1. The Basic Neurological Exam (Part I)
Physical Exam Curriculum

2. Outline
Lecture
Review a brief version of the complete neurological exam
Highlight the highest yield components of the neurological exam
Focus on primary care
Discuss how to focus a neurological exam based upon symptoms
Practice!
Ophthalmoscopic exam
Any component of the neuro exam

3. The Well-Visit Neurology Exam
Cognition
Wakefulness and alertness
Orientation
Basic language and speech function
Repeating phrases
Naming objects
Following commands (ascertained through rest of exam)
Cranial nerves
Pupillary exam
Eye movements
Facial strength
Palatal elevation
Shoulder shrug
Tongue movements
Motor
Pronator drift
Finger tapping
Coordination
Finger to nose
Heel to shin
Sensory
Romberg testing
Gait
Normal walk and turn
Stand on heels, Stand on toes
Tandem gait

4. The Well-Visit Neurology Exam
Cognition
Wakefulness and alertness
Orientation
Basic language and speech function
Repeating phrases
Naming objects
Following commands (ascertained through rest of exam)
Cranial nerves
Pupillary exam
Eye movements
Facial strength
Palatal elevation
Shoulder shrug
Tongue movements
Motor
Pronator drift
Finger tapping
Coordination
Finger to nose
Heel to shin
Sensory
Romberg testing
Gait
Normal walk and turn
Stand on heels, Stand on toes
Tandem gait
DISCLAIMER
This is not a “rule out neurology” exam
Please never just do this exam for anyone with neurologic complaints
Please never just do this exam while rotating on neurology
You still have to use your brain to figure out the necessary parts of the exam
When in doubt, test more and/or refer to neuro

5. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

6. Mental Status and Cognition
Complete exam includes discussion of:
Level of consciousness
Alertness
Language
Speech
Attention
MMSE: orientation, attention, concentration, memory, language, construction abilities
Sn 71-92%, Sp 56-96%
not as good in MCI
MOCA: useful for detecting mild cognitive impairment (MCI)
Sn 90%, Sp 87%
memory
visuospatial processing
executive functioning
perceptual disturbances
thought form/content
Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):

7. Mental Status and Cognition
Complete exam includes discussion of:
Level of consciousness
Alertness
Language
Speech
Attention
MMSE: orientation, attention, concentration, memory, language, construction abilities
Sn 71-92%, Sp 56-96%
not as good in MCI
MOCA: useful for detecting mild cognitive impairment (MCI)
Sn 90%, Sp 87%
memory
visuospatial processing
executive functioning
perceptual disturbances
thought form/content
Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):

8. Mental Status and Cognition
Screening tests for Dementia
Clock Draw (organization/planning) Sn 76%, Sp 81%
Verbal Fluency (animal naming) (<15), Sn 88%, Sp 96%
Mini-Cognitive Assessment Instrument (Mini-Cog), Sn 76%, Sp 89%
Three item recall plus clock draw
0-2: high likelihood of dementia, 3-5: low likelihood of dementia
Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):

9. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

10. Cranial Nerves

11. Cranial Nerves: How do I test?
Olfactory: smelling salts
Optic: fundoscopic exam, visual fields, visual acuity, pupillary light reflex
Oculomotor/Trochlear/Abducens: extraocular movements
Trigeminal: sensation across three planes of face (V1, V2, V3), forced bite
Facial: close eyes tightly, smile, grimace, puff out cheeks
Vestibulocochlear: finger rub, tuning fork tests (Rinne, Weber)
Glossopharyngeal/Vagus: gag reflex, “ahhh”
Spinal Accessory: shrug shoulders, turn head
Hypoglossal: tongue movement from side to side

12. Cranial Nerves: How do I test?
Olfactory: smelling salts
Optic: fundoscopic exam, visual fields, visual acuity, pupillary light reflex
Oculomotor/Trochlear/Abducens: extraocular movements
Trigeminal: sensation across three planes of face (V1, V2, V3), forced bite
Facial: close eyes tightly, smile, grimace, puff out cheeks
Vestibulocochlear: finger rub, tuning fork tests (Rinne, Weber)
Glossopharyngeal/Vagus: gag reflex, “ahhh”
Spinal Accessory: shrug shoulders, turn head
Hypoglossal: tongue movement from side to side

13. More Details on Extraocular Movement Testing
Strength of eye movements – testing patients for fullness of eye movements to assess for gaze paresis e.g. abducens nerve palsy, internuclear ophthalmoplegia
Examining quality of eye movements
Fast saccades
Smooth pursuits
Examining for nystagmus
First test at primary gaze i.e. have the patient stare straight at your finger and observe eye movements. The eyes should not move.
Look for nystagmus during and at the end of eye movements
Physiologic nystagmus – 3-4 beats of lateral beating nystagmus at end gaze (e.g. look all the way to the right) that extinguishes
Any other nystagmus is potentially abnormal!
Vertical nystagmus is very, very bad and can indicate posterior fossa disease

14. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

15. Motor Exam Muscle Bulk: inspection
LMN: muscle wasting or atrophy
Muscle Tone: resistance to passive movement
Increased tone: “rachety” (cogwheel-->Parkinson’s), “clasp knife” (spasticity-- >UMN), “lead pipe” (basal ganglia)
Decreased tone: indicative of lower motor neuron disease
Muscle Strength: graded on scale
0=no movement, 1= flicker, 2=horizontal plane, 3= against gravity, 4= against some resistance, 5=normal
Pronator Drift: helps elucidate subtle arm weakness (weaker arm “drifts”)
Dexterity: finger taps, open/close hand, toe taps
slowed movement suggests pyramidal/extrapyramidal issues
Note any abnormal movements
chorea, tremor

16. Motor Exam Muscle Bulk: inspection
LMN: muscle wasting or atrophy
Muscle Tone: resistance to passive movement
Increased tone: “rachety” (cogwheel-->Parkinson’s), “clasp knife” (spasticity-- >UMN), “lead pipe” (basal ganglia)
Decreased tone: indicative of lower motor neuron disease
Muscle Strength: graded on scale
0=no movement, 1= flicker, 2=horizontal plane, 3= against gravity, 4= against some resistance, 5=normal
Pronator Drift: helps elucidate subtle arm weakness (weaker arm “drifts”)
Dexterity: finger taps, open/close hand, toe taps
slowed movement suggests pyramidal/extrapyramidal issues
Note any abnormal movements
chorea, tremor

17. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

18. Deep Tendon Reflexes Reflexes: Grading: Babinski/Plantar Response:
Achilles: S1, S2
Patellar: (L2), L3, L4
Biceps: C5, C6
Triceps: (C6), C7, C8
Grading:
Absent (0), Reduced (1+), Normal (2+), Brisk (3+), Clonus (4+)
Hyperactive reflexes: UMN
Brisk reflexes can be normal in young healthy people
Reduced reflexes: LMN
May be present in radiculopathies and mononeuropathies
Babinski/Plantar Response:
Normal: flexion of great toe with curling of toes
Present: great toe extends and toes fan out <--UMN lesion

19. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

20. Sensation Dermatomes: Neuropathies: Modalities:
small-fiber = pain/temp DM
large-fiber = vibration/proprioception
B12
Modalities:
light touch
pain and temperature
vibratory
Proprioception (includes Romberg Test)

21. Sensation Romberg Testing: Where to test
Patient stands with eyes closed
Positive test: imbalance
Where to test
If unclear localization, test hands and feet
If spinal cord localization is suspected, test for sensory level
If spinal cord or nerve root is suspected, test for specific dermatomes

22. Sensation Romberg Testing: Where to test
Patient stands with eyes closed
Positive test: imbalance
Where to test
If unclear localization, test hands and feet
If spinal cord localization is suspected, test for sensory level
If spinal cord or nerve root is suspected, test for specific dermatomes

23. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

24. Coordination
Involve multiple integrated systems: sensory, vestibular, pyramidal, extrapyramidal, basal ganglia, cerebellum
Cerebellum combines proprioception with information from muscles to allow smooth limb/trunk movements
Abnormalities results in ataxia (midline lesions cause truncal ataxia)
Testing for appendicular ataxia:
finger to nose
heel to shin
rapid alternating movements (rhythmic)
Testing for truncal ataxia:
stance
gait

25. Coordination
Involve multiple integrated systems: sensory, vestibular, pyramidal, extrapyramidal, basal ganglia, cerebellum
Cerebellum combines proprioception with information from muscles to allow smooth limb/trunk movements
Abnormalities results in ataxia (midline lesions cause truncal ataxia)
Testing for appendicular ataxia:
finger to nose
heel to shin
rapid alternating movements (rhythmic)
Testing for truncal ataxia:
stance
gait

26. Gait Assessment: Assess for symmetry
Speed
Stride Length
Turning
Associated Movements
Assess for symmetry
Testing: walk and turn, stand on heels/toes, tandem
Types of abnormal gaits:
Ataxic (cerebellar): wide-based, “drunk”
Gait spasticity (UMN): stiffness
Hemiparetic gait: favoring one side
Parkinsonian: decreased arm swing, shuffling
ASM

27. Gait Assessment: Assess for symmetry
Speed
Stride Length
Turning
Associated Movements
Assess for symmetry
Testing: walk and turn, stand on heels/toes, tandem
Types of abnormal gaits:
Ataxic (cerebellar): wide-based, “drunk”
Gait spasticity (UMN): stiffness
Hemiparetic gait: favoring one side
Parkinsonian: decreased arm swing, shuffling
ASM

28. The Complete Neurological Exam
Cognition
Cranial Nerves
Motor Function
Deep Tendon Reflexes
Sensation
Coordination (cerebellar)
Gait

29. The Well-Visit Neurology Exam
Cognition
Wakefulness and alertness
Orientation
Basic language and speech function
Repeating phrases
Naming objects
Following commands (ascertained through rest of exam)
Cranial nerves
Pupillary exam
Eye movements
Facial strength
Palatal elevation
Shoulder shrug
Tongue movements
Motor
Pronator drift
Finger tapping
Coordination
Finger to nose
Heel to shin
Sensory
Romberg testing
Gait
Normal walk and turn
Stand on heels, Stand on toes
Tandem gait