OLFU MD2024 | CLINICAL MEDICINE

NEUROLOGIC EXAM
SCRIPT (CHECKLIST-BASED)

GENERAL RULES CALCULATE

1. Wash hands (Show in video) Ask patient a simple equation only
2. Introduce self and check patient identification Next, can you tell me the answer to this equation: 5+5?
“Good morning, po! My name is _______, I’m a 2nd year medical → Patient shows good judgment and calculation ability
student. I will be the one examining you today. May I know your
name?” ORIENTATION
3. Explain the purpose of the examination and obtain consent. 10. What is the complete date today?
“I will be conducting a neurological exam to determine your 11. Where are you now?
neurologic function. Would that be okay for you?” 12. Who are you? Who am I?
What is the date today? Do you know where you are right now?
CEREBRUM Can you tell me your name? Do you know who I am?
Let’s begin. First, I will be assessing your cerebral function. → Patient is oriented to person, place, and time
APHASIA
1. Ask patient to repeat spoken phrase/sentence CRANIAL NERVES
Can you repeat the following phrase for me? CN 1 – OLFACTORY NERVE
I LOVE CLINICAL MEDICINE 13. Test patency of nostril (patient
covering his nostril)
2. Ask patient to name objects shown 14. Doctor covering nostril of patient
(Three objects completely non-associated” letting him smell substance
I will be showing you 3 things. Can you tell me what they are? 15. Identify smell
1. Ballpen 2. Hairbrush 3. Baso * Don’t use pungent/irritating smell
like alcohol and perfume.
3. Command patient to do something
Can you please get the pen from my hand using your left hand? Now, I want you to close your eyes and cover your nostril using
your finger. Inhale. Now the other nostril. Next, I will let you smell
4. Report if patient has fluent/non-fluent dysarthric, aphonic speech a substance, and I want you to tell me what is it.
→ The patient is alert, conscious, and coherent →The olfactory nerve is intact. The patient is able to identify in both
→ Speaks fluently and with ease. nostrils the scent of [coffee]
→ Is able to follow simple commands.
CN 2 – OPTIC NERVE
PROSOPAGNOSIA 16. Patient places fine print to read 14
5. Ask patient to name familiar faces inches in front of the eye tested
Next, I’d like for you to tell me the name of this person? 17. Cover non-tested eye
→ The patient was able to recognize the person in the photo.
I want you to cover one eye using
your hand. Now, I will be showing
APRAXIA you a Snellen’s chart, I want you to
6. Ask patient to use/manipulate objects read the smallest letters down
Next, I’ll be giving you a hairbrush. Can you please demonstrate below if you can.
to me how to use one?
→ The patient was able to use the object given without any difficulty → Optic nerve is intact. Patient has a vision of [20/20], and can read
the smallest letter in the Jaeger’s chart at 1 foot distance. Patient
has a normal confrontation test.
MEMORY
7. Immediate memory 18. Do pupillary light testing (Describe
Can you repeat to me the following numbers: 2, 4, 6, 8, 10 size of pupil & reaction to light)

8. Recent memory Now, look straight ahead. I will be

Can you tell me what did we celebrate last November 1? making a shield using my hand
between your eyes. I will then shine
9. Remote memory light on your pupils.
Can you tell me what did we celebrate last December 25, 2020? →The pupillary size on both the left and right light reflex is [2-3mm]
and equally reactive to light. The pupillary light reflex is normal.
→ Patient shows good recall of immediate, recent, and remote
memories

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 CN 3 - OCULOMOTOR, 4 - TROCHLEAR, AND 6 - ABDUCENS
19. Note if with ptosis or none
20. Monitor eye muscle movement and nystagmus
I want you too look at this penlight and follow its movement using
your eyes only, no head movements.
→ The motor part of CN7 is intact. The patient’s facial muscle
strength is normal and equal bilaterally. The patient can smile,
wrinkle forehead, puff cheeks, and purse lips equally; Patient can
symmetrically close eyes completely.
26. Show to preceptor the solution as test
substance; Show to preceptor a paper list
of possible taste
27. Ask patient to protrude tongue; Place
test solution on one side of the tongue; Ask
patient to point in the list taste of substance
28. Place another solution in other half of
tongue, identify taste (pointing to the list)

Now we will be testing your taste sensation. I want you to close

your eyes and protrude your tongue. I will be putting different
substances on your anterior tongue. After doing so, I want you to
point to me on this piece of paper the taste of the solution.
→ The sensory part of CN7 is intact. The patient is able to
distinguish different kinds of taste sensation in the anterior 2/3 of
the tongue.

CN 8 – VESTIBULO-COCHLEAR
29. Rinne test (N = AC > BC)
Put tuning for on mastoid process, and then in front of ear.

→ The patient has intact extraocular muscle movement and is

negative for ptosis and nystagmus;
I will conduct what we call a Rinne test.
CN 5 - TRIGEMINAL
I will put this behind your ear and I want
21. Test symmetrical areas of the face for pin prick you to raise your hand if you don’t hear
• Forehead – V1 anything. Now, I will put it beside your
• Cheeks – V2 ear. Again, raise your hand if you don’t
• Pre-mandibular area – V3 hear anything.

Close your eyes. I will be touching 30. Weber test (N = vibration heard on both ears)
some parts of your face and you Put tuning fork on top of head.
tell me if you can feel the Next is what we call a Weber test. Tell me where you hear the
sensation. Is the sensation equal? vibration most, if left, right, or equal side.
→ The sensory part of CN5 is intact.
The patient can feel light touch on the lower, middle, and upper → Hearing is normal bilaterally. The patient is normal for the Rinne
portion of the face on both sides test and Weber test.

22. Ask patient to open mouth (note for jaw deviation)

CN 9 - GLOSSOPHARYNGEAL AND 10 - VAGUS
Can you open your jaw and fight the
31. Ask patient to speak
resistance of my hand
32. Inquire about presence/absence of
dysphagia (swallowing difficulty)
23. Ask to clench teeth
Can you speak? I want you to drink
Now can you clench your teeth for
this glass of water and tell me if there
me? (Show gigil)
are any difficulty swallowing
→ The motor part of CN5 is intact. The
33. Note palatal and pharyngeal wall motion
patient can clench teeth and move jaw
34. Note position of uvula
side to side. There is no jaw deviation.
Now I want you to open your mouth so I can assess your uvula.
Say ahhhhh.
CN 7 - FACIAL
→ Patient is negative for dysarthria and dysphagia; Uvula is in the
24. Wrinkle forehead; close eyes tightly midline and muscles surrounding are moving symmetrically; Patient
25. Smile, puff cheeks, purse lips is negative for hoarseness

Next, can you show me the 35. Do the gag reflex

following: wrinkle your forehead, Now I will assess your gag reflex
close your eyes tightly, smile, puff → Patient has normal gag reflex;
cheeks, and purse your lips

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 CN 11 – SPINAL ACCESSORY
36. Ask patient to elevate shoulders; Ask
patient to offer resistance upon head rotation
I need you to raise your shoulders and fight
the resistance as I try to push it down. Next
turn your head to the side and fight the
resistance from my hand, now other side.
→ The patient is able to shrug his shoulder
against pressure and is able to turn head side
to side against pressure
CN 12 – HYPOGLOSSAL
37. Note position of protruded tongue
38. Ask patient to do ROM of tongue
39. Note patient for hemi atrophy/fasciculation of tongue
I need you to stick your tongue out and retract it? Next can you
move it to the left, and right? Next can you put it on your palate
and protrude?
→ There is negative fasciculation of the tongue. The tongue is
midline on protrusion, with no atrophy or hypertrophy noted. Patient
can do normal range of motion of the tongue.
CEREBELLUM
Next, I will be assessing your cerebellum function.
40. Ask patient to stand from his seat and walk commenting stance
and gait. Note for signs of disequilibrium and difficulty taking a seat
Can you stand up and walk casually from here to there?
41. Ask patient to do tandem gait
Can you walk again as if you’re
walking on a tightrope? With one
foot in front of another.
→ The patient can stand and sit, stand and walk, sustain tandem
walking all throughout. The patient’s gait is balanced and posture is
erect.
42. Each limb tested for finger to nose
test; arm in full extension; move target
with eyes of patient open
Now, close your eyes. Can you touch
my index finger with your index finger
using your right/left hand? Keep going
back and forth. Same with the other
finger in your other hand
→ The patient can perform finger to nose test
43. Each limb tested for heel to shin
test: ask patient to elevate one leg and
place heel on opposite knew
45. Do procedure using other leg
Place your right heel on your left
knee and slide it down the front of
your leg, lift it up and put it back on
your knee. Just keep doing that.
Next, for the other side.
→ Patient can do perform heel to shin test.
MOTOR EXAMINATION
Next will be your motor assessment.
46. Inspect size, note if with fasciculation of limb
47. Passive flexion/extension of 4 limbs for tone
• Close eyes
• Pronation/supination of arms (Pronator drift)
I’m going to inspect first your arms. Can you put it in front of
you? Next, close your eyes and turn your arm over. Keep it still
and your eyes closed. Now, turn your arm over once again.
→ There are no visible scars. No hypertrophy/atrophy of muscles.
No fasciculations, wasting, or involuntary movements.
Now I’m going to assess the tone of your muscles. Let your arms
get floppy or don’t put any effort as I hold it.
→ Patient has good muscle tone. Muscle bulk is normal. No
flaccidity, spasticity, and rigidity of the extremities.
48. Test muscle strength of each limb both proximal and distal parts
with correct MMT grading (check strength against resistance)
UPPER EXTREMITY
49. Adduction/abduction at shoulder joint
50. Flexion/extension at elbow joint
51. Flexion/extension at wrist joint
52. Grip joint
LOWER EXTREMITY
53. Flexion/extension at hip joint
54. Flexion/extension at knee joint
55. Flexion/extension at ankle joint
I will be doing a couple of range of motions, and I want you to
resist it or oppose the action as it happens.
→ Muscle power is 5/5 bilaterally on both upper and lower
extremities.
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 SENSORY SYSTEM
Now, we will assess your sensory system.
74. Examine pain sensation in the face (Trigeminal Nerve) Touch
with a pin the forehead, maxilla, and area above the mandible
symmetrically

I will touch areas of your face using a toothpick. Respond to “yes”

every time you feel the sensation. Is the sensation equal on both
sides?
→ The patient can feel pain sensation on forehead, maxilla, and
portion above the mandible symmetrically.

75.Touch with a pin the proximal and

distal parts of the limbs symmetrically
(foot, leg, thigh, hand, forearm, arm)
I will test the sensation of your
limbs. Respond to “yes” every time
you feel the sensation. Is the
Upper Extremity: Biceps & Triceps
sensation equal on both sides?
56. Supports arm while doing reflexes
→ The patient can feel light touch on proximal and distal parts of the 57. Does biceps on both sides followed by triceps on both sides
limbs symmetrically 58. Grades reflexes correctly
Allow me to support your arm as I test your reflexes on both
76. Examine proprioceptive sense: position
biceps and triceps.
sense. Using the fourth digit of the fingers (R/L)
→ Reflex of left and right biceps and triceps of patient are both 2 =
and using the big toe (R/L)
normal
I will touch your ring
Lower Extremity:
finger/big toe. Close
Knee Jerk
your eyes, and tell me
59. Palpates depression on the knee; strike knee depression using
which way I’m
pointed end of reflex hammer
moving it. Up or
60. Proceeds to do reflex on the opposite leg
down? Now, other
61. Grades reflex correctly
side.
Allow me to support your arm as I test your reflexes on both biceps
and triceps.
→ Patient’s position test is intact.
Sit down properly as I test your reflexes of your knees.
→ Reflex of left and right knees of patient are both 0 = absent
77. Romberg’s test
Can you please stand, feet together with
Ankle
eyes open, then with eyes closed. Hold
62. Properly supports / position ankle; palpates the Achilles tendon;
your position for 30 secs.
strike tendon using blunt end of reflex hammer
63. Proceeds to do reflex on the opposite leg
→ Patient is negative for Romberg test. 64. Grades reflex correctly
Bend your foot upward (dorsiflex) and relax. I will test your ankle
reflexes on both feet.
→ Reflex of left and right ankle of patient are both 2 = normal
Babinski Reflex
DEEP TENDON REFLEXES 65. Position of patient
I will be 66. Use of blunt
assessing instrument
your 67. Use of correct
reflexes strength of stimulus
next. 68. Technique of
examination
69. Test both soles
→ Patient is negative for Babinski reflex

MENINGEAL SIGNS
Last for this neurologic exam is to conduct test for meningeal signs.

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NUCHAL RIGIDITY
70. Ask patient to lie flat & flexes neck
71. Note tone of neck muscle
I need you to lie down flat on the
sofa and then flex your neck. I will
assess for the tone of your neck
muscle.
→ Patient is negative for nuchal rigidity

BRUDZINSKI
72. While doing A Mentions (+) Finding of Brudzinski test

Remember:
BrudziNsKi:
Neck flexion
leads to Knee
flexion

Next, what we’ll do is the Brudzinski test. While you are lying
down, I will passively flex your neck. And if you involuntarily flex
your hip or knee, it means you are positive for it.
→ Patient is negative for Brudzinski test

KERNIG’s
73. Flexion at hip joint / extension at knee joint mentions (+) finding

Remember:
KErnig sign =
Knee Extension
if painful

Lastly, what we’ll do is the Kernig’s test. While you are lying down,
I will flex your knee and leg at 90°. And if you feel any pain or
resistance as I lift your knee up, you are positive for this test.
→ Patient is negative for Kernig’s sign.

And that concludes our neurologic exam. Thank you so much for
your cooperation. *Alcohol*

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 CEREBRUM
1. Can you repeat the following phrase for me: I LOVE CLINMED
2. I will be showing you 3 things. Can you tell me what they are?
Ballpen, Hairbrush, Baso
3. Can you please get the pen from my hand using your left hand?
→ The patient is alert, conscious, and coherent
→ Speaks fluently and with ease.
→ Is able to follow simple commands.
5. Next, I’d like for you to tell me the name of this person?
→ The patient was able to recognize the person in the photo.
6. Next, I’ll be giving you a hairbrush. Can you please demonstrate to me how to
use one?
→ The patient was able to use the object given without any difficulty
7. Can you repeat to me the following numbers: 2, 4, 6, 8, 10
8. Can you tell me what did we celebrate last November 1?
9. Can you tell me what did we celebrate last December 25, 2020?
→ Patient shows good recall of immediate, recent, and remote memories
10. Next, can you tell me the answer to this equation: 5+5?
→ Patient shows good judgment and calculation ability
11. What is the date today? Do you know where you are right now? Can you tell me
your name? Do you know who I am?
→ Patient is oriented to person, place, and time
CRANIAL NERVES
CN I: Now, I want you to close your eyes and cover your nostril using your finger.
Inhale. Now the other nostril. Next, I will let you smell a substance, and I want you to
tell me what is it.
→The olfactory nerve is intact. The patient is able to identify in both nostrils the
scent of coffee
CN II. I want you to cover one eye using your hand. Now, I will be showing you a
Snellen’s chart, I want you to read the smallest letters down below if you can.
→ Optic nerve is intact. Patient has a vision of [20/20], and can read the smallest
letter in the Jaeger’s chart at 1 foot distance. Patient has a normal confrontation
test
Now, look straight ahead. I will be making a shield using my hand between your
eyes. I will then shine light on your pupils.
→ The pupillary size on both the left and right light reflex is [2-3mm] and equally
reactive to light. The pupillary light reflex is normal.
CN III, IV, VI: I want you to look at this penlight and follow its movement using your
eyes only, no head movements.
→ The patient has intact extraocular muscle movement and is negative for ptosis
and nystagmus;
CN V: Close your eyes. I will be touching some parts of your face and you tell me if
you can feel the sensation. Is the sensation equal?
→ The sensory part of CN5 is intact. The patient can feel light touch on the lower,
middle, and upper portion of the face on both sides
Can you open your jaw and fight the resistance of my hand? Now can you clench
your teeth for me? (Show gigil)
→ The motor part of CN5 is intact. The patient can clench teeth and move jaw side
to side. There is no jaw deviation.
CN VII: Next, can you show me the following: wrinkle your forehead, close your
eyes tightly, smile, puff cheeks, and purse your lips
→ The motor part of CN7 is intact. The patient’s facial muscle strength is normal
and equal bilaterally. The patient can smile, wrinkle forehead, puff cheeks, and
purse lips equally; Patient can symmetrically close eyes completely.
Now we will be testing your taste sensation. I want you to close your eyes and
protrude your tongue. I will be putting different substances on your anterior
tongue. After doing so, I want you to point to me on this piece of paper the taste of
the solution.
→ The sensory part of CN7 is intact. The patient is able to distinguish different
kinds of taste sensation in the anterior 2/3 of the tongue.
CN VIII: I will conduct what we call a Rinne test. I will put this behind your ear and I
want you to raise your hand if you don’t hear anything. Now, I will put it beside your
ear. Again, raise your hand if you don’t hear anything.
Next is what we call a Weber test. Tell me where you hear the vibration most, if left,
right, or equal side.
→ Hearing is normal bilaterally. The patient is normal for the Rinne test and Weber
test.
CN IX and X: Can you speak? I want you to drink this glass of water and tell me if
there are any difficulty swallowing. Now I want you to open your mouth so I can
assess your uvula. Say ahhhhh.
→ Patient is negative for dysarthria and dysphagia; Uvula is in the midline and
muscles surrounding are moving symmetrically; Patient is negative for hoarseness
CN XI: Now I will assess your gag reflex
→ Patient has normal gag reflex;
CN XII: I need you to raise your shoulders and fight the resistance as I try to push it
down. Next turn your head to the side and fight the resistance from my hand, now
other side.
→ The patient is able to shrug his shoulder against pressure and is able to turn
head side to side against pressure
CN XIII: I need you to stick your tongue out and retract it? Next can you move it to
the left, and right? Next can you put it on your palate and protrude?
→ There is negative fasciculation of the tongue. The tongue is midline on
protrusion, with no atrophy or hypertrophy noted. Patient can do normal range of
motion of the tongue.
CEREBELLUM
Next, I will be assessing your cerebellum function. Can you stand up and walk
casually from here to there? Can you walk again as if you’re walking on a
tightrope? With one foot in front of another.
→ The patient can stand and sit, stand and walk, sustain tandem walking all
throughout. The patient’s gait is balanced and posture is erect.
Now, close your eyes. Can you touch my index finger with your index finger using
your right/left hand? Keep going back and forth. Same with the other finger in your
other hand
→ The patient can perform finger to nose test
Place your right heel on your left knee and slide it down the front of your leg, lift it
up and put it back on your knee. Just keep doing that. Next, for the other side.
→ Patient can do perform heel to shin test.
MOTOR
Next will be your motor assessment. I’m going to inspect first your arms. Can you
put it in front of you? Next, close your eyes and turn your arm over. Keep it still and
your eyes closed. Now, turn your arm over once again.
→ There are no visible scars. No hypertrophy/atrophy of muscles. No
fasciculations, wasting, or involuntary movements.
Now I’m going to assess the tone of your muscles. Let your arms get floppy or
don’t put any effort as I hold it.
→ Patient has good muscle tone. Muscle bulk is normal. No flaccidity, spasticity,
and rigidity of the extremities.
I will be doing a couple of range of motions, and I want you to resist it or oppose
the action as it happens.
→ Muscle power is 5/5 bilaterally on both upper and lower extremities.
SENSORY
Now, we will assess your sensory system. I will touch areas of your face using a
toothpick. Respond to “yes” every time you feel the sensation. Is the sensation
equal on both sides?
→ The patient can feel pain sensation on forehead, maxilla, and portion above the
mandible symmetrically
I will test the sensation of your limbs. Respond to “yes” every time you feel the
sensation. Is the sensation equal on both sides?
→ The patient can feel light touch on proximal and distal parts of the limbs
symmetrically
I will touch your ring finger/big toe. Close your eyes, and tell me which way I’m
moving it. Up or down? Now, other side.
→ Patient’s position test is intact.
Can you please stand, feet together with eyes open, then with eyes closed. Hold
your position for 30 secs.
→ Patient is negative for Romberg test.
DEEP TENDON REFLEXES
I will be assessing your reflexes next. Allow me to support your arm as I test your
reflexes on both biceps and triceps.
→ Reflex of left and right biceps and triceps of patient are both 2 = normal
Sit down properly as I test your reflexes of your knees.
→ Reflex of left and right knees of patient are both 0 = absent
Bend your foot upward (dorsiflex) and relax. I will test your ankle reflexes on both
feet.
→ Reflex of left and right ankle of patient are both 2 = normal
Next is the Babinski test.
→ Patient is negative for Babinski test
MENINGEAL SIGNS
Last for this neurologic exam is to conduct test for meningeal signs.
I need you to lie down flat on the sofa and then flex your neck. I will assess for the
tone of your neck muscle.
→ Patient is negative for nuchal rigidity
Next, what we’ll do is the Brudzinski test. While you are lying down, I will passively
flex your neck. And if you involuntarily flex your hip or knee, it means you are
positive for it.
→ Patient is negative for Brudzinski test
Lastly, what we’ll do is the Kernig’s test. While you are lying down, I will flex your
knee and leg at 90°. And if you feel any pain or resistance as I lift your knee up, you
are positive for this test.
→ Patient is negative for Kernig’s sign.
And that concludes our neurologic exam. Thank you so much for your cooperation.
*Alcohol*