand resting on
abdomen or lap
 Tap the tendon of the
radius (2 inches above
wrist)
Normal:
 1+ to 3+ forearm flexes
& supinates
Abnormal:
 NR or exaggerated

85. Patellar/Knee Reflex
 Evaluates function of spinal
levels L2, L3 & L4
 Approach:
 Ask patient to hang both
legs freely off examination
table
 Tap the patellar tendon
located just below the
patella
Normal:
 1+ to 3+, knee extends,
quadriceps muscle
contracts
Abnormal:
 NR or exaggerated

86. Achilles Reflex
 Evaluates function of spinal
levels S1 & S2
Approach:
 Patient’s leg hanging
freely, dorsiflex the foot
 Tap achilles tendon with
the reflex hammer
Normal:
 1+ to 3+, plantar flexion of
the foot
Abnormal:
 NR or exaggerated
* May be absent or difficult to
elicit for older clients

87. Ankle Clonus Testing
(Hyperreflexia)
Done when other reflexes have
been hyperactive
Approach:
 Place one hand under the
knee to support leg
 Briskly dorsiflex the foot
toward the client’s head
Normal:
 No rapid contractions or
oscillations (clonus) of the
ankle
Abnormal:
 Repeated rapid
contractions or oscillations
of ankle & calf muscle
( lesions of upper motor
neurons)

88. Plantar/Babinski Reflex
Evaluates function of spinal levels
L5, S1
Approach:
 Use the end of the reflex
hammer
 Stroke lateral aspect of the
sole from heel to the ball of
the foot
 Curve medially across the
board
Normal:
 Flexion of the toes
Abnormal:
 Extension (dorsiflexion) of the
big toe & fanning of all toes =
normal in children 2 yrs &
below, lesions of UMN, drug &
alcohol intoxication, brain
injury, subsequent epileptic
seizure

90. Abdominal Reflexes
Evaluates function of spinal levels T8,
T9, T10 for upper & T10, T11, T12 for
lower)
Approach:
 Use the wooden end of a
cotton tipped applicator
 Lightly & briskly stroke each
side of the abdomen
 Above & below the umbilicus
Normal:
 Abdominal muscles contract
 Umbilicus deviates toward the
side being stimulated
Abnormal:
 Absent = LMN or UMN lesions
* Abdominal reflex may be concealed
because of obesity or muscular
stretching from pregnancy

91.  Hyperreflexia = UMN lesion
 Hyporeflexia = LMN lesion
 Clonus = severe hyperreflexia
- repeated rhythmic contraction elicited
by striking a tendon/dorsiflexing the ankle

92. Neck Mobility
 Make sure there is no cervical vertebrae or
cervical cord injury
 Approach:
› supine position
› Place hand behind patient’s head
› Flex neck forward until chin touches the chest if
possible
 Normal:
› supple neck
› Easily bend head & neck forward
 Abnormal: Nuchal Rigidity
› Pain in the neck
› Resistance to flexion
 Meningeal irritation, arthritis or neck injury

93. 1. Brudzinski Sign
Approach:
 Flex the neck
 Watch the hips
& knees
Normal:
 Remain relax &
motionless
Abnormal:
 Pain & flexion
of hips & knees
 Meningeal
inflammation

94. 2. Kernig’s Sign
Approach:
 Flex patient’s leg at
both the hip & knee
 Then straighten the
knee
Normal:
 Discomfort behind
the knee during full
extension
 No pain is felt
Abnormal:
 Pain & increased
resistance to
extending the knee
 Bilateral = meningeal
irritation