Complete Neurological Examination of the Normal Patient

The neurological exam is primarily meant to test the hypotheses you developed during your history. However, you may have no hypothesis you want to test with the exam, because you believe the exam will be normal. Or 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 as testing 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 is 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 to your 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.

The following neurological exam is the minimum requirement for the SIU MSII OSCE :

Cranial nerves

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.
Number Name of nerve Function Test
I Olfactory Detection of smells Smell coffee, peppermint
II Optic Vision Pupil contraction to light*
Swinging flashlight test
Visual acuity using near card at 14 inches
Visual acuity using a Snellen chart or pinhole
Confrontation visual fields using fingers
Confrontation fields using white or red stimuli
Fundus examination
III, IV, VI Oculomotor, Trochlear, Abducens Eye movement Gaze in nine directions
Horizontal pursuit
Horizontal saccades
V Trigeminal Facial sensation Touch in V1, V2 and/or V3 distributions
Temp. or prick in V1, V2, and/or V3
Corneal reflex**
Innervates masseter, temporalis muscles Bite, jaw jerk***
VII Facial Innervates facial muscles Smile, forcibly close eyes 
Puff cheeks, wrinkle forehead
Taste on anterior 2/3 of tongue Test sweet, salt
VIII Vestibulocochlear Hearing Finger rub
Ticking watch, Weber's test, Rinne's test
Balance No test
IX, X Glossopharyngeal, vagus Elevation of the soft palate Palate elevates in midline
Gag reflex Touch posterior pharynx with swab
XI Spinal accessory Motor innervation trapezius muscles Shoulder shrug
Motor innervation sternocleidomastoid muscles Head turning
XII Hypoglossal Motor innervation tongue Protrude the tongue
* 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 carotid artery.
** 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 also use a 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 normal.
    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
    Pupillary reflex
Dim the room light and test with a strong penlight. Shine the light in one eye, 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 nerve is less than the right. This patient has an "afferent pupillary 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 sclerosis. 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.

    Visual acuity
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, using 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.


    Confrontation visual fields
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.

    Fundus examination
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 look at 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 ophthalmoscope light.

III, IV, and VI Oculomotor, trochlear, and abducens nerves
These are the muscles of eye movement. Test them by asking the patient to look in the nine cardinal positions of gaze.
R Up Up L Up
R Center L
R Down Down L Down
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.

V Trigeminal nerve
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.

VIII Vestibulocochlear nerve
The best screening test is light rubbing of the fingertips together. This is especially good for detection of high frequency hearing loss that occurs in presbycusis.

IX, X 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.

XII Accessory nerve
Test strength of the trapezei (shoulder shrug) and sternocleidomastiods (the R sternocleidomastoid rotates the head to the L).

XII Hypoglossal nerve
Test tongue protrusion. The tongue deviates to the weak side.


Motor Examination

  1. Muscle strength bilaterally in grip, biceps, triceps, deltoid, iliopsoas, quadriceps, hamstrings, foot dorsiflexion and foot plantar flexion.
  2. 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 downward and pronating drift.
  3. 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 does not test iliopsoas, quadriceps, and hamstrings. However, students must know how and when to perform the test.

Sensory Examination 

  1. 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.
  2. Vibration in ankles or toes bilaterally.
  3. Joint position sense in one digit on each limb.
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.

Reflex Examination

  1. Biceps
  2. Brachioradialis
  3. Triceps
  4. Patellar
  5. Achilles tendon
  6. Plantar reflex using Babinski's technique.

Coordination Examination

  1. Finger-nose-finger testing and/or
  2. Rapid alternating movements
  3. Heel-knee-shin testing.
The Head to Toe Screening Examination requires only finger-nose-finger testing.

Examination of Gait and Station

  1. Normal gait.
  2. Tandem walking. Ask the patient to walk heel-to-toe. Observe for instability.
  3. Toe walking. Primarily a test of muscle strength.
  4. Heel walking. Useful mainly to observe for dystonic posturing of the arms while walking.
  5. Test for stability in Romberg's position. The test is positive if the patient sways markedly or loses balance after closing eyes.

Mental status

I recommend using the Mini-Mental State Exam. It is validated, and a properly done exam yields a simple score that has a meaningful and easily-understood result. At a minimum, test 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. 

 Two reminders:
  1. 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.
  2. There may be some disagreement over where in a written report specific observations belong. For example, the fundus examination might be classified under 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.
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 OSCE.

Other examinations:

 For more information on the Medicare 1997 Neurological Single System Examination, click here.
 For more information on more advanced exam techniques, click here.

M. Steven Evans, M.D.
Professor of Neurology
University of Louisville
Louisville, KY

URL of this page

Revision history 
4 April 2006, 12 February 2008, 13 Sept 2013

Email the author