DALHOUSIE UNIVERSITY

MED 2 CLINICAL SKILLS

OUTLINE: ADULT NEUROLOGIC EXAMINATION
Prepared by C. Jubenville
Revised by I. Grant
Last revised 06/14
Visit http://neuroexam.med.utoronto.ca/ for demonstrations of the individual components of the exam

Overview:

Students will have five sessions dedicated to the neurologic exam in adult patients
The focus is on learning physical exam skills, although the neurologic history may also be discussed
The elements of the screening examination will be emphasized
More specialized exam techniques may be covered, depending on time and the spectrum of
patients available during the rotation
Although exposure to abnormal clinical findings is valuable, the number one priority is to develop
good exam techniques, to practice those techniques under observation from a preceptor, and to
understand the rationale for the elements of the exam.
Contacts:
o Dr. Ian Grant (iagrant@dal.ca) Halifax
o Dr. Wendy Stewart (wastewar@dal.ca) Saint John

DURING THE ROTATION, DEMONSTRATE AS MUCH OF THE EXAM AS POSSIBLE TO YOUR PRECEPTOR!

General Principles:
1) OBSERVATION: observe the patient in conversation, moving in bed, walking from the waiting room
etc.
2) COMPARE left and right sides, as many lesions cause unilateral signs.
3) Rule of PARSIMONY try to localize deficits with respect to a single lesion in the nervous system.
4) Cranial nerves do up to 3 things: motor, sensory/special sensory, and autonomic (largely
parasympathetic).
5) CN reflexes are organized such that the afferent (sensory) component runs in the lower numbered
nerve, and the efferent (motor) in the higher numbered nerve (i.e., II/III pupils, V/VII corneals, IX/X
gag).
6) Think SYSTEMATICALLY: The nervous system is composed of the brain, brainstem, spinal cord, nerve
roots, plexus, peripheral nerves, neuromuscular junction and muscles. Where is the lesion along this
axis?

THE NEUROLOGIC EXAMINATION: the purpose is to test each area of the neurologic axis, looking for
neurologic abnormalities to redirect a focused physical exam.
1) Mental status Orientation, attention, expressive and receptive language function.
2) Cranial nerves visual fields, pupils, eye movements, facial strength, facial sensation,
SCM/trapezius, tongue movements.
3) Motor system Muscle bulk, tone and strength. Always include pronator drift.
4) Reflexes biceps, brachioradialis, triceps, patellar, ankle reflexes, plantar responses (Babinski)
bilaterally.
5) Sensation light touch, pin prick, joint position sense and vibration distally in all 4 limbs;
Romberg test (mainly a test of proprioception).
6) Coordination - Fine finger movements, finger-to-nose, rapid alternating movements and heelknee-shin.
7) Gait/balance forward, on heels, on toes, and tandem gait.

In following sections, detailed or specialized aspects of the examination, not part of the routine
screening examination, are indicated in these blue boxes.

COGNITIVE EXAMINATION
General Points
Not always examined in a routine screening examination
Very important in patients with cognitive symptoms or impairments, or language dysfunction
Differs in many respects from the MSE performed in the psychiatric setting
The specific tests that should be done depend on the clinical setting, e.g., language testing will be
important in a patient with suspected hemispheric stroke, to rule out aphasia
Speech and Language
Does the patient have impaired language function (aphasia)?
Does the patient have a motor problem affecting articulation (dysarthria)?
Tests of language function:
Spontaneous speech
o Fluent vs. Non-fluent
Grammatic, effortless (as in Wernickes aphasia)
Non-grammatic, effortful (as in Brocas aphasia)
o Paraphasic errors
Phonemic Paraphasia: cog instead of dog
Semantic Paraphasia: cat instead of dog
Comprehension
o Have patient point to objects; show me your left thumb
Naming
Repetition
Reading
Writing

For general cognitive testing, the Montreal Cognitive Assessment (MoCA) is recommended:
http://www.mocatest.org

CRANIAL NERVE EXAMINATION

CN I Olfactory Nerve occlude one nostril and identify a common scent (eg, coffee, peppermint,
cinnamon, cherry lip balm) placed under the other nostril. Avoid noxious stimuli, as this may stimulate
V2 branch of trigeminal nerve.
Not done routinely
Test in patients with head trauma, suspected Parkinsons disease, or in patients complaining of
abnormal taste or smell.

CN II Optic Nerve
Functions: Vision, afferent limb of pupillary response
a. Visual fields test by confrontation. Test each eye separately by showing one, two, or five
fingers in each quadrant. Alternatively, hand/finger waving can be used.

b. Acuity Near card 14 inches from each eye. Test best corrected vision, meaning the patient
should wear his or her usual corrective lenses if used for reading.
c. Funduscopic examination Examine the patients right eye with your right eye, left with left.
Start at arms length and identify the red reflex. Follow it in. Track the vessels to the optic disc
and make note of: disc outline (sharp vs. blurred), venous pulsations (absent in about 20% of
the population). If it is hard to switch eyes, perform the examination with the patient lying
down; stand at the head of the bed so your face is not directly in front of the patients face.
d. Pupillary light reflex (CN II = afferent, III = efferent) have patient fixate at a distance in a
dimly lit room. Shine a bright light close and briskly for greatest effect. Look for direct and
consensual responses.
i. Pupil sizes. Slight anisocoria (asymmetry of pupil size) can be normal (usually <0.5mm).
To determine whether the large or small pupil is the abnormal one, observe in low light
(small pupil is likely abnormal), and bright light (large pupil is likely abnormal).
ii. Direct and consensual response. When the light is shone in one eye, assess constriction
of both pupils. Some ambient light may be needed to see the opposite eye, especially
in patients with dark irises.

iii. Swinging flashlight test. This is to detect a relative afferent pupillary defect (aka
Marcus Gunn pupil). Move the light rapidly from one pupil to the other, holding for 1-2
seconds; the pupil size should not change. Swing back to original pupil; again, the pupil
size should remain constant. If the pupils dilate, there is disruption of the AFFERENT
(sensory) pathway from the eye into which the light is being shone. You have a lower
RELATIVE amount of AFFERENT light being detected so both pupils dilate (PUPILLARY
DEFECT). Remember that normal pupils can fluctuate in size from moment to moment
(hippus).

CN III, IV, and VI

Eye movements (Extra-ocular muscles=EOM)
Mnemonic - (LR6,SO4,AO3) lateral rectus CN 6, Superior Oblique CN 4, All others CN3
Function:
CN III Oculomotor nerve superior, inferior, medial rectus, inferior oblique and levator palpebrae
superioris (upper eyelid retraction). Parasympathetic fibres (pupillary constriction).
Damage to CN III therefore presents as a (complete or partial) triad:
- Eye deviated down and out
- Ptosis
- Dilated pupil
CN IV - trochlear nerve superior oblique, which moves eyes down and in (walking down stairs), and
intorsion. In a unilateral palsy, the eye may be deviated slightly up and out, and the patients head may be
tilted away from side of the lesion.
CN VI - abducens nerve Lateral rectus. Weakness results in
inability to abduct that eye.
Testing:
a. Primary gaze (straight ahead) Are the eyes conjugate?
Observe for involuntary movements and ptosis.
b. H - Method Have patient follow your finger slowly
(smooth pursuit) and hold at the six cardinal directions
of gaze. Observe for nystagmus (named for direction of
the fast component).

c. Accomodation have patient look straight ahead at a distant target and then focus on your
finger held close to the patients nose. The eyes should converge and the pupils should
constrict.
d. Saccadic eye movements have patient look rapidly between two fingers. Eye movements
should be direct, rapid and accurate with no intrusions or breaks in the movement or
over/undershooting (saccadic dysmetria)

CLINCIAL CORRELATION:
Internuclear ophthalmoplegia INO the CN VI nucleus from one side of the
brainstem is connected to the CN III nucleus on the other side by the medial
longitudinal fasciculus (MLF). Horizontal gaze in a particular direction is
coordinated between the lateral and medial rectus muscles via this
pathway, and is directed by the contralateral frontal eye field (FEF). A lesion
in the MLF manifests by impaired adduction on the IPSI lateral/affected side
(signal doesnt get to CN III/ medial rectus) accompanied by nystagmus in
the other, abducting eye (mismatch between eyes).
Figure: Lesion in the Right MLF causing a Right INO (INO named for the eye
that cannot Adduct). Nystagmus is fast phase to the left, occurs in L eye.
CN V Trigeminal Nerve
Function: sensation to the face, muscles of mastication, afferent limb of corneal reflex
a. Sensory three branches: ophthalmic (V1), maxillary (V2), mandibular (V3). Test each area
(forehead, cheek and chin) for light touch and pinprick. Compare side to side. Avoid the angle of the
jaw as it is supplied by the great auricular nerve and the C2 - C3 nerve roots.
b. Muscles of mastication Masseter/ MDL pterygoid, and temporalis = mouth closing (think Mmm);
Lat pterygoid = mouth opening/ jaw deviation (think La). Tested by resisted mouth opening,
volitional jaw deviation, palpation of masseter and temporalis.
c. Corneal reflex (V = afferent, VII = efferent) have the patient gaze up and away from the side
being tested and touch the peripheral part of the cornea. Approach from the side. Look for
direct and consensual responses. Most often tested in comatose patients.
CN VII - Facial Nerve
a. Facial Expression Observe for flattened nasoabial fold, and asymmetry of forehead creases.
Have patient wrinkle forehead, close eyes tight, puff out cheeks, show teeth.
Differentiate UMN (forehead sparing), vs. LMN (forehead involved).
b. Taste anterior 2/3 of tongue not routinely tested.
c. Nerve to Stapedius dampens sounds. Patient may complain of HYPERacusis on history.
EXPLANATION: Facial weakness facial nuclei are divided into upper and lower portions corresponding to
the upper and lower face. The upper portion (forehead/eye) has bilateral projections and the lower portion
(mouth) has unilateral projection from the cortex. With a central or UMN lesion (such as a stroke in one
cerebral hemisphere), the forehead muscles are spared because of the bilateral projection. If there is

damage to the facial nerve itself (lower motor neuron), then the whole side of the face is affected (as in
Bells palsy).
CN VIII - Vestibulo-cochlear nerve hearing and balance
Testing: Finger rub or whisper

Rinne 512 Hz compared in front of ear and on mastoid process

Weber 512 Hz centrally placed on forehead
Used together to differentiate conductive vs. sensorineural hearing loss

Normal
Conductive loss

Rinne
AC > BC
BC > AC

Sensorineural

AC > BC

Weber
No lateralization
Lateralizes toward
obstructed ear
Lateralizes away
from affected ear

CN IX and X - Glossopharyngeal and Vagus nerves

Function:
CN IX afferent gag, taste posterior 1/3 of tongue, parotid innervation (salivation)
CN X efferent gag, palatal elevation, swallowing, phonation, articulation
Testing
a. Observe palatal movement - "aaah"
Palate will pull to the normal side, or away from the affected side
b. Gag test each side by touching the tonsillar pillars with a tongue depressor (not routinely
tested)
NB: About 20 percent of normal individuals do not have a gag reflex

CN XI - Accessory Nerve
a. SCM - Head rotation; head turns away from the activated side (i.e., left SCM moves head right).
Test resisted head rotation while palpating the SCM body with the other hand
b. Trapezius - shoulder elevation: observe for atrophy. Test resisted shrug.
CN XII Hypoglossal tongue movement
a. Observe tongue atrophy and fasciculation (signs of LMN) with mouth open, tongue relaxed
b. Tongue movement - protrude the tongue and move it side to side. Tongue deviates toward the side
of weakness.
c. Power - push the tongue against the cheek

MOTOR EXAMINATION
Main Components: Bulk, tone and strength
A) Observation: Bulk
i. Bulk look atrophy, asymmetry, hypertrophy. Pay particular attention to the intrinsic hand
muscles, thenar and hypothenar emminence.
ii. Involuntary movements
Fasciculations Twitches, indicative of LMN damage, can also be normal;
Myoclonus brief, rapid, muscle jerks;
Chorea rapid, semi-purposeful, dance-like movements;
Athetosis slow, writhing movements;
Ballismus large amplitude flinging limb movements;
Tics abrupt, stereotyped, coordinated movements or vocalizations;
Dystonia maintenance of an abnormal posture or repetitive twisting movements
B) Tone
Definition: resistance to passive movement
Testing:
Upper limb: Flex/extend the elbow, pronate/supinate the wrist, move the wrist through a circular arc.
Lower limb: With the patient supine and relaxed, briskly lift the patients knee; log-roll the leg.
i. Spasticity velocity dependent. Clasp knife phenomenon. A sign of upper motor neuron
dysfunction. Generally found in flexors of the upper extremity and extensors of the lower
extremity.
ii. Rigidity velocity independent. Resistance throughout ROM. Lead pipe rigidity. Cogwheel rigidity
(tremor plus rigidity). A sign of extrapyramidal (basal ganglia) dysfunction.
iii. Paratonia patient unconsciously facilitates or inhibits passive movement, aka. Gegenhalten. Can
be caused by frontal lobe dysfunction but also common in elderly patients.
C) Strength
i. Pronator Drift VERY IMPORTANT screening test for subtle UMN weakness.
Technique: have the patient stretch out the arms palms up with eyes closed. Watch for 10
seconds to see if either arm pronates (so that the palm turns inward) and drifts downward.
ii. Strength testing Be systematic! Test each side individually and compare side to side. When
possible, expose the muscle belly so you can see and palpate it. Purpose is to screen nerve roots
and peripheral nerves (table below).

Grade
0
1
2
3
44
4+
5

MRC scale
Strength equivalent
No movement
Flicker of movement
Active movement, gravity eliminated
Active movement against gravity
Slight resistance to examiner
Moderate resistance
Able to break
Full power

Action
Upper Extremity
Shoulder abduction
Elbow Flexion
Elbow Extension
Wrist Extension
Wrist Flexion
Finger Extension
Finger Abduction
Finger Flexion
Lower Extremity
Hip Flexion
Hip Extension
Hip Abduction
Hip Adduction
Knee Extension
Knee Flexion
Dorsiflexion/ Eversion
Inversion
Plantarflexion

Major Nerve
roots

Peripheral Nerve

C5/6
C5/6
C7
C6/7
C6/7
C7/8
C8/T1
C8

Axillary
Musculocutaneous
Radial
Radial
Median and Ulnar
Radial
Ulnar
Median and Ulnar

L2/3
S1
L5
L2/3/4
L3/4
L5/S1
L5
L5
S1

Femoral/Iliopsoas
Inferior gluteal
Superior gluteal
Obturator
Femoral
Sciatic
Peroneal
Tibial
Tibial

Notes:
A) Upper motor neuron lesions often cause the following pattern of weakness:
Extensors weaker than flexors in the upper limb
Flexors weaker than extensors in the lower limb
B) Fine finger movements (finger tapping) are a sensitive way to look for UMN dysfunction.
Finger tapping will be slower on the side affected by UMN lesion
Should be distinguished from cerebellar dysfunction, in which tapping will be slow but also irregular
(see below).

REFLEX EXAMINATION
Principles:
Patient should be relaxed
Examiner should be relaxed. Hold the hammer loosely
Strike the tendon briskly
Positioning is important. For most reflexes, place joint in mid-position of ROM. For ankle jerk, slight
passive stretch of calf is helpful
Look for spread reflexes elicited in muscle groups not being directly tested suggests hyperreflexia
Reflex
Jaw Jerk
Biceps
Brachioradialis
Triceps
Quadriceps
Ankle jerks
Grade
0
1+
2+
3+
4+

Nerve Root(s)
CN V
C5/6
C5/6
C6/7
L2/3/4
S1
Response
None
Hypoactive
Normal
Brisk, no clonus (can be elicited
without a hammer)
Brisk with clonus

Reinforcement: used when a patients reflexes are difficult to elicit.

Upper limb reflexes: Have patient clench his or her teeth; make a fist with the opposite hand
Lower limb reflexes: hook together the flexed fingers of both hands and pull (Jendrassik maneuver)
Clonus: A rhythmic series of muscle contractions induced by stretching the tendon. It most commonly
occurs at the ankle, where it is typically elicited by forcefully dorsiflexing the patient's foot and
maintaining light upward pressure on the sole. Recorded as a few beats, or sustained. It is essentially
another way to elicit brisk ankle jerks (S1).
Plantar response/ Babinski
Use a blunt, narrow surface and stroke the sole of the patient's foot on the lateral edge, starting
near the heel and proceeding along the lateral edge almost to the base of the little toe, then curve
the path medially just proximal to the base of the other toes. This should take the form of a smooth
J stroke.
Normal: flexion of toes
Abnormal (Babinski sign): extension of great toe and fanning of other toes
o An upper motor neuron sign

SENSORY EXAMINATION
Principles:
a. Compare side to side.
b. Keep it simple. Many normal individuals will report minor sensory differences between body areas,
so focus on detecting gross sensory loss rather than subtle changes.
c. Start distally and move proximally if abnormal. Length-dependent, symmetric stocking glove
sensory loss is common (e.g.,diabetics), thus if distal testing is normal, proximal testing will also be
normal. Exceptions: if the patient complains of focal sensory changes you must test the affected
area.
d. If clinically indicated, test areas that represent individual nerve roots (dermatomes) and/or
peripheral nerves (median carpal tunnel, ulnar, radial) (see figure below).
e. Remember that the spinothalamic pathways cross shortly after entering the spinal cord, where as
the dorsal columns ascend ipsilaterally and cross at the level of the medulla. Dissociated sensory
loss (different pain/temp vs. vibration/joint position) can be suggestive of a cord lesion.
Primary sensory modalities: test afferent pathways represented by the dorsal column medial lemniscus
pathway (vibration and joint position) and the spinothalamic pathway (pain and temp). Remember to test
one side vs the other.
a. Light touch use a Kleenex or cotton
b. Pain and temperature tested by comparing ability to discriminate between sharp and dull. Use a
safety pin or split tongue depressor. Note however, that ability to sense cold and pin prick indicate
intact pathways; feeling dullness does not, so P&T are not abnormal unless the patient calls sharp
objects dull. Randomly switch between sharp and dull stimuli so patients cannot guess.
c. Vibration 128Hz tuning fork. Start by showing the patient what the vibrating stimulus feels like by
applying the vibrating tuning fork to the sternum or skull. Next, check the patients understanding
by applying a non-vibrating tuning fork to the finger or toe. Compare patient sensation to your own.
If any abnormalities are detected, apply the tuning fork to progressively more proximal joints.
d. Joint position sense remember to hold the sides of the finger or toe. Make small up/down
movements.
Discriminative sensation: tests sensory association areas of the brain. NB: You require intact primary
modalities before discriminative function can be tested. Not included in the routine screening exam.
a. Stereognosis have the patient identify a small recognizable object (eg, nickel, dime, quarter,
penny, key, paper clip) with his/her eyes closed.
b. Graphesthesia ask the patient to close the eyes and identify a number from 0 to 9 that you
draw on his or her index finger.
c. Two-point discrimination the ability to recognize two points applied simultaneously to the skin
as distinct from a single point. There are normative distances) age and body part for two point
discrimination; closer for fingers, greater for arms/legs and trunk
d. Extinction the inability to recognize two stimuli applied simultaneously; can be visual, tactile or
auditory. Often abnormal in right parietal lobe lesions such as stroke.

Nerve Root/
Peripheral Nerve
C5
C6
C7
C8
T4
T10
L1
L4
L5/ common
peroneal n.
S1/ tibial n.
S2/3/4
Median
Ulnar
Radial

Location to test
Shoulder tip
Thumb
Middle finger
Pinky
Nipple line
Umbilicus
Inguinal ligament
Medial leg
Top of foot
Sole of foot
Perianal saddle distribution
Palmar surface of lateral 3 digits
Palmar surface of medial 1 digits
Lateral dorsal side of the hand

Sensory Level: in a patient with sensory deficits throughout one or both lower limbs, test light touch and
pin prick moving caudalrostral (toes to head) up the abdomen. Pay attention to where sensation
returns. Repeat testing moving rostralcaudal and note where sensation changes. Repeat both on the
back, noting that the sensory level, should be higher there, as the segmental nerves wrap down and
around to the abdomen (see pic above light blue)

COORDINATION/ CEREBELLAR
Principles:
a. Important to tease out whether abnormalities in this testing are due to weakness, sensory
dysfunction or cerebellar dysfunction.
b. Compare side to side
c. Remember that cerebellar findings are IPSI-lateral to the affected side as the cerebellar circuitry
undergoes a double decussation
d. Observe for consistency in speed, rate, rhythm and accuracy, tremor and involuntary movements.
Testing:
a. Fine finger movements have the patient mimic playing the piano.
b. Rapid alternating movements have the patient rapidly pronate and supinate the hand.
Breakdown of the rate, rhythm and force of rapid alternating movements is referred to as
dysdiadochokinesis.
c. Finger-to-nose testing have the patient touch rapidly with the tip of their finger between his/her
nose and your finger. Hold your finger so that it is near the end of the patient's reach. If the patient
performs normally, make the test harder by moving your finger to several different positions.
Abnormalities here are referred to as dysmetria.
d. Heel-to-shin testing Have the patient lie supine and run the heel of one foot along the tibia of the
other leg and tap the knee cap with the heel.

GAIT/BALANCE:
Observe:
a. Casual, forward gait observe both forward and away. Pay attention to the length of time spent on
the left vs. right legs, as well as for circumduction (UMN/spacticity), steppage gait (foot drop) heelstrike, toe-off and heel-toe transition.
b. Walk on tip-toes and on heels assures at least a 4/5 strength in foot dorsi/plantar flexion. Useful
comparison to supine strength tesing.
c. Tandem gait walk heel to toe alone a straight line.
d. Pull-back test apply a sufficiently strong backward force (requiring them to take a step
backward) to the shoulders while standing behind the patient. In Parkinsons disease, patients
may have trouble regaining their stance with only one step back. Abnormalities are referred to as
retropulsion.