To put it simply start with the head (cranial nerves) and work your way through the rest of the examination. Finally it is often appropriate to complete the examination with the mini-mental status examination as detailed in the psychiatric examination. This is a convenient way to test most patients. However the order of testing may be varied depending on the patients history or level of consciousness for example. The key to performing an effective neurologic examination is to be complete and record the examination accurately. It is important during and at the conclusion of the examination to determine if the findings have localizing significance and what types of disease they are likely to represent. We have prepared video tapes of normal and abnormal neurologic examinations to help you get started.

Be sure to come to the clinic prepared to do a proper neurologic examination. This means you will need the proper equipment as illustrated in the videos.

Cranial Nerve Examination

CNI-Usually not done unless indicated by history. Test each nostril one at a time with a subtle odor such as cloves or musk oil.

CNII-Test the peripheral visual fields by confrontation and test the central vision with the Amsler grid card or a small (1mm) red pin. Then perform the funduscopic examination with your opthalmoscope noting the conformation and color of the optic nerve, the retinal vessels, the fovea, and retina. Perform the swinging flashlight test to determine if there is an afferent pupillary defect.

CN III, IV, VI- Observe for ptosis, make sure that the pupils are equal round and reactive to light and accomodation (PERRLA). Then check ocular motility in the six cardinal directions observing for palsies (weakness of muscles) and nystagmus.

CN V- Test facial sensations in all three dermatomes with pin, light touch and/or temperature. Check the corneal reflexes. Test masseter strength on both sides.

CN VII- Observe the symmetry of the face and spontaneous facial expression. Then have the patient raise their eyebrows, close their eyes against resistance and puff up their cheeks.

CN VIII- Test hearing in both ears by having the patient listen to you rubbing your fingers against your thumb or to a watch. Then perform the Weber and Rinne tests. Be sure you can interpret the findings of these tests.

CN IX, X- Observe the palate for symmetric elevation and check the swallow. If you suspect the patient has multiple cranial nerve palsies or the patient has a slurred speech with a nasal quality you may wish to test the gag reflex on both sides (this noxious test is not necessary in the vast majority of patients).

CN XI- Test the strength of the sternocleidomastoids and upper trapezius muslces.

CN XII- Have the patient protrude the tongue. Make sure it is in the midline. Check the strength of the tongue on protrusion into the right and left cheeks.

Motor Examination- Observe for atrophy, fasiculations or involuntary movements. Then test muscle strengths in all four extremities.

Deep Tendon Reflexes and Pathologic Reflexes- Check the biceps, brachioradialis and triceps deep tendon reflexes in the upper extremities. Check the knee and ankle jerks in the lower extremities. Next test for pathologic reflexes including the Babinski and Hoffmann signs. As you become more skilled you will find that this is a good time to test for primitve reflexes such as the grasp reflex and palmomental response which are important to test in patients with cognitive problems.

Coordination- Test finger to nose, heel knee shin, knee tapping and rapid alternating movements.

Gait and Station- Observe the gait and note associated arm movements. Test heel, toe and tandem gaits. Test for the presence or absence of Romberg’s sign. Note the patient must be able to stand on a narrow base with their eyes open and the fall with their eyes closed for Romberg’s sign to be present.

Sensory Examination- Test pinprick, light touch, vibration and position sense in all four extremities. You may wish to test temperature sensation as well. Observe any patterns of sensory loss such as glove and stocking or dermatomal sensory loss.

Cognitive Testing: Observe the quality of the patients speech and language. Do you suspect a dysarthria (slurred speech) or a dysphasia (abnormal language). Note the level of consciousness.

Is the patient alert, lethargic, stuporous or comatose. Perform a mini-mental status examination.

Finally, be sure to record your examination accurately, before you have forgotten the details of the findings. This will be invaluable to you and other physicians caring for the patient.