The neurological examination is a systematic method used by health care providers and particularly by neurologists to look for abnormalities or lesions in the nervous system. The neurological examination is not performed in isolation, but as part of a general physical examination. The following is an abbreviated neurological examination for an alert, adult patient. The neurological examination contains several broad rubrics to test the patient’s (1) mental status, (2) cranial nerves, (3) reflexes and motor ability, (4) coordination and gait, and (5) sensory responses.
The mental portion of the examination is conducted informally by having a conversation with the patient. Questions are asked, such as, “Is the patient oriented?” “Confused?” “Are there alterations in short-term memory?” “In recall?” More formally, the physician may use the Folstein Mini Mental Examination, which tests for items such as orientation, registration, reading, and naming objects. These items and answers are scored on a 30-point scale.
The cranial nerves are listed and tested as follows:
Cranial nerve I (olfactory nerve): This nerve can be tested by having the patient smell a non-noxious smell such as coffee in each nostril.
Cranial nerve II (optic nerve): Visual acuity, visual fields, and ocular fundi (the interior surface of the eye) are confirmed. Specifically, the patient’s sight is tested using a handheld visual acuity card. To test the visual fields, the examiner brings his or her fingers into the visual field and has the patient indicate when he or she can see the moving fingers. The fundoscopic examination is performed using an ophthalmoscope. The physician looks for the color of the fundus, the cup to disc ratio, and the presence of spontaneous venous pulsations.
Cranial nerves II and III (oculomotor nerves): Pupillary responses are confirmed. The examiner tests to see that the pupils are of equal size and constrict in response to light, the consensual pupillary light reflex.
Cranial nerves III, IV (trochlear nerves), and VI (abducens nerve): These three nerves control eye movements and are typically tested together by having the patient follow a target, such as a pen light, and look up, look down, look side to side, and then look toward the nose to test for accommodation. One examines for the smoothness of the eye movement, conjugate eye movements, and any nystagmus.
Cranial nerve V (trigeminal nerve): The patient is asked to clench the masseter muscles, which control jaw movement. The examiner tests for asymmetry between the two sides.
Cranial nerve VII (facial nerve): The examiner looks for weakness of facial muscles during a smile and when cheeks are puffed out. Also, the examiner looks for weakness when the eyebrows are raised.
Cranial nerve VIII (vestibulocochlear nerve): The examiner rubs fingers together and has the patient report if a sound is heard. Balance is assessed during the coordination and gait exams.
Cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve): The patient elevates the palate and the examiner looks for any asymmetry of movement.
Cranial nerve XI (accessory nerve): The patient shrugs the shoulders upward to test the strength of the trapezius muscles. The patient then turns the head to either side against resistance provided by the examiner to test for the strength of the sternocleidomastoid muscle of the neck.
Cranial nerve XII (hypoglossal nerve): The patient protrudes the tongue out and moves it from side to side. The examiner looks for any asymmetry of movement.
The deep tendon reflexes in the extremities are tested and rated on a scale of 0 to 5 or from no reflex to a presence of sustained clonus. Stroking the lateral aspect of the bottom of the foot checks the plantar response. The normal response is for the toes to move down in contraction.
One examines the muscles for any abnormalities such as fasciculation (brief, spontaneous contractions of a few muscle fibers). One tests the tone of the extremities, asking, “Are they flaccid? Spastic?” and so on. The strength of the arms and legs are tested by muscle group and then rated on a scale of 0 to 5 or from no muscle contraction present to full strength.
Coordination is tested by examining “finger to nose to finger” testing to determine if the patient can hit the target or if there is any overshoot while attempting to hit the target. In the legs, coordination is examined by having the patient place the heel on the shin and then slide the heel up and down the shin.
One examines casual gait, then tandem gait in which one foot is placed in front of the other. The patient walks on heels and toes. This identifies any weakness in dorsi and plantar flexion of the feet.
Pain and temperature are tested using a sharp object and the cool touch of the tuning fork. Vibration and proprioception are tested by vibration of the tuning fork and by moving a toe or finger up or down and asking the patient to identify which direction the digit is moved.
Audrey S. Yee
See also: Accommodation; Cranial Nerves; Neurologist; Nystagmus; Reflex; Touch
Blumenfeld, Hal. (n.d.). Neuroanatomy through clinical cases. Retrieved from http://www.neuroexam.com/neuroexam/content.php?p=2
Russell, Stephen, & Marc Triola. (n.d.). The precise neurological exam. Retrieved from http://informatics.med.nyu.edu/modules/pub/neurosurgery/index.html