John W. Engstrom, M.D.

October 24, 2008

The Neurological Exam

Mental Status Examination

Before beginning the mental status examination, assess education level and native language of
the patient. The results of the exam must be interpreted in the context of these factors.

1. Orientation – Ask for the patient's name, the date (as day, month, year), and where the
patient is located now. You will have an excellent index of orientation simply by
interviewing the patient. “Learning effect” – a patient repeatedly asked the same
orientation question on successive days will “learn” the answers. Ask about other items
(i.e. – seasons, holidays close to the current date).
2. Attention span – One simple test of attention span is the instantaneous recall of a
particular order of numbers, such as a telephone number. Normally a patient should be
able to recall 7-8 digits forward and 4 - 5 digits backward. An alternative is to ask the
patient to spell “world” forward and backward. The likelihood of normal recent recall at
5 minutes is low if attention span is impaired.
3. Recent recall – Ask the patient to remember 3 items and repeat them back to you after 5
minutes. This test is best performed if the objects to be remembered are familiar to the
patient. For example, one might ask a carpenter to remember a hammer, a board, and a
house. In addition, you should always ask the patient to repeat all 3 items immediately
back to you to make sure the patient understands each item.
4. Aphasia – Aphasia can be detected by the ability of the patient to repeat, to name, and to
comprehend. A sentence can be repeated such as, “Today is a sunny day”. Naming can
be performed with common objects such as a pencil, tie, shoe, or belt. Objects should be
easily identifiable and appropriate to the cultural background and educational level of the
patient. Comprehension is tested throughout the examination history and by the ability of
the patient to follow directions and answer questions.
5. Calculations (optional) – Calculations can be difficult to assess depending on the
educational level of the patient and cultural background, but can be useful under certain
circumstances. For example, it would be abnormal for an accountant to be unable to
perform simple subtraction (i.e. – serial 7s).
6. Abstractions – Abstractions are complex, difficult tasks for a cognitively impaired patient
to perform. Examples of testing simple abstractions are, “What is the difference between
a cat and a dog?” “How would you distinguish between a lake and a river?” or “How are
a lake and river alike?” The answers will be abnormal in patients with either delerium or
dementia.
7. Speech – One can easily argue that the evaluation of language is a part of the mental
status examination (i.e. – the aphasia screen). Speech is often placed under the mental
status examination as well. Abnormalities of speech (dysarthria) can be related to cranial

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 nerve abnormalities including VII (labial dysarthria), X (palatal dysarthria), or XII
(lingual dysarthria). For simplicity, one can include speech under the mental status
examination when a specific etiology for the speech difficulty is not clear.
8. The above guidelines are for a screening mental status examination only. There are many
different forms of the mental status examination that can be adapted to specific
circumstances.

Cranial Nerve Examination

If in doubt about whether or not a cranial nerve finding is abnormal, check for symmetry
between the two sides.

I – Smell (optional) – Testing smell is not part of a routine screening examination. Coffee, floral
scents, or cloves are all adequate. Avoid using noxious odors (i.e. – ammonia, alcohol). Smell
testing is particularly useful when a subjective lack of taste or smell is a primary symptom. Two
most common causes – prior head trauma and smoking.

II – Vision – Screen corrected (i.e.- with glasses) visual acuity with a vision card. Allow the
patient to hold the card. Screen for major visual field deficits by having the patient cover one
eye and identify an object (often a finger) in the center of each visual quadrant of each eye.

II, III – Pupillary examination – Normal size in moderate light for adults is 3-4 mm. Larger in
children and smaller in the elderly (senile miosis). Acceptable asymmetry is ≤ 1 mm. Check
both direct and consensual reactions. For patients with a dark pigmented iris, try using a second
flashlight held from below or above the face to illuminate the pupils without causing
constriction.

III, IV, VI – Extraocular movements. Check horizontal, vertical, and inferonasal (down and in)
eye movements. Can the patient move the eyes from side-to-side fully so as to eliminate the
sclera from view? Nystagmus is a rapid, beating movement of the eyes – (usually in a horizontal
plane) that is triggered by eye movement. Remember that VI controls abduction and IV controls
inferonasal movement. III controls the other eye movements. Ask the patient to follow your
finger with his/her eyes as you elicit the eye movements.

V – Corneal response, facial sensation, and pterygoid power. Use a wisp of cotton and lightly
touch the cotton to the surface of each cornea. Note if both the direct and consensual corneal
responses are present. Check pin and light touch sensation on each cheek. Check pterygoid
muscle power by having the patient keep the jaw open against resistance provided by the
examiner’s hand. If the pterygoid muscles are weak, then the jaw will deviate toward the side of
the weakness.

VII – Facial expression – Test the muscles of facial expression by having the patient raise the
eyebrows, close the eyes tightly, and smile. Note any asymmetry in the extent of facial
movement and speed of movement on the two sides of the face.

VIII – Hearing – Rub the fingers together by each ear so that the fingers can normally be heard,
but no movement of the fingers or arms seen by the patient. Vestibular function is screened

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during testing of the extraocular movements by noting the presence or absence of nystagmus. A
few beats of nystagmus at the extremes of horizontal eye movement is normal. The direction of
the nystagmus (by convention) is named for the fast component of the beating eye movements.

IX, X – Soft palate function – Gag reflex, nasal voice, elevation of the palate. Elevation of the
palate is the best screening test. The uvula will normally elevate in the midline when the patient
says 'Ahhhhhhhl" A nasal voice is an indication of soft palate dysfunction. The gag reflex is
helpful when asymmetric, but it is uncomfortable for patients and may be bilaterally absent in
normal patients.

XI – Sternomastoid (SM) – Many muscles turn the head from side-to-side. The SM turns the
head toward the opposite side. As a practical matter, compare the bulk of the SM muscles on the
two sides. It is very difficult to convincingly demonstrate weakness limited to this muscle.

XII – Tongue – Note the bulk of the two sides of the tongue when protruded. If the tongue is
weak from a XIIth nerve lesion, it will protrude toward the side of the lesion. Strength can be
tested by having the patient push the tongue against the inside of each cheek. In the presence of
facial weakness, one can be misled into thinking the tongue protrudes to one side. Be careful to
line up the position of the tongue with the tip of the nose and the middle of the chin to determine
if the tongue has protruded to one side or another.

The Motor Examination

1. If in doubt about whether or not a finding (bulk, power, reflexes) is abnormal, check for
symmetry between the two limbs.

2. A screening examination will include sampling of the proximal and distal muscles of the
arms and legs. In otherwise healthy patients, the ability to perform a deep-knee bend is a
good screen of proximal leg power.

3. You cannot perform an adequate muscle examination unless you can see the muscles! The
patient must be positioned and dressed appropriately.

4. You will not remember the innervation and action of all the muscles. You may want to get
a portable book with diagrams that can serve as an instant resource (i.e.-Aids to the
Examination of the Peripheral Nervous System).

Bulk – Check the bulk of the deltoid, abductor pollicis brevis (APB), quadriceps, and the
extensor digitorum brevis (EDB) muscles. Visually compare the same muscles on the right with
the left arm. Repeat inspection in the legs.

Tone – Move the limbs slowly and quickly through their range of motion with the patient relaxed
and supine. Increased tone consists of resistance to passive movement of the limbs, despite
adequate relaxation and the absence of pain during the movement. Spasticity is a velocity-
dependant increase in resistance that is greatest in the flexors of the arms and extensors of the
legs.

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Power – Check one proximal and one distal arm muscle: biceps and first dorsal interosseus
muscle are good choices in the arms. Check one proximal and one distal leg muscle: iliopsoas
and tibialis anterior are good choices. Alternatively, screen the proximal muscles of the legs by
having the patient perform a deep-knee bend.

Coordination – Check finger-to-nose and heel-knee-shin on both sides. Check tandem gait by
having the patient walk while placing the toe of one foot to the heel of the opposite foot
repetitively. The patient can use laterally outstretched arms for balance while walking and
should keep their eyes open. Tandem gait is not a speed test! Correct results for patient age;
tandem gait normally begins to deteriorate over age 60.

Check for fast finger movements by having the patient tap the first finger and thumb in a
rhythmic and rapid fashion. Asymmetric, slow, but rhythmic fast finger movements or foot
tapping is a sensitive test for an upper motor neuron lesion. Check for pronator drift by having
the patient extend outstretched arms fully forward with the palms up and close the eyes. The
patient is instructed to hold the arms steady. The hand of a weak arm in an upper motor neuron
lesion (i.e. – a stroke) will pronate, flex, and tend to drift downward.

Gait – Many neurologic problems may be subtle until a patient attempts to walk. Walking can
be difficult for the hospitalized patient due to pain, instrumentation, or extreme fatigue. Can the
patient independently bear weight on both legs? Can the patient independently maintain balance
while standing? Do the legs move symmetrically when walking? These questions can be
answered when a patient stands and takes just a few steps at the bedside. Specific gait disorders
(i.e. – spastic, parkinsonian, steppage, and elaboration) for inpatents able to ambulate will be
demonstrated.

Reflexes – The limbs to be tested should be relaxed and in a comparable position bilaterally if
interpretation of the results is to be valid. Always check for symmetry. The most common
cause of an unobtainable ankle reflex is improper positioning of the leg! Your reflex screen
should include the biceps, triceps, finger flexors, quadriceps, and ankle reflexes. For the
neuroanatomy of each reflex, consult your handout. Check for a Babinski response by lightly
stroking the lateral aspect and ball of the foot from back to front with a key. You can use a more
vigorous stimulus if a response is initially absent. A normal response is plantar flexion of the
toes. A Babinski response consists of dorsiflexion of the great toe.

The Sensory Examination

“The sensory examination almost kept me out of the field of neurology” – Robert A. Fishman,
MD, former Professor and Chairman, UCSF Neurology.

The sensory examination should ideally include small fiber modalities (pain or temperature) and
large fiber (light touch, vibration, position) modalities because disease may selectively involve
one or the other.

Light touch – Use a cotton swab or fingertip to check for asymmetry of touch sensation or a
proximal-to-distal gradient below the knees. If the patient has a subjective complaint of
diminished sensation, compare sensation on the affected patch of skin with an analogous patch of

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skin on the opposite limb. Define normal touch as 10 (on a scale of 0-10) and complete absence
of touch as 0. Ask the patient to assign a number to the “amount of touch” always beginning
with demonstration of normal sensation as 10. Reduction of touch sensation below 7 strongly
suggests decreased sensation.

Pin – Use a safety pin and lightly touch the patient asking if a sharp sensation can be felt. Check
one spot on each hand and foot. Check from proximal-to-distal below the knees to see if
perception of the sharpness declines. An increase in sensitivity from proximal to distal can be
normal, but a decrease is abnormal.

Romberg – The patient stands with the feet together as closely as possible and the eyes open.
First verify that balance is maintained, then ask the patient to close the eyes. The most common
cause of a “false positive” test is failure to perform this first step. If the patient cannot maintain
balance when the eyes are closed, then a Romberg sign is present. The Romberg sign is a
sensory test of large fiber sensation, not a cerebellar test of coordination.

Cold (optional) – Check (as with pin) for asymmetry of cold sensation and proximal-to-distal
gradient below the knees. Be careful if the hands and feet are already cold, the cold object will
feel warmer distally than proximally. The patient detects both the difference in temperature
between the test object and skin as well as the absolute temperature of the test object. For this
reason, cold can be a difficult screening test for sensation.

Position (optional) – The patient must relax the hands and feet for this test to be successful and
should be in a supine position. Place your thumb and index finger on the sides of the great toe
and flex or extend the DIP joint of the toe with your other hand. Ask the patient to state if the
perceived movement is up (toward the patient) or down (toward the examiner).

Vibration (optional) – Check for vibration by placing the 128 Hz tuning fork dorsally on the IP
joint of the great toe and your index finger DIP joint ventrally under the patient's joint. Ask the
patient to say immediately when the vibration stops. Can you still feel the vibration in your
finger? Repeat the same test on the other foot and the index fingers of both hands.

Direction sense (optional) – Use a cotton swab and check the feet and hands (in areas without
hair). Lightly touch and move the swab up (toward the patient) or down (toward the examiner)
or to the patient's left or right side. The patient should have the eyes closed to avoid visual cues
regarding the direction of the movement. Ask the patient (with each movement) about the
direction of the movement. This test is a sensitive measure of large sensory fiber function in
peripheral nerves and dorsal columns of the spinal cord.

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Helpful Tables

Table 1 – COMMON DRUGS CAUSING DELIRIUM

Barbiturates Benzodiazepines
Anticholinergics
Clonidine Antihistamines
Digitalis Dopamine agonists
Levodopa Antipsychotics
Lithium Tricyclic antidepressants
Glucocorticoids Anticholinergics
Opiate analgesics

Table 2 – COMMON CAUSES OF DRUG-INDUCED HEADACHE

Nifedipine Isosorbide dinitrite

Cimetidine Estrogen
Indomethacin Cyclosporin
Atenolol Nytroglycerin
Ranitidine Oral Contraceptives
Trimethoprim-sulfamethoxazole

Table 3 – CAUSES OF HORNER'S SYNDROME

Brainstem/cervical cord (diminished sweating ipsilateral body)

Wallenberg's syndrome (brainstem infarction)
Multiple sclerosis
Tumor
Syringomyelia
Cord/C8-T1 root/Sympathetic chain (diminished sweating ipsilateral face)
Pancoast tumor (carcinoma of lung apex)
Aortic aneurysm
Neck surgery
Superior cervical ganglion/Carotid artery/Orbit (no anhydrosis)
Tumors
Carotid artery dissection
Cluster headache

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Table 4 – SOME NEUROLOGIC CAUSES OF DIPLOPIA

NEUROANATOMIC SITE CLINICAL EXAMPLE

Brainstem pathways (MLF lesion)
Lower motor neuron (III, IV, VI)
Cranial nerve nuclei/nerves:
Subarachnoid Space
Nerve trunks
Neuromuscular junction
Muscle
Retina
Multiple sclerosis
Brainstem stroke
Basilar meningitis (tuberculosis)
IIIrd nerve compression (aneurysm),
Diabetes
Myasthenia gravis
Thyrotoxicosis, oculopharyngeal dystrophy
Congenital retinal anomaly

Table 5 – SELECTED CAUSES OF VERTIGO

PNS
Vestibular neuronitis
Benign positional vertigo (BPV)
Meniere's syndrome
Cerebellopontine angle tumor
Drug-induced
Post-traumatic
Systemic-infection, hypotension
CNS
Vertebrobasilar ischemia
Temporal lobe disease (rare)
Brainstem/cerebellar glioma or AVM
Demyelinating disease (MS)
Posterior fossa mass lesions
Hereditary spinocerebellar degeneration

Table 6 – NEUROLOGIC CAUSES OF DYSPHAGIA

Oropharyngeal Esophageal
Amyotrophic lateral sclerosis (ALS) Achalasia
Brainstem stroke or tumor Vagus nerve injury
Multiple Sclerosis Scleroderma
Myasthenia Gravis Dysautonomia
Tardive Dyskinesia Esophageal spasm
Myopathy Amyloidosis
Syrinx Myopathy
Spinocerebellar degeneration
Arnold-Chiari malformation
Parkinson’s disease
Tardive dyskinesia (drug-related)

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Table 7 – SCORING SYSTEM FOR REFLEXES

Score Observation
0 Absent (areflexia)
Trace Present with reinforcement only
1 Hypoactive (hyporeflexia)
2 Normal
3 Brisk (hyperreflexia)
4 Clonus

Table 8 – COMMONLY TESTED REFLEXES

Reflex Peripheral Nerve Root/Segmental Level

Jaw jerk Trigeminal Pons
Biceps Musculocutaneous C5/C6
Triceps Radial C7
Finger flexors Median/Ulnar C8
Knee (quadriceps) Femoral L4
Ankle Tibial S1
Anal sphincter Pudendal S3/S4

Table 9 – CAUSES OF FOOT DROP

L5 root compression
Peroneal neuropathy
Sciatic nerve palsy
Motor neuron disease
Polyneuropathy (bilateral)
Anterior cerebral artery stroke

Table 10 – URINARY INCONTINENCE AND DRUGS

Class/Medication Effect on Urination

Diuretics, Alcohol, Caffeine Polyuria

Tricyclic ats Retention, Overflow
Opiates Retention, Overflow
Anticholinergies Retention, Overflow
Calcium channel blockers Retention

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 Table 11 – SOME NEUROLOGIC CAUSES OF URINARY INCONTINENCE

Multiple sclerosis
Anterior spinal artery syndrome
Spinal cord compression (abscess, tumor, disk)
Cauda equina syndrome
Spinal stenosis
Intrinsic spinal cord tumors (glioma)
Diabetes mellitus

Table 12 – CSF FINDINGS IN MENINGITIS

Pressure [mm White cells Protein Glucose

water] [cells/mm3] [mg/dl] [mg/dl]
Normal 50-200 Not > 5 white blood 15 - 50 60-80% of
cells blood glucose
Acute bacterial Usually elevated 100s-1000s; 100-500 5-40
meningitis Polymorphs
Acute viral Normal or 5-100 ; Normal or Normal
meningitis moderate Lymphocytes <100
elevation
Tuberculous Usually elevated 25-100; Usually 100- Reduced
meningitis Lymphocytes 200
Cryptococcal Usually elevated Lymphocytes 20-500 Reduced;
meningitis Average 30
Carcinomatous Normal or 0-300 mononuclear Elevated to Normal/reduced
meningitis elevated cells, malignant cells very high
Subarachnoid Normal or raised Red and White cells Raised Normal or
hemorrhage if acute reduced

May be higher in obesity

Always abnormal if < 40 mg/dl
Rarely > 1000 cells/mm{\s\up2(3)}

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Table 13 – CAUSES OF INCREASED CSF PRESSURE
DESPITE A NORMAL OR NONDIAGNOSTIC
CT/MR BRAIN SCAN

Elevated central venous pressure

Meningitis and encephalitis
Respiratory failure
Postanoxic encephalopathy
Fulminant hepatic encephalopathy
Reye’s syndrome
Lead encephalopathy
Water intoxication/hyponatremia
Dural venous sinus occlusion
Psuedotumor cerebri
Spinal cord tumors
Acute polyneuritis (Guillian-Barre syndrome)

Table 14 – CAUSES OF PIGMENTED CSF

Subarachnoid blood
Bilirubin > 10-15 mg/dl in serum
Carotenemia
Protein > 150 mg/dl
Chromatins of old age
Rifampin, pyridium, INH

Table 15 – MRC MUSCLE STRENGTH TESTING SCORE

SCORE RESPONSE

5 Full power
4+/5- Minimal weakness
4 Mild weakness
4- Moderate weakness
3 Severe weakness with slight movement vs. gravity
2 Moves, but not against gravity
1 Flicker of contraction
0 No muscle contraction

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Table 16 - CAUSES OF AN ISOLATED THIRD NERVE PALSY

LOCATION
Brainstem (nucleus or
fascicle)
Subarachnoid space
Cavernous sinus
Orbit/superior orbital fissure
Not localized clearly
LESION
Stroke, Mass lesion
Posterior communicating aneurysm,
Meningitis(infectious, neoplastic), Uncal herniation with
raised ICP.
Fistula, tumor, aneurysm
Trauma (fracture), mass lesions, ??MG
Diabetic infarction, GBS, Migraine

Table 17 – CAUSES OF STIFF NECK

Menigeal
Infectious meningitis
Parameningeal infection (mastoiditis)
Subarachnoid hemorrhage
Neoplastic invasion of the meninges
Mechanical/Other
Cervical Spondylosis
Musculoskeletal neck injury
Retropharyngeal abscess
Paraspinal muscle spasm
Axial rigidity (Parkinsonian syndromes)

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The “High-Yield” Neurologic Examination: Top Ten Suggestions for a Better
Neurologic Examination

1. If the patient can give a completely coherent history, then the mental status
examination is probably normal

2. The neurologist says the encephalopathy is metabolic… and is almost always

correct

3. Dementia – the lights are on but nobody is home; Delerium – the lights are
flickering on and off.

4. After establishing new-onset coma, the pupillary examination is the most

important initial neurologic examination test

5. There are only two kinds of headaches-old headaches and new headaches.

6. Visual field testing is highly informative and underutilized by the non-

neurologist

7. Weakness is either neurologic or non-neurologic

8. The presence of diminished sensation is more helpful in defining a neurologic

deficit than positive sensory phenomena (i.e.-paresthesias or pain).

9. Use the history to determine which parts of the neurologic examination need to
be performed in detail.

10. Symmetry, or lack thereof, is a powerful diagnostic observation on the cranial

nerve, motor, sensory, coordination, and reflex examinations.

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References

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