Complete Neurological Examination Study Guide
A systematic approach to the neurological examination, from mental status to gait. This guide covers examination techniques, normal findings, and how to recognize pathological patterns for clinical skills assessments and practice.
Learning Objectives
- ✓Perform a systematic and efficient neurological examination
- ✓Recognize normal versus abnormal findings
- ✓Localize neurological lesions based on examination findings
- ✓Document neurological examination findings professionally
1. Mental Status Examination
The mental status examination assesses cerebral cortical function. It should be performed early in the exam and includes assessment of consciousness, orientation, attention, memory, language, and executive function.
Key Points
- •Level of consciousness: Alert, drowsy, lethargic, obtunded, stuporous, comatose (use GCS if impaired)
- •Orientation: Person, place, time, situation
- •Attention: Spell "WORLD" backward, serial 7s, months backward
- •Memory: Immediate (digit span), recent (3 words at 5 minutes), remote (historical events)
- •Language: Fluency, comprehension, repetition, naming (assess for aphasia)
- •Executive function: Abstractions, judgment, insight
2. Cranial Nerve Examination
Systematic assessment of all 12 cranial nerves provides information about the brainstem and peripheral cranial structures. Develop an efficient routine.
Key Points
- •CN I: Test olfaction with non-irritating scents (often skipped unless indicated)
- •CN II: Visual acuity, visual fields, pupillary reflexes, fundoscopy
- •CN III, IV, VI: Eye movements, pupil size/reactivity, ptosis
- •CN V: Facial sensation, corneal reflex, jaw strength
- •CN VII: Facial symmetry, expressions (forehead, eyes, mouth)
- •CN VIII: Hearing (whisper, Rinne, Weber), balance if indicated
- •CN IX, X: Palate elevation, gag reflex, voice quality
- •CN XI: Shoulder shrug, head turn against resistance
- •CN XII: Tongue protrusion and strength
3. Motor Examination
The motor examination assesses the corticospinal tract and lower motor neurons. Evaluate muscle bulk, tone, strength, and look for abnormal movements.
Key Points
- •Inspection: Muscle bulk (atrophy?), fasciculations, involuntary movements
- •Tone: Passive movement - spasticity (velocity-dependent), rigidity (lead-pipe or cogwheel)
- •Strength: MRC scale 0-5 (0=no contraction, 3=against gravity, 5=normal)
- •Test proximal and distal muscles in upper and lower limbs
- •UMN pattern: Weakness of extensors in upper limb, flexors in lower limb
- •LMN pattern: Weakness in specific myotome distribution with atrophy
4. Sensory Examination
Sensory examination tests the spinothalamic tract (pain, temperature), dorsal columns (vibration, proprioception), and peripheral nerve function. Compare sides.
Key Points
- •Light touch: Cotton wisp, all dermatomes, compare sides
- •Pain: Pinprick with sharp object, test spinothalamic tract
- •Vibration: 128 Hz tuning fork on bony prominences (great toe, medial malleolus, etc.)
- •Proprioception: Position sense in fingers and toes
- •Cortical sensory: Stereognosis, graphesthesia, two-point discrimination (if cortical lesion suspected)
- •Document sensory level if spinal cord lesion suspected
5. Reflexes
Deep tendon reflexes (DTRs) test the spinal reflex arc and are modified by upper motor neuron input. Pathological reflexes indicate UMN dysfunction.
Key Points
- •Grade reflexes: 0 (absent), 1+ (diminished), 2+ (normal), 3+ (brisk), 4+ (clonus)
- •Upper limb reflexes: Biceps (C5-6), brachioradialis (C5-6), triceps (C7-8)
- •Lower limb reflexes: Patellar (L3-4), Achilles (S1-2)
- •Babinski sign: Upgoing toe indicates UMN lesion (pyramidal tract dysfunction)
- •Hoffmann sign: Finger flexion with middle finger flick (UMN sign in upper limbs)
- •Clonus: Rhythmic oscillations with sustained stretch (UMN sign)
6. Coordination and Gait
Coordination testing assesses cerebellar function. Gait examination integrates motor, sensory, cerebellar, and vestibular function.
Key Points
- •Finger-nose-finger: Test for intention tremor, past-pointing (cerebellar)
- •Heel-shin test: Run heel down opposite shin smoothly
- •Rapid alternating movements: Dysdiadochokinesia indicates cerebellar dysfunction
- •Romberg test: Sensory ataxia (positive Romberg) vs cerebellar ataxia (unsteady with eyes open)
- •Gait: Observe normal walking, tandem walking (heel-to-toe), walking on heels and toes
- •Gait patterns: Hemiplegic, Parkinsonian, ataxic (cerebellar vs sensory), steppage (foot drop)
High-Yield Facts
- ★UMN signs: Weakness, spasticity, hyperreflexia, Babinski (upgoing toe), clonus
- ★LMN signs: Weakness, atrophy, fasciculations, hyporeflexia, no Babinski
- ★Forehead spared = UMN facial lesion (stroke); forehead involved = LMN lesion (Bell's palsy)
- ★Positive Romberg indicates sensory ataxia (dorsal columns or vestibular), not cerebellar ataxia
- ★Pronator drift with supinated arms extended is a sensitive sign of mild UMN weakness
- ★The Babinski reflex is normal in infants before myelination is complete
Practice Questions
1. A patient has right arm and leg weakness with hyperreflexia, right upgoing toe, and normal sensation. The face is spared. Where is the lesion?
2. A patient has weakness of finger abduction, wasting of the first dorsal interosseous, decreased sensation over the medial 1.5 digits, and normal reflexes. Where is the lesion?
3. A patient is unsteady with eyes open and worsens with eyes closed. What type of ataxia is this, and what is being tested?
FAQs
Common questions about this topic
A screening neurological exam can be done in 5-10 minutes if the patient is neurologically intact. A detailed exam for a patient with neurological symptoms takes 15-30 minutes. In exams (OSCEs), you typically have 8-10 minutes - focus on the most relevant components based on the clinical scenario.
Use a screening exam for patients without neurological complaints. Perform a detailed exam for any patient with neurological symptoms (weakness, numbness, coordination problems, altered mental status) or when neurological disease is suspected. The history often guides which components to emphasize.