Complete Neurological Examination of the Normal Patient
The neurological exam is primarily meant to test the
developed during your history. However, you may have no hypothesis you
want to test with the exam, because you believe the exam will be
you may not have done a history at all, because you are simply doing
the exam as part of a test to show that you indeed do know how to
perform the neurological exam. There is a daunting number of
neurological examination techniques that are occasionally useful, such
ability to smell (CN I), testing abdominal reflexes, testing pectoralis
reflexes, the straight leg raising test for lumbar root irritation,
Kernig's sign, and many more. To test for all possible things
not practical--but which parts of the exam should you do in a normal
person expected to have a normal exam? However, this exam will be useful for much more
than just passing your OSCE. If a
patient's findings are normal on this exam, then you may truthfully say
examiner, or third-party payer "I have done a complete neurological
examination, and the findings were normal." The minimum
recommended Complete Neurological Examination of the Normal Patient is
almost identical to the neurological components of the Head to Toe Screening Examination. When different this is noted and italicized.
If you want information
on more advanced exam
techniques, click here.
Medicare exam requirements are different. If you want more information on the Medicare 1997 Neurological Single System Examination, click here.
neurological exam is the minimum requirement for the SIU MSII
Tests underlined and highlighted in yellow are required. They are the
minimum to demonstrate normal nerve function. Others tests are
often or occasionally useful, but are not always required, and are not
underlined or highlighted.
* The afferent arc of the pupillary light reflex is mediated by CN II.
The efferent arc is mediated by CN III (parasympathetic fibers).
Pupillary dilation is mediated by sympathetic fibers branching from the
||Name of nerve
||Detection of smells
||Smell coffee, peppermint
contraction to light*
||Swinging flashlight test
acuity using near card at 14 inches
||Visual acuity using a Snellen chart or pinhole
visual fields using fingers
||Confrontation fields using white or red stimuli
|III, IV, VI
||Oculomotor, Trochlear, Abducens
in nine directions
in V1, V2 and/or V3 distributions
||Temp. or prick in V1, V2, and/or V3
||Innervates masseter, temporalis muscles
||Bite, jaw jerk***
||Innervates facial muscles
||Smile, forcibly close eyes
||Puff cheeks, wrinkle
||Taste on anterior 2/3 of tongue
||Test sweet, salt
||Ticking watch, Weber's test, Rinne's test
||Elevation of the soft palate
elevates in midline
||Touch posterior pharynx with swab
||Motor innervation trapezius muscles
||Motor innervation sternocleidomastoid muscles
||Motor innervation tongue
** The afferent arc of the corneal reflex is through CN V. The efferent
arc is mediated by CN VII.
*** The afferent arc of the jaw jerk is mediated through sensory CN V,
and the efferent arc by motor CN V.
How to perform these cranial nerve tests
I Olfactory nerve
Use fresh coffee or peppermint in a small container. You can
fresh "scratch 'n sniff" paper, but a strong stimulus is best. Test
each nostril separately. If the patient can detect a fragrance with
both nostrils, then this screening test for intact CN I function is
The Head to Toe Screening Examination does not require Cranial Nerve I testing, but students must know how and when to perform the test.
II Optic nerve
- Testing both nostrils at the same time. You will not detect
- Using too strong a stimulus, like ammonia. This stimulates
general sensory afferents in CN V, which innervates the nasal mucosa.
Dim the room light and test with a strong penlight. Shine the light in
take the light away, then shine it in the other. Note symmetry of
response. You may try a "swinging flashlight test"
in which you directly move the light from one eye to the other. If you
swing the light from the right eye to the left and the left
pupil dilates, then the afferent input from the left optic
is less than the right. This patient has an "afferent
defect", also called a "Marcus-Gunn pupil". If the optic media in the
left eye look normal with your ophthalmoscope, then the patient must
have a defect of the optic nerve between the retina and the optic
chiasm. This finding is common in the demyelinating disease multiple
You may also test for the response
of the pupil to accomodation--simply
ask the patient to focus on a near object, near enough for them to need
to cross their eyes. The normal response is for the
pupils to narrow slightly. These findings are commonly written
with the abbreviation PERRL or PERRLA (Pupils Equal Round Reactive to
Light and Accomodation).
The Head to Toe Screening Examination does not require the swinging flashlight test, but students must know how and when to perform the test.
- Calling a slight asymmetry abnormal. Up to 1 mm asymmetry
- Being fooled by "hippus". This is a normal slight
spontaneous opening and closing of the pupil.
- Failing to detect small responses in patients with small
If seeing the pupil is difficult, darken the completely and use a
You are not interested in how well the patient can see without his
glasses--you want to know his best corrected visual acuity, so ask them
to wear their glasses. Use either a Snellen chart at 20 feet, or a near
card at 14 inches. If the patient correctly identifies half of the
letters on the line, he gets credit. Even without glasses,
a pinhole can markedly improve visual acuity--a pinhole camera is
always in focus! Make a pinhole by shoving the tip of a ballpoint pen
through an index card.
The Head to Toe Screening Examination tests visual acuity with a near card at 14 inches.
- The Snellen chart really must be 20 feet away--not some other distance.
- The near card must really be 14 inches away--not some other distance.
- The patient's best possible visual acuity may occur at some distance other than these two commonly tested.
You should test each eye individually, and compare the patient's fields
to your own (assuming yours are normal). Use moving fingers, or a white
stimulus to test peripheral vision. Make sure you test all 4
quadrants in each eye. Color visual fields can be tested with a red
stimulus, and this is the best way to detect a subtle visual field
defect at the bedside.
The Head to Toe Screening Examination tests confrontation visual fields only with moving fingers.
You should at least get a decent look at the optic disk. The disk
should have a pink color, have an obvious cup, and relatively sharp
edges. You may be able to detect venous pulsations. Try to
the rest of the eye grounds too. Look at the macula. This is the
easiest part--just ask the patient to look directly into your
III, IV, and VI
Oculomotor, trochlear, and abducens nerves
- Using your left eye to look at the patient's right eye, or
right to look at their left. This brings your nose and mouth into
unnecessarily close proximity to the patient's. It also makes you look
very unskilled to any examiner, so don't do it!
your left for their left, your right for their right. If your vision is
impaired in one eye, say to the patient you must use only one eye and
warn them clearly, so the examiner observing you will
understand it too.
- Using too bright a room or too bright a light. Some
small pupils. For these, use a dark room, dim your opthalmoscope and
narrow its beam.
- Failing to use the patients glasses. Some patients need
very strong glasses, and the opthalmoscope diopters may
not compensate for it properly. In that case, ask the patient to put
their glasses on.
These are the muscles of eye movement. Test them by asking the patient
to look in the nine cardinal positions of gaze.
Test eye movement by asking the patient to follow your finger to each
position. You should also test horizontal pursuit movements--follow the
finger from R to L and L to R--and horizontal saccadic movements--look
quickly from a finger on the patient's R to one on L and from L to R.
Note whether movements are smooth, conjugate, accurate, and whether
there is nystagmus. If all these are normal, the patient's eye
movements can be considered normal.
You may find abnormalities that
require further testing to elucidate, such as:
The Head to Toe Screening Examination tests only movement to the nine cardinal positions of gaze.
- Esophoria and esotropia.
- Dysconjugate movements.
- Overshoot and undershoot during saccadic movments.
- Mistaking physiological nystagmus for pathological
Test light touch, temperature or prick in all three divisions of the
nerve (V1, V2, V3) bilaterally. I recommend routine testing of
temperature with a cool tuning fork rather than prick, because most
patients recoil in fear if you approach them with a pin, and the
pathways subserving pain and temperature are essentially the same.
However, if you want to do detailed mapping, you'll have to use a pin.
To test a corneal reflex, touch a swab on the patient's conjunctiva,
and gradually move it to the limbus of the cornea. There, but not on
the conjunctiva, the patient will blink.
The Head to Toe Screening Examination does not test the corneal reflex, but students are required to know how and when to perform the test. The
Head to Toe Screening Examination requires testing of sharp sensation
with the broken wooden stick of a cotton swab. This will suffice, but I
recommend a safety pin for it's sharper and more reproducible stimulus. Remember to use a different pin on each patient, and to discard the pin in a red sharps box.
VII Facial nerve
Test the patient's ability to symmetrically smile and show their teeth.
Subtle asymmetry is common, and if present its normality can
usually be established by looking at a previous photo ID of the
patient. This tests the lower face, which is weak in upper motor neuron
lesions. The upper face is weak in Bell's palsy, and is tested by
wrinkling the forehead, or asking the patient to forcibly close the eyes and resist the examiner's attempt to open them.
Occasionally, testing of taste is useful for diagnosis of cranial nerve VII lesions.
The Head to Toe Screening Examination uses forcible eye closure to assess cranial nerve VII. Taste is not tested.
The best screening test is light rubbing of the fingertips together.
This is especially good for detection of high frequency
loss that occurs in presbycusis.
Glossopharyngeal and vagus nerves
The patient says "Ahhh" and the normal patient's palate elevates in the
midline. The normal screening neurological exam does not require
testing the gag reflex, but if you do, use a tongue blade to hold down
the tongue and a swab to stimulate the posterior pharynx.
The Head to Toe Screening Examination does not test the gag reflex.
Test strength of the trapezei (shoulder shrug) and sternocleidomastiods
(the R sternocleidomastoid rotates the head to the L).
Test tongue protrusion. The tongue deviates to the weak side.
- If the face is asymmetrical, the tongue may falsely appear
deviate. If in doubt, note the position of the chin with respect to the
The Head to Toe Screening Examination does not test iliopsoas, quadriceps, and hamstrings. However, students must know how and when to perform the test.
- Muscle strength bilaterally in grip, biceps, triceps,
iliopsoas, quadriceps, hamstrings, foot dorsiflexion and foot
- Observe for a pronating drift of the
outstretched arms. This can detect degrees of weakness more subtle
than can be found with direct testing. A positive test is a slow
- Test muscle tone in the arms. Ask the patient to relax,
test tone at the elbow and wrist bilaterally.
The Head to Toe Screening Examination
requires testing of sharp sensation with the broken wooden stick of a
cotton swab. This will suffice, but I recommend a safety pin for it's
sharper and more reproducible stimulus. Remember to use a different pin on each patient, and to discard the pin in a red sharps box.
- Pinprick on both hands and feet. Use a safety
pin or other moderately sharp disposable item. It isn't necessary to do
specific dermatomes unless you're investigating a specific sensory
complaint, but compare the same areas on each side. Ask the patient if
the quality of the prick is approximately
the same on the two sides. If it is markedly different (e.g. the left
side has a "dollar's worth" of prickiness but the right side only 50
cents) then there is an abnormality.
- Vibration in ankles or toes bilaterally.
- Joint position sense in one digit on each limb.
- Paying too much attention to small changes. The assessment
very subjective, and it is impossible for you to get the stimulus
exactly right. It is a "real" finding only if it is a definite and
- Cold feet. Cold reduces vibratory sensation markedly. This
invalidates vibratory testing on the toes.
- Achilles tendon
- Plantar reflex using Babinski's technique.
- Striking the brachioradialis muscle instead of the tendon.
struck directly, the muscle will contract, even if there is no actual
tendon reflex present.
- Stating a reflex is absent or hypoactive when really
you are using a lightweight hammer you must use great skill to give the
tendon an adequate blow. If you use a soft, heavy hammer, less
skill is required.
- Stimulating the soft middle of the sole to test the plantar
reflex. This always elicits a flexor response.
the more calloused outer foot.
The Head to Toe Screening Examination requires only finger-nose-finger testing.
- Finger-nose-finger testing and/or
- Rapid alternating movements
- Heel-knee-shin testing.
Examination of Gait and Station
- Normal gait.
- Tandem walking. Ask the patient to walk heel-to-toe.
Observe for instability.
- Toe walking. Primarily a test of muscle strength.
- Heel walking. Useful mainly to observe for dystonic
posturing of the arms while walking.
- Test for stability in Romberg's position. The test is
positive if the patient sways markedly or loses balance after closing
I recommend using the Mini-Mental
It is validated, and a properly done exam yields a simple score that
has a meaningful and easily-understood result. At a minimum,
orientation and repetition.
The Head to Toe Screening Examination
does not require assessment of mental status, and it is not required
for the MSII OSCE. However, at least a brief examination of mental
status is required for any complete neurological examination.
- What is today's date?
- What is the year?
- What is the month?
- What is the day of the week?
- What town are we in?
- Please repeat "No ifs ands or buts".
This is the minimum
Complete Neurological Exam in the Normal Patient, and is essentially identical to the neurological components of the Head to Toe Screening Examination. Good performance on
this exam is required to pass the SIU MSII Neuromuscular and Behavior
- Although it is not part of the neurological exam per se,
the cardiac examination, and examination of the carotids for bruits are
so important for neurological diagnosis they are an essential part of
any exam truly meant to diagnose a neurological problem. So if you have
a patient with a problem, you should do this. On the other hand, if
this is a "Neuro. Exam OSCE", it is not required.
may be some disagreement over where in a written report specific
observations belong. For example, the fundus examination might
your HEENT exam. There's nothing wrong with that, but it is also a part
of the Complete Neurological Exam, and it must be done in all cases,
otherwise your exam is incomplete.
For more information on the Medicare 1997 Neurological Single System Examination, click here.
For more information
on more advanced exam
techniques, click here.
Professor of Neurology
University of Louisville
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4 April 2006, 12 February 2008, 13 Sept 2013
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