Guidelines for a Comprehensive Neurologic Examination
By the end of the clerkship, the student will demonstrate the ability to perform the following parts of the neurologic examination.
A. Mental Status
1. Level of alertness
2. Language function - Students should assess fluency (listening for fluency of language output) and formally check at least 1 of the following 3 items
a. Comprehension - Follow a simple command such as "Show me your right thumb". Be sure to not give any visual cues to the patient.
b. Repetition - "Repeat after me: No ifs, ands, or buts."
c. Naming - Point to 2 objects and have the patient name them (Example: pen, watch)
i. This can be tested in 1 of 2 ways:
1. Immediate and delayed - Have the patient recite 3 words: apple, table, penny. Then ask the patient to repeat the 3 words later
2. Answer a couple of orientation questions (place, date, month, etc)
b. Long-term - Ask the patient a question regarding a generally known historical fact. For example "Who is the president?"
4. Calculation - Simple arithmetic but not just 2 + 2. Example: "What is 21 minus 7?"
5. Visuospatial processing - Have the patient draw intersecting pentagons or a clock
6. Abstract reasoning - Have the patient interpret a proverb. Examples:
a. If you find a letter with a stamp and address on it lying on the ground, what would you do?
b. What does this mean: "A rolling stone gathers no moss."
B. Cranial Nerves
1. Smell - Checking each nostril separately, have the patient identify a common smell such as coffee or cinnamon
a. Visual fields
b. Visual acuity - Using the Snellen eye chart, this should be best corrected, meaning ask the patient to wear their glasses if they use them
c. Funduscopic examination
3. Pupillary light reflex
4. Eye movements - H-test
5. Facial sensation - Using your fingers or a cotton swab, test the right and left side of the face in all 3 divisions
6. Facial strength - Check muscles of facial expression and muscles of mastication
7. Hearing - Rub your fingers or whisper next to each ear. Do not snap your fingers, just rub them. If they can't hear the rub, click your fingernails
8. Palatal movement - Observe palatal movement when the patient says "ahh"
9. Speech - Check articulation. Example: Have the patient say "po-ti-ka" which checks labial (lips), lingual (tongue), and palatal (palate) sounds
10. Neck movements against resistance
a. Head rotation
b. Shoulder elevation
11. Tongue movement
C. Motor Function
1. Pronator Drift - Have the patient hold both arms out straight in front, close their eyes, and observe for drift downward or pronation of either or both arms
2. Muscle tone in the arms and legs (resistance to passive manipulation)
3. Bulk - Observe for atrophy, etc.
a. Upper extremities: Shoulder abduction, elbow flexion, elbow extension, wrist flexion, wrist extension, finger flexion, finger extension, finger abduction, and thumb abduction
b. Lower extremities: Hip flexion, knee flexion, knee extension, ankle dorsiflexion, ankle plantar flexion
5. Involuntary movements - Observe for any involuntary movements
1. Light touch - Use your fingertips or a cotton swab and test each arm and each leg
2. Pinprick or temperature - Use an unused safety pin and test each arm and each leg
3. Vibration - Use a 128 Hz tuning fork and test the distal joint in 1 finger on each hand and both great toes. If the patient cannot detect vibratory sense distally, then move proximally.
4. Proprioception - Test joint position sense at the distal joint in 1 finger on each hand and in both great toes. If the patient cannot detect joint movement distally, then move proximally.
1. Deep tendon reflexes
d. Patellar (knee jerk)
e. Achilles (ankle jerk)
2. Plantar responses
3. Frontal release signs
1. Rapid alternating movements - finger tapping, foot tapping, pronation/supination of the hands
1. Casual gait - check stride length, arm swing, turns, etc.
2. On toes - have the patient walk away from you on their toes to assess heel height
3. On heels - have the patient walk toward you on their heels to assess toe height
4. Tandem walking - have the patient walk in a straight line with heel touching toes
5. Romberg - have the patient stand with their feet touching together, arms at their sides, and eyes open, then ask them to close their eyes and observe for swaying for a few seconds