Neurological Exam

Front 1

1 Assess Cranial Nerve I
-Olfactory

Back 1

Examiner checks for patient’s
sense of smell by, e.g. coffee,
soap, peppermint, orange peels,
etc.

Front 2

2 Assess Cranial Nerve II
-Optic: Assess Visual
Fields by Confrontation

Back 2

•
Examiner stands at
approximate eye-level
with patient, making
eye contact.
•
Patient is then asked to
return examiner’s gaze
e.g. by saying “Look at
me.”
•
Examiner starts by
placing his / her hands
outside the patient’s
field of vision, lateral to
head.
•
With fingers wiggling
(so patient can easily
see them) the examiner
brings his / her fingers
into the patient’s field of
vision.
Hands diagonal
Or, hands horizontal
•
Examiner must ask the patient “Tell me when you see my
fingers.”
•
Assess upper, middle and lower fields, bilaterally.

Front 3

Assess Cranial Nerve II –
Optic: Accessing Visual
Acuity

Back 3

•
For ICC purposes,
handheld Rosenbaum
Pocket Screener (eye
chart)
•
NOTE: Use handheld
Snellen eye chart if
patient stand 20’ from
the chart
•
Ask patient to cover one
eye while testing the
other eye
•
Rosenbaum eye chart
is held in good light
approximately 14” from
eye
•
Determine the smallest
line of print from which
patient can read more
than half the letters
•
The patient’s visual
acuity score is recorded
as two numbers, e.g.
“20/30” where the top
number is the distance
the patient is from the
chart and the bottom
number is the distance
the normal eye can
read that line.
•
Repeat with the other
eye

Front 4

4 Assess Cranial Nerves II and III
-Optic and Oculomotor:
Assess direct and Consensual
Reactions

Back 4

•
Examiner asks the patient to look
into the distance, then shines a
light obliquely into each pupil
twice to check both the direct
reaction (pupillary constriction in
the same eye) and consensual
reaction (pupillary constriction in
the opposite eye).
•
Must be assessed bilaterally.
•
Assessed in normal room light,
testing one eye at a time.

Front 5

5 Assess Cranial Nerves II and III Optic
and Oculomotor: Assess
Near Reaction and Near Response
•

Back 5

Examiner holds a finger, pencil,
etc. about 10 cm. from the
patient’s eye.
•
Asks the patient to look
alternately at the finger or pencil
and then into the distance.
Close focus
•
Note pupillary constriction with
near focus.
Distant focus

Front 6

6 Assess Cranial Nerve III
-Oculomotor: Assess Convergence

Back 6

•
Examiner asks the patient to follow
his / her finger or pencil as he / she
moves it in toward the bridge of the
nose to within about 5 to 8
centimeters.
Converging eyes normally follow the
object to within 5 – 8 cm. of the nose.

Front 7

7 Assess Cranial Nerve III, IV and VI
-Oculomotor, Trochlear And
Abducens:
Assess Extra Ocular Muscle
Movement

Back 7

Examiner assesses muscle
movements in at least 6 positions
of gaze by tracing, for example, an
“H pattern” with the hand and
asking the patient to follow the
hand with their eyes without turning
the head

Front 8

Assess Cranial Nerve V
-Trigeminal (Motor)

Back 8

•
Examiner asks the patient to
move jaw his or her jaw from
side to side


OR

•
Examiner palpates the
masseter muscles and asks
patient to clinch his / her teeth.
•
Note strength of muscle
contractions.

Front 9

Assess Cranial Nerve V
-Trigeminal (Sensory)

Back 9

Examiner assesses sensation in 3
sites:


•
Ophthalmic
•
Maxillary
•
Mandibular
•
Examiner may use fingers,
cotton, etc. for the
assessment.
•
Assess bilaterally.
Mandibular

Front 10

Assess Cranial Nerve VII

– Facial:
Motor Testing

Back 10

Examiner asks patient to
perform any 4 of the
following 6 exams:

•
Raise both eyebrows
•
Close eyes tightly, then
try to open against

Raise eyebrows Opening eyes against resistance

examiner’s resistance

•
Frown
•
Smile
•
Show upper and lower
teeth
•
Puff out cheeks
Note any weakness or
asymmetry.

Frown Smile
Show teeth
Puff cheeks

Front 11

Assess Cranial Nerve VIII –
Acoustic

Back 11

•
Use a 512 Hz or 1024 Hz
turning fork.
•
Examiner starts the fork
vibrating e.g. by tapping it
on the opposite hand, leg,
etc.
•
Base of the tuning fork
placed firmly on top of the
patient’s head.
•
Patient asked “Where does
the sound appear to be
coming from?” (normally it
will be sensed in the
midline).

Front 12

Assess Cranial Nerve VIII –
Acoustic

Back 12

Rinne test – to compare air
and bone conduction

•
Use a 512 Hz or 1024 Hz
turning fork.
•
Examiner starts the fork
vibrating, e.g. by tapping it
on the opposite hand, leg,
etc.
•
Base of fork placed
against the mastoid bone
behind the ear.
•
Patient asked to say when
he / she no longer hears
the sound
•
When sound no longer
heard, examiner moves
the tuning fork (without restriking
it) and holds it near
the patient’s ear and ask if
he / she can hear the
vibration.
•
Examiner must vibrate the
tuning fork again for the
second ear.
•
Bilateral exam.
NOTE: (AC>BC): Air
conduction greater than bone
conduction.

Mastoid Bone


Ear

Front 13

Assess Cranial Nerve VIII -Gross
Auditory Acuity

Back 13

•
Examiner asks patient to
occlude (cover) one ear.
•
Examiner then whispers
words or numbers into non-
occluded ear from
approximately 2 feet away.
•
Asks patient to repeat
whispered words or
numbers.
•
Compare bilaterally.
OR

•
Examiner asks patient to
occlude (cover) one ear.
•
Examiner rubs thumb and
forefinger together next to
patient’s non-occluded ear
and asks the patient if the
sound is heard.
•
Compare bilaterally.

Front 14

Assess Cranial Nerve IX and

X – Glossopharyngeal and
Vagus: Motor Testing

Back 14

•
First, examiner asks the
patient to swallow.
Swallowing


•
Next, patient asked to say
‘aah’ and examiner
observes for symmetrical
movement of the soft
palate or a deviation of the
uvula.
•
OPTIONAL: Use a light
source to help visualize
palate and uvula.
NOTE: sensory component of
cranial nerves IX and X is
testing for the “gag reflex”

Saying “Aah”

Front 15

Assess Cranial Nerve XI
-Spinal Accessory:
Motor Testing

Back 15

•
Examiner asks the patient to
shrug his / her shoulders up
against the examiner’s hands.
Apply resistance.
•
Note strength and contraction of
trapezius muscles.
•
Next, patient asked to turn his
or her head against examiner’s
hand. Apply resistance.
•
Observe the contraction of the
opposite sternocleido-mastoid
muscle.
•
Assess bilaterally.

Front 16

Assess Cranial Nerve XII

– Hypoglossal:
Motor Testin

Back 16

•
First, examiner inspects
patient’s tongue as it
lies on the floor of the
mouth.
•
Note any asymmetry,
atrophy or
fasciculations.
•
Next, patient asked to
protrude the tongue.
•
Note any asymmetry,
atrophy or deviations
from the midline.
•
Finally, patient asked to
move the tongue from
side to side.
•
Note any asymmetry of
the movement.
Inspect tongue
Protruding Tongue


Side to Side Movement

Front 17

17 Assess Lower Extremities – Motor
Testing

Back 17

With patient in supine position, test
bilaterally
•
Test flexion of the hip by placing
your hand on patient’s thigh, and
ask them to raise his / her leg
against resistance.
•
Test extension of the hip by
having patient push posterior
thigh against your hand

CONTINUED




13

 



17 Assess Lower Extremities – Motor
Testing
With patient in seated position, test
bilaterally
•
Test adduction of the hip by
placing hands firmly between the
knees, and asking them to bring
the knees together
•
Test abduction of the hip by
placing hands firmly outside the
knees, and asking patient to
spread their legs against
resistance

Front 18

18 Assess Upper Extremities -Motor
Testing

Back 18

•
Examiner asks patient to pull (flex)
and push (extend) the arms against
the examiner’s resistance.
•
Bilateral exam.
Flexion Extension

19 Assess Lower Extremities – Motor
Testing
•
Examiner asks the patient to pull
(flex) and push (extend) the legs
against the examiner’s resistance.
•
Bilateral exam.
Flexion Extension

Front 19

20 Assess Lower Extremities – Motor
Testing

Back 19

•
Examiner asks patient to dorsiflex
and plantarflex the ankle against
resistance
•
Compare bilaterally

Front 20

Assess the Biceps Reflex

Back 20

•
Examiner partially flexes patient’s
arm.
•
Strike biceps tendon with reflex
hammer with enough force to elicit a
reflex, but not so much to cause
patient discomfort.
OPTIONAL: Examiner places the thumb
or finger firmly on biceps tendon.
•
Reflexes must be assessed
bilaterally.
•
Examiner must produce a reflex for
credit.

Front 21

Assess the Triceps Reflex

Back 21

•
Examiner flexes the patient’s arm at
the elbow, and then taps the triceps
tendon with reflex hammer.
•
Reflexes must be assessed
bilaterally.
•
Examiner must produce a reflex for
credit.

Front 22

23 Assess the Brachioradialis
Reflex

Back 22

•
With the patient’s hand resting
in a relaxed position, e.g. on a
table, his / her lap or supported
by examiner’s arm, the
examiner strikes the radius
about 1 or 2 inches above the
wrist with the reflex hammer.
•
Reflexes must be assessed
bilaterally.
•
Examiner must produce a reflex
for credit.

Front 23

24 Assess the Patellar Tendon Reflex

Back 23

•
First, patient asked to sit with their legs
dangling off the exam table.
•
Reflexes assessed by striking the
patient’s patellar tendon with a reflex
hammer on skin.
•
Reflexes must be assessed bilaterally.
•
Examiner must produce a reflex for
credit.
OPTIONS:
•
Examiner can place his / her hand on
the on patient’s quadriceps, but this is
optional.

Front 24

25 Assess the Achilles Reflex

Back 24

•
Examiner dorsiflexes the
patient’s foot at the ankle
•
Achilles tendon struck with
the reflex hammer on skin,
socks completely off
(removed at the direction
of the examiner).
•
Reflexes must be
assessed bilaterally.
•
Examiner must produce a
reflex for credit.

Front 25

26 Assess the Plantar, or Babinski,
Response

Back 25

•
Examiner strokes the lateral aspect
of the sole from the heel to the ball of
the foot, curving medially across the
ball, with an object such as the end
of a reflex hammer.
•
On skin, socks completely off
(removed at the direction of the
examiner).
•
Assessment must be done bilaterally
•
Note movement of the toes (normally
toes would curl downward).

Front 26

Assess Rapid
Alternating Movements

Back 26

Pronate Supinate

Examiner must do all three
assessments for credit:


•
Examiner directs the
patient to pronate and
supinate one hand
rapidly on the other.
Touching Thumbs Rapidly

•
Patient directed to
touch his / her thumb
rapidly to each finger
on same hand,
bilaterally.
Slapping Thighs Rapidly

•
Patient directed to slap
his / her thigh rapidly
with the back side of
the hand, and then with
the palm side of the
hand, bilaterally.

Front 27

28 Assess Finger-to-Nose Movements

Back 27

•
Examiner directs the patient to touch
the examiner’s finger with his or her
finger, and then to place his or her
finger on their nose.
•
Examiner moves his / her finger
randomly during multiple movements.

Front 28

29 Assess Gait

Back 28

Examiner asks patient to perform the
following:
Walk, turn and come back
•
Note imbalance, postural asymmetry,
type of gait (e.g. shuffling, walking on
toes, etc.), swinging of the arms, and
how patient negotiates turns.
Heel-to-toe (tandem walking)
•
Note an ataxia not previously obvious

Front 29

Romberg Test

Back 29

•
Examiner directs the patient to stand
with feet together, eyes closed for
at least 20 seconds without support.
•
During this test, examiner must stand
behind the patient to provide support
in case the patient loses his / her
balance.
Testing for Pronator Drift
•
Examiner directs the patient to stand
with eyes closed, simultaneously
extending both arms, with palms
turned upward, for at least 20
seconds.
•
During this test, examiner must stand
behind the patient to provide support
in case the patient loses his / her
balance.

Front 30

SPECIAL TESTING


Sensory Testing

Back 30

•
First, examiner
demonstrates what
sharp vs. dull means by
brushing the patient
with a soft object, e.g. a
cotton ball or smooth
end of tongue
depressor, and a semi-
sharp object, e.g.
broken end tongue
depressor.
•
Examiner performs this
test on arms and legs
bilaterally by randomly
brushing the patient’s
arms and legs with the
soft and semi-sharp
objects, e.g. a cotton
ball, semi-sharp object,
etc..
•
Patient directed to keep
his / her eyes closed
during the examination
as he or she identifies
sharp vs. dull on skin.
•
Bilateral exam, upper
and lower extremities.