The Traditional Screening Neurological Exam

What follows is a more traditional screening neurological exam. Although it looks quite long, there are
tricks to performing it efficiently that are best learned through observation. It can be easily accomplished
in 5 minutes with a little practice.

The traditional screening neurological exam

Mental status (tested through history taking).

Gait, including walking on toes and heels, tandem, and running, if possible.
Visual acuity (using a pocket Snellen acuity card).
Visual fields to confrontation.
Fundoscopy.
Pupillary response to light (direct and consensual).
Eye movements.
Smooth pursuit on up gaze and lateral gaze.

Saccades  rapidly looking to a target on the left and right.

Facial sensation to pinprick on forehand, cheek, and chin bilaterally.

Facial movementclose eyes tightly, show teeth.

Hearing  finger rub at arm's length.

Palate  say Ahh.

Tongue  stick out your tongue.

Motor
Look for wasting and extraneous movement (e.g., fasciculations or tremor).
Test tone in wrists, elbows, and knees.
Strength: shoulder, abduction, elbow flexion/extension, wrist extension, finger abduction,
thumb abduction, hip flexion, knee flexion/extension, ankle dorsiflexion/plantar flexion.
Fine finger movements (tap thumb and index finger rapidly, first on one hand, then the
other).

Barre sign/pronator drift (hold arms out to the front with palms up and eyes closed 
look for pronation and downward drift).

Reflexes  biceps, triceps, knees, ankles, plantar.

Sensation.
Vibration or joint position sense in toes and fingers.
Pinprick or temperature in hands and feet.

Coordination  finger-nose-finger and heel-knee-shin.

Sample Normal Screening Neurological Exam

Despite the fact that the number of specific tests is reduced in the essential screening neurological
exam, if you are observant during history taking and the gait exam and know what you are looking for,
you will still end up with important information on almost all aspects of neurological function. This is
apparent from the following sample normal screening exam. (The findings in italics apply only to the
commonly accepted screening neurological exam)

Mental status: alert, attentive, and oriented; speech clear & fluent with normal comprehension; able to
provide clear account of historical and recent events.

Cranial nerves:
II corrected visual acuity 20/20 bilaterally*; visual fields full; optic discs sharp with venous
pulsations present bilaterally.
III, IV, VI pupils 4 mm and reactive to light; extraocular movements intact; no ptosis.
V facial sensation equal to pinprick in all 3 divisions bilaterally.

VII face symmetric with normal eye closure and smile.

VIII hearing normal to rubbing fingers*.
IX, X palate elevates symmetrically; phonation normal.
XII tongue midline with good movements.

Motor: normal bulk, tone, and strength bilaterally; no pronator drift.

Sensory: vibration felt in toes and fingers bilaterally; pinprick intact in feet without distal
gradient.
Reflexes: 2+ and symmetric at biceps, triceps, knees, and ankles; plantar responses flexor
bilaterally.
Coordination: normal fine finger movements, finger-nose-finger, and heel-knee-shin.
Gait: steady with normal steps, base, arm swing, and turning; normal heel, toe, and
tandem walking.

*tested as part of general exam

One last reminder: the screening neurological exam discussed above, particularly the essential
screening exam, is intended for use in the asymptomatic patient in whom you have no particular
suspicion of neurological disease (e.g., yearly physical exam). It is not sufficient for anybody with
neurological complaints (including headache or back pain) or those at high risk for neurological disease.
Step-by-Step Guide to the Neurological Examination

I. Mental Status.
A. Level of consciousness.
1. Note if awake and alert.
2. If not, describe what level of stimulation is needed to arouse and keep patient awake. E.g.,
“opens eyes to noxious stimuli; falls back asleep if not continuously stimulated.”
B. Attentiveness.
1. Patient is attentive if able to attend to you and the examination without getting easily
distracted.
2. Have patient spell WORLD backwards or count backwards or say the months of the year
backwards.
C. Orientation.
1. Ask patient full name, location, and full date.
2. Patient is “oriented x 3” if all 3 are entirely correct.
3. If not oriented x 3, write out patient’s responses. Do not say “oriented x 2 (or 1)”.
D. Speech and language.
Listen to patient’s verbal output: motor ability to produce words, quantity of spontaneous speech,
rate of speech production, sentence structure, accuracy/appropriateness of words used, and
ability to repeat a sentence, follow commands, and come up with the right words for things.
1. Fluency is normal if patient speaks in complete sentences without hesitancy between words.
2. Comprehension is normal if patient is able to answer your questions appropriately and follow
exam instructions.
a. “Do what I say: Look to the door and then look to the window.”
b. If not done perfectly, give simpler command: “Show me your thumb.”
3. Repetition.
a. “Repeat after me: I went to the store and forgot my wallet.”
4. Naming.
a. Point to objects around room, asking what they are: watch, pen, telephone.
b. If done well, ask more difficult ones: (watch) band, (pen) cap, (telephone) receiver.
5. Reading.
a. Have patient read and follow a written command: Close Your Eyes.
6. Writing.
a. Have patient write a complete sentence of their choosing.
 E. Memory.
1. Registration: “Repeat these words after me: apple, table, penny.” Do not proceed to memory
testing until patient says them all correctly.
2. Immediate Recall: 1-3 minutes later, “What were those 3 words I asked you to remember?”
3. Recent memory: “What did you have for breakfast this morning?”
4. Remote memory: “Where did you grow up/go to school? When was your wedding/child
born/military service?”
F. Higher intellectual function.
1. General knowledge: “Who is the U.S. president/Missouri governor? What is the capital of
Illinois?”
2. Abstraction: “What does ‘People in glass houses shouldn’t throw stones’ mean?”
3. Judgment: “What would you do if you found a sealed, stamped, addressed envelope lying on
the ground?”
4. Insight: “Why did your daughter bring you to the hospital?”
5. Reasoning: “How do a lie and a mistake differ?”

Note: the examples of commands and questions used in assessing mental status that are provided in the
preceding section are merely examples, not specific instructions you are expected to follow.

II. Cranial Nerves.

A. CN I Olfactory.
1. Have patient close eyes.
2. Occlude one nostril and test other using nonirritating substances (e.g., vanilla, cloves,
coffee). Avoid those that stimulate trigeminal nerve endings or taste buds (e.g., peppermint,
menthol, ammonia, alcohol swabs).
3. Compare 2 sides.

B. CN II Optic.
1. Visual acuity.
a. Hold Snellen chart at comfortable reading distance (about 14 inches).
b. Cover 1 eye and have patient read chart.
c. For each eye, record smallest line patient can read.
d. Glasses should be left on (looking for optic nerve lesion, not refractive error).
2. Visual fields.
a. Stand directly in front of patient and have patient look you in both eyes.
b. Hold your hands midway between you and the patient far enough laterally that you can
barely see them out of the corner of your eyes.
c. Wiggle a finger on one hand.
d. Ask patient to indicate on which side the finger is moving.
e. Repeat in upper and lower temporal quadrants.
 f. If abnormality is suspected or is found on screening test above, test all 4 quadrants of
each eye individually.
i. Have patient close one eye; you should close your own eye that is opposite the
patient’s closed eye, since you will be serving as the normal control.
ii. Move a finger or penlight into the periphery of each visual quadrant (upper and lower
temporal and nasal), asking patient to indicate when movement is detected. It should
be seen by you and patient at the same time.
3. Fundoscopy.
a. Have patient focus on distant wall.
b. Be sure your head is not obstructing patient’s view of that target.
c. View optic disc using ophthalmoscope.
d. Note disc color and presence of venous pulsations, papilledema (disc hyperemia, blurred
margins, absent venous pulsation), or hemorrhages.
4. Pupillary function (CN II and CN III).
a. Test pupillary reaction to light.
i. Dim room lights as necessary.
ii. Ask patient to look into distance to avoid effect of accommodation.
iii. Shine bright light obliquely into each pupil.
iv. Look for both direct (same eye) and consensual (other eye) constriction.
v. Record pupil size in mm (normal is about 2-5 mm) and any asymmetry or irregularity.
b. If light reflex is abnormal, test pupillary reaction to accommodation.
i. Hold finger 10 cm from patient’s nose.
ii. Have patient alternate looking into distance and at finger.
iii. Observe pupillary response.

C. CN III, IV, VI Oculomotor, Trochlear, Abducens.

1. Visual inspection.
a. Look at ocular alignment at rest (primary gaze). Does the reflection of light hit at same
location in each eye? Is one eye deviated in, down and out, or up?
b. Observe for ptosis (lid droopiness).
2. 6 cardinal directions of gaze.
a. Stand 3-6 feet in front of patient.
b. Ask patient to follow your finger with the eyes without moving the head. Place your hand
on top of head to keep it still if necessary.
c. Move your finger in the six cardinal directions and observe whether movements are full in
each eye.
 3. Convergence.
a. Ask patient to follow your finger with the eyes without moving the head. Hold lids up
if necessary.
b. Move your finger toward bridge of patient's nose and observe eye movements.
4. Smooth pursuits (smooth following movements).
a. Steadily move your finger horizontally and then vertically as in testing individual
extraocular muscles, but this time, look at smoothness of following movements.
5. Saccades (discrete, rapid movements from one object to another).
a. Hold up your hands in front of patient (with each hand held a few inches lateral to the
eye).
b. Have patient alternate looking from one hand to the other.
c. Observe accuracy with which eyes reach target. Do they consistently undershoot or
overshoot the target? Is there oscillation before hitting the target?
6. Nystagmus.
a. Observe for involuntary horizontal, vertical, or rotary oscillation of the eyeballs at primary
gaze (looking straight ahead) and on sustained horizontal and vertical gaze.
b. If present, note direction of movement and whether movement persists or fatigues.
c. (a few beats of nystagmus at extremes of gaze is a normal finding).
7. Pupillary light response. (see CN II)

D. CN V Trigeminal.
1. Facial sensation.
a. Explain to patient what you intend to do.
b. Use sharp end of a broken cotton swab or a pin to test pain sensation on forehead,
cheek, and jaw of each side of face.
c. Ask patient to tell you whether it feels about the same on both sides.
d. If not, map out where abnormality is to see if it conforms to distribution of trigeminal
nerve. Specifically, march stimulus from forehead back past hairline, from cheek to tragus
of the ear, and from jaw to neck. (V1 extends far back to the top of the skull—it does not
end at the hairline. V3 ends just above the jaw line inferiorly and just before the ear
laterally.)
 2. Corneal reflex (CN V and CN VII).
a. Lightly touch peripheral aspect of cornea from the side with fine wisp of cotton.
b. Look for normal blink reaction of both eyes.
c. Repeat on other side.
d. If response is less than brisk, touch cornea more centrally.
3. Temporalis and masseter strength.
a. Ask patient to open mouth and clench teeth.
b. Palpate temporalis and masseter muscles.

E. CN VII Facial.
1. Observe for any facial asymmetry at rest in forehead wrinkles, palpebral fissure width,
nasolabial folds, or corner of mouth.
2. Ask patient to do the following and note any lag, weakness, or asymmetry:
a. Smile.
b. Puff out cheeks.
c. Close both lips and resist your attempt to open them.
d. Close both eyes and resist your attempt to open them.
e. Raise eyebrows.
3. Corneal reflex (see CN V).

F. CN VIII Acoustic.
1. Screen hearing.
a. Face patient and hold out your arms with your fingers near each ear.
b. Rub your fingers together on one side.
c. Ask patient to tell you when and on which side the rubbing is.
d. Increase intensity as needed.
e. Note any asymmetry.

G. CN IX & X Glossopharyngeal & Vagus.

1. Listen to patient’s voice. Note any hoarseness, nasal, or breathy quality.
2. Ask patient to say “Ah” and watch movement of soft palate and pharynx. (Do not pay
attention to uvula, which can deviate to one side or another in the normal person.)
a. Note any asymmetry of palate elevation.
3. Ask patient to swallow and to cough.
4. In the unconscious or uncooperative patient, test gag reflex.
a. Stimulate back of throat with a cotton swab on each side.
b. Look for gagging after each stimulus.
 H. CN XI Spinal Accessory.
1. Trapezius.
a. From behind patient, look for atrophy or asymmetry of trapezii.
b. Ask patient to shrug shoulders against resistance and note strength.
c. Ask patient to push head back against resistance and note strength.
2. Sternocleidomastoid.
a. Place hand on lower face and ask patient to turn head towards that side against
resistance.
b. Observe contraction of opposite sternocleidomastoid.

I. CN XII Hypoglossal.
1. Note tongue position at rest in the mouth and on protrusion. Does tongue deviate in either
position?
2. Ask patient to stick out tongue and move it from side to side. Note strength and rapidity of
movements.
3. Have patient push tongue into each cheek while you push from the outside. Note strength.

III. Motor System.

A. Visual inspection.
1. Note muscle bulk. Look for generalized or focal muscle wasting or hypertrophy.
2. Look for extraneous movements, e.g., tremor (At rest? With action?), fasciculation
(muscle twitching).
3. Note speed of movement, e.g., slow to initiate (bradykinesia).
B. Tone (muscle tension at rest).
1. Ask patient to relax.
2. Flex and extend patient’s wrists, elbows, ankles, and knees.
3. Look for resistance that is decreased (hypotonia) or increased (throughout range of
motion=rigidity; spring-like=spasticity).
C. Strength and Endurance.
1. Isolate muscle you are testing so patient can’t use strong muscles that have similar
function to compensate for weak one being tested.
2. Fix proximal joint when testing distally. E.g., if testing pronation, fix the humerus, so
patient can’t use shoulder to compensate for weak pronation.
3. Give yourself the advantage. E.g., when testing deltoid, press on outstretched hand
rather than on elbow.
4. Have patient walk on heels and toes and do deep knee bend or get out of chair without
using arms.
 5. Test at least the following muscles on both sides:
a. Deltoid: abduction (elevation) of upper arm (C5-6; axillary nerve).
b. Biceps: flexion of forearm at elbow (C5-6; musculocutaneous nerve).
c. Triceps: extension of forearm at elbow (C6-8; radial nerve).
d. Extensor carpi radialis: dorsiflexion of hand at wrist (C5-6; radial nerve).
e. Abductor pollicis brevis: palmar abduction of thumb with thumb at right angle to palm
(C8-T1; median nerve).
f. Interossei: finger abduction (dorsal) and adduction (palmar) (C8-T1; ulnar nerve).
g. Iliopsoas: hip flexion (L1-3; femoral nerve).
h. Quadriceps: knee extension (L2-4; femoral nerve).
i. Hamstrings: knee flexion (L5-S2; sciatic nerve).
j. Tibialis anterior: foot dorsiflexion (L4-5; deep peroneal nerve).
k. Gastrocnemius/soleus: foot plantar flexion (S1-2; tibial nerve).

6. Assign score of 0-5 for each muscle based on Medical Research Council scale.

Grade Description
0/5 No muscular contraction

1/5 Visible muscle contraction, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5 Movement against gravity, but not against added resistance

4/5 Movement against resistance, but less than full

5/5 Movement against full resistance; normal strength

7. Note if strength fatigues after sustained muscle contraction.

IV. Reflexes.
A. Muscle stretch reflexes.
1. Position limb and place muscle in slight tension.
2. Quickly tap the tendon/periosteum to which muscle is attached.
3. Observe vigor and briskness of response and compare side-to-side.
4. If reflexes are diminished or absent, try reinforcing the reflex by distraction or via isometric
contraction of other muscles (clenched teeth).
 5. Test at least the following reflexes: (spinal nerve root in bold is the predominant contributor).
a. Biceps (C5, C6; musculocutaneous nerve).
i. Patient's arm should be partially flexed at the elbow with palm down.
ii. Place your thumb or finger firmly on biceps tendon.
iii. Strike your finger with reflex hammer.
iv. You should feel the response even if you can't see it.
b. Triceps (C6, C7; radial nerve) .
i. If patient is seated: support upper arm and let forearm hang free.
ii. If patient is lying down, flex arm at elbow and hold it close to chest.
iii. Strike the triceps tendon above the elbow.
c. Knee (L2, L3, L4; femoral nerve).
i. Have patient sit or lie down with knee flexed.
ii. Strike patellar tendon just below patella.
iii. Note contraction of the quadriceps and extension of the knee.
d. Ankle (S1, S2; tibial nerve).
i. Dorsiflex foot at ankle.
ii. Strike Achilles tendon.
iii. Watch and feel for plantar flexion at the ankle.
6. Test for clonus (rhythmic oscillations of flexion/extension) at the ankle.
i. Support knee in a partly flexed position.
ii. With patient relaxed, quickly dorsiflex foot.
iii. Observe for rhythmic oscillations.

7. Assign grade on scale of 0-4.

Grade Description
0 Absent

1 Hypoactive

2 Normal

3 Brisk/hyperactive

4 Markedly hyperactive with clonus and/or spreading

 B. Plantar response (L4-S2, especially S1; tibial nerve).
1. Using the end of a reflex hammer, a broken tongue blade, or a key, stroke lateral aspect
of the sole of each foot from heel to toes, then drag the stimulus across the foot just
beneath the toes.
2. Note movement of toes.
3. If no response, increase pressure of stroking.
4. If patient ticklish or withdrawing whole foot, either have patient stroke own foot or apply
stimulus along lateral aspect of foot only.
5. Flexion of all toes (downgoing toe) is a normal response. Extension of the great toe
(upgoing toe; positive Babinski) with fanning of the other toes is abnormal.

V. Sensory System.
A. General points.
1. Explain each test before you do it.
2. Unless otherwise specified, the patient's eyes should be closed during testing.
3. Test all 4 extremities.
4. Compare side to side and ask if the two sides are about the same. Avoid leading
questions like “Is this sharp?”
5. Compare distal and proximal areas of the extremities.
6. When you detect an area of sensory loss, map out its boundaries in detail.
B. Vibration.
1. Use a 128-Hz (low-pitched) tuning fork.
2. Lightly strike tines against your hand and place stem of the fork over most distal joint of
patient’s great toe.
3. Ask whether patient feels anything and what the sensation is.
4. If vibration is felt, ask when it goes away. Count number of seconds.
5. Repeat on other side, being sure to strike the fork with about equal force, and compare
duration vibration is felt.
6. If vibration sense is impaired, move proximally one joint at a time until it is felt.
7. Test the fingers in a similar fashion.
C. Joint position sense.
1. Grasp patient's great toe on sides of distal phalanx and hold it away from other toes to
avoid friction.
2. Demonstrate to patient what "up" and "down" feel like and tell patient you will move the
toe in one of these two directions only.
3. Move toe a few degrees and ask patient to identify direction in which toe was moved.
4. If position sense is impaired, increase stimulus intensity (move toe a greater distance); if
still impaired, test at more proximal joint (ankle-->knee-->hip).
5. Test fingers in a similar fashion.
D. Pain.
1. Use a safety pin or sharp end of a broken cotton swab.
2. Test for a distal gradient of sensory loss in leg by applying stimulus at toes and
marching your way up to knee.
a. Ask patient if the sensation is “about the same” or if it changes as you move up the
leg.
3. Test for sensory loss in most commonly affected nerve and nerve root distributions.
a. Test the following areas:
i. Palmar aspect of index finger (median nerve).
ii. Palmar aspect of 5th finger (ulnar nerve).
iii. Web space between thumb and index finger on dorsal surface of hand (radial
nerve).
iv. Web space between great toe and 2nd toe on dorsal surface of foot (L5).
v. Lateral surface of foot (S1).
b. Apply stimulus to one and then another of these locations in the upper or lower
extremity, asking patient if the two areas are “about the same.”
4. In the patient complaining of sensory symptoms, move stimulus from abnormal area
to normal area, asking patient to report when stimulus begins to feel stronger.
a. Another technique is to apply stimulus to an uninvolved part of the body and say,
“If this sharpness/coolness is worth $1, how much is this worth?” and then apply
stimulus to the involved part.
E. Temperature.
1. Testing of temperature is usually reserved for the patient in whom testing of pain
sensation is abnormal.
2. Press a cold tuning fork against the skin to make sure there is temperature loss in same
distribution as pain loss.
F. Light touch.
1. Touch the skin lightly with your fingers.
2. Ask patient to respond whenever a touch is felt (e.g., “left arm”).
3. Test face, arms, and legs in random order.
 G. Double simultaneous stimulation (test for extinction/tactile neglect).
1. Can be performed only when light touch is intact.
2. Touch both sides of patient’s face or body simultaneously.
3. Ask patient to indicate whether touch is felt on the left, right, or both.
H. Graphesthesia (integrative sensation).
1. Can be performed only when light touch is intact.
2. Using a pen cap, paper clip, or your finger, draw a number in patient’s palm or, for more
sensitivity, on index finger.
3. Ask patient to identify the number.
I. Stereognosis (integrative sensation).
1. Can be performed only when light touch and position sense are intact.
2. Place a familiar object (e.g., coin, paper clip, key) in patient’s hand.
3. Ask patient to move it around using fingers and to identify it.
J. Romberg.
1. Have patient stand with feet together and eyes open.
2. Have patient close eyes.
3. Hold your arms out to steady/catch patient if necessary.
4. Watch for development of swaying or falling when eyes are closed (“positive
Romberg”)—indicates either impaired proprioception or vestibular dysfunction.

VI. Coordination.
A. Truncal stability.
1. Observe patient sitting on a chair or side of bed with hands in lap. (Make sure if sitting on
side of bed that bed is reclined flat.)
2. Note any leaning towards one side or falling backwards.
B. Fine finger movements (finger tapping).
1. Have patient tap distal joint of thumb with tip of index finger as fast as possible.
2. Observe rhythm, speed, and precision of movements.
3. Repeat on other side.
C. Toe tapping.
1. Have patient tap your hand with ball of each foot as fast as possible.
2. Observe rhythm, speed, and precision of movements.
3. Repeat on other side.
 D. Finger-nose-finger.
1. Have patient alternately touch your outstretched finger and own nose.
2. Be sure your finger is far enough away that patient’s arm must fully extend to reach it.
3. Observe speed, and precision of movements. Note any oscillation, especially one that
worsens as patient’s finger nears the target. Note if patient consistently passes
(overshoots), fails to reach (undershoots), or is off to left or right of target.
4. Repeat on other side.
E. Heel-knee-shin.
1. Patient should be lying down on exam table/bed. Place heel of one foot just below knee
of the other leg.
2. Have patient run that heel up and down shin of other leg.
3. Observe speed, and precision of movements. Note any wavering.
4. Repeat on other side.
F. Rapid Alternating Movements.
1. Have patient alternately tap dorsal and plantar surface of one hand onto other hand, the
thigh, or the bed (as fast as possible).
2. Observe rhythm, speed, and precision of movements.

VII. Station and Gait.

A. Observe the patient do the following:
1. Rise from a seated position.
2. Walk across room, turn, and come back.
3. Walk on toes.
4. Walk on heels.
5. Walk heel to toe (tandem gait) in a straight line. (Many otherwise normal elderly people
cannot perform this task.)
B. Be prepared to catch the patient if necessary. If there is any doubt in your mind as to
whether the patient may fall, get assistance (nurse, patient care technician, resident)
before testing gait. Do not use this doubt as a reason not to test gait, however.
C. Pay attention to the following:
1. Posture of body and extremities (e.g., leaning or pulling towards one side or backwards,
twisting or holding back one arm).
2. Length, speed, and rhythm of steps.
3. Base of gait (how far apart are the legs).
4. Arm swing (is it reduced unilaterally or bilaterally).
5. Steadiness.
6. Turning (steadiness of turns and number of steps required to complete the turn).

VIII. Meningeal Signs.

A. Ask patient to flex and extend neck.
B. Passively flex and extend patient’s neck.