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.

Pitfalls:

Testing both nostrils at the same time. You will not detect unilateral dysfunction.
Using too strong a stimulus, like ammonia. This stimulates general sensory afferents in CN V, which innervates the nasal mucosa.

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.

Pitfalls:

Calling a slight asymmetry abnormal. Up to 1 mm asymmetry is normal.
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 pupils. If seeing the pupil is difficult, darken the completely and use a brighter light.

    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.

Pitfalls:

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.

    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.

Pitfalls:

Using your left eye to look at the patient's right eye, or your 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! Use 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 patients have 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.

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:

Esophoria and esotropia.
Dysconjugate movements.
Overshoot and undershoot during saccadic movments.
Nystagmus.
Diplopia.

The Head to Toe Screening Examination tests only movement to the nine cardinal positions of gaze.

Pitfalls:

Mistaking physiological nystagmus for pathological nystagmus.

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.

Pitfalls:

If the face is asymmetrical, the tongue may falsely appear to deviate. If in doubt, note the position of the chin with respect to the tongue.

Motor Examination

Muscle strength bilaterally in grip, biceps, triceps, deltoid, iliopsoas, quadriceps, hamstrings, foot dorsiflexion and foot plantar flexion.
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.
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

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.

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.

Pitfalls:

Paying too much attention to small changes. The assessment is 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 reproducible finding.
Cold feet. Cold reduces vibratory sensation markedly. This invalidates vibratory testing on the toes.

Reflex Examination

Biceps
Brachioradialis
Triceps
Patellar
Achilles tendon
Plantar reflex using Babinski's technique.

Pitfalls:

Striking the brachioradialis muscle instead of the tendon. If struck directly, the muscle will contract, even if there is no actual tendon reflex present.
Stating a reflex is absent or hypoactive when really present. If 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. Instead, stimulate the more calloused outer foot.

Coordination Examination

Finger-nose-finger testing and/or
Rapid alternating movements
Heel-knee-shin testing.

The Head to Toe Screening Examination requires only finger-nose-finger 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 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.

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".

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:

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.
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.

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

URL of this page
http://www.msevans.com/neurostudents/neuroexam/neuroexam.htm

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

Questions?
Email the author