An approach to…

The Neurologic Examination

Updated September 2025 by Dr. Dan Berger

But first, a history!

1. Identifying data, including handedness
2. Past medical history – major comorbidities including strokes/TIAs (be specific! Where were they, what was the proposed mechanism, treatments, residual deficits), HTN, DM, DLD, MI, arrhythmia, CNS infections, migraines, thyroid disease, etc.
3. Medications – current dose, route of administration, time of day. For specific presentations like migraine or seizure, helpful to go back and identify previous medication trials, reasons for failure, etc.
4. Allergies
5. History of presenting illness – onset of symptoms & temporal evolution, provoking/palliating factors, timing, fluctuation of symptoms, other focal neurologic concerns (diplopia, changes to visual acuity, hearing changes, vertigo, dysarthria, dysphagia, headache, numbness, paresthesias, weakness, bowel and bladder symptoms, ataxia, seizures.
6. Social history – includes marital and family status, education, employment, ADLs/IALDs (for older adults), habits (smoking, drinking, recreational drugs), employment, medical insurance.
7. Family history – ask about neurologic disease and be context-specific (migraine, multiple sclerosis, stroke…), genetic illnesses, rheumatologic illnesses, etc.
8. Relevant investigations – recent/prior head imaging (CT, MRI, CT angiogram, FDG-PET etc), EEGs, EMG/NCS, labwork including things like HbA1c, lipids, rheumatologic screening, basic metabolic panel, CBC, CRP, SPEP/UPEP, B12, TSH).

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Mental status examination

1. Orientation
• Name, location, date (year, then month, then day), reason for hospitalization.
2. Attention
• Months of the year or “world” backwards, serial 7s (included in the MMSE)
3. Memory
• Delayed recall (memorize 3 words, recall them after the attention task)

Level up! Try to learn one or two tests for each lobe to interrogate on your MSE.

• Frontal lobe (executive function, attention, inhibition, motor programming)
• Verbal fluency, trail-making test (part B), Luria’s three-step motor sequence, go no-go test, abstraction
• Temporal lobe (memory, language, visual/auditory processing)
• Delayed recall, repetition of phrases, semantic memory questions, procedural memory questions
• Parietal lobe (visuospatial, praxis, attention, body schema)
• Clock drawing, intersecting figures, serial subtraction, praxis testing (transitive and intransitive actions), left-right orientation, finger naming, constructional tasks (copy cube, house etc).
• Occipital lobe (visual processing)
• Visual field testing, object recognition

Language examination

• Naming (start with high frequency objects, move to low frequency objects, use the NIHSS stroke cards pictures if you have them! ALL aphasias have difficulty with naming)
• Fluency (listen for broken, halting speech versus fluid speech)
• Repetition (use a simple sentence first, move to more complex sentences)
• Reading (write a sentence down or use the NIHSS stroke cards sentences)
• Writing (have your patient write a simple sentence)
• Comprehension (assess comprehension of simple, 1 step commands, move on to more complex, 2-3 step commands)

• Non-fluent + can comprehend + cannot repeat → Broca’s aphasia (inferior frontal gyrus)

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• Fluent + can’t comprehend + cannot repeat → Wernicke’s aphasia (superior temporal gyrus)

Cranial nerve examination

LR6 SO4

Tested with extraocular movements

I: Olfactory (rarely test this)

II: Optic

• Visual acuity → ocular, optic nerve
• Colour vision → ocular, optic nerve
• Visual fields → chiasm and posterior to the chiasm
• Fundoscopy → retina, disc (papilledema)
• Pupillary light reflex (afferent)

III: Oculomotor

• Motor: levator palpebrae superioris, superior rectus (elevates), medial rectus (aDducts), inferior rectus (depresses), inferior oblique (extorts/elevates), Parasympathetic: pupillary constriction (sphincter pupillae) and accomodation (ciliary muscles)
• Lesion: complete ptosis, down out and out pupil (diagonal diplopia with near objects), impaired convergence, fixed dilated pupil OR any combination of these findings

IV: Trochlear

• Motor: superior oblique (intorts and depresses)
• Lesion: hypertropia (vertical diplopia, head tilt away from the affected side) *nerve crosses behind the midbrain, so lesion produces contralateral palsy.

VI: Abducens

• Motor: lateral rectus (aBducts)
• Lesion: esotropia (horizontal diplopia worse with far objects and when looking to the affected side

Cranial nerve examination

V: Trigeminal → facial sensation, sensation to anterior ⅔ of tongue, temporalis, masseter, corneal reflex (afferent)

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VII: Facial → motor function, taste to anterior ⅔ of tongue, labial sounds, corneal reflex (efferent)

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VIII: Vestibulocochlear → hearing, vestibular sense

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IX: Glossopharyngeal → sensation to posterior third of tongue and pharynx, taste posterior 1/3 tongue, stylopharyngeus (palate elevation), gag (with CNX), guttural sounds (with CN X)

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X: Vagus → parasympathetic innervation heart, lungs, GI tract to splenic flexure, pharyngeal muscles (gag), upper esophageal muscles (swallow), larynx (voice box via recurrent laryngeal branch of CNX), sensation to pharynx

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XI: Spinal accessory → trapezius and sternocleidomastoid motor (weakness with ipsilateral shoulder shrug and head turning AWAY from the affected side)

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XII: Hypoglossal → tongue movement, lingual sounds (causes ipsilateral tongue weakness, thus tongue will be pushed towards the side of the lesion)

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Motor examination

1. Bulk
• Atrophy → LMN
• Preserved bulk → UMN

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• Abnormal movements
• Many have basal ganglia localization
• Fasciculations → LMN

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• Tone
• Flaccid/hypotonic → LMN
• Rigidity → extrapyramidal system
• Spasticity (velocity dependent) → UMN

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• Power
• Myotome or nerve distribution → LMN
• Pyramidal pattern (lesion anywhere along corticospinal tract) → UMN
• Flexors stronger than extensors in UE, extensors stronger than flexors in LE

Hint: ENCOURAGE your patient and use repeated trials to separate out true weakness from effort/pain/functional weakness.

Level up! Think about testing specific muscles like the FDP, PFL, EIP, and groups like ankle inversion/eversion. Connect them to specific peripheral nerves and/or spinal levels to refine your localization.

Reflex examination

Biceps

Triceps

Brachioradialis

Patellars

Ankles

Plantars

• Brachioradialis (C6)
• Elbow flexion/supination
• Biceps (C5-C6)
• Elbow flexion
• Triceps (C7)
• Elbow extension
• Patellars (L2-L4)
• Knee extension
• Ankles (S1-S2)
• Ankle plantarflexion, don’t forget to look for ankle clonus (knee supported and bent at 90 degrees!)
• Plantars

Hint: watch for spread to muscle groups outside of the reflex arc (i.e. for biceps, should be elbow flexion only – if you see wrist/finger flexion, that’s a 3+ reflex!

Level up! Learn to test for crossed adductors, Hoffman’s and Tromner’s sign, pectoralis reflexes, finger jerks, superficial and deep abdominal reflexes, and know what they mean.

Sensory examination

Spinothalamic tracts

• Pain (pinprick): use a safety pin, asking patient to perceive sharpness
• Temperature: use your tuning fork/cold metal

General principles

• Begin proximally → test pinprick, vibration or temperature
• Confirm patient perceives sharpness/vibration
• Move distally → start at the great toe

Assess for:

• Proximal-to-distal gradient → distal symmetric polyneuropathy
• Side-to-side asymmetry → dermatomal or peripheral nerve pattern (look for differences >20-30%)

Dorsal column medial lemniscus

• Vibration: use your tuning fork, ask patient to tell you when it extinguishes naturally
• Proprioception: fingers on sides of great toe, thumb, small movements up and down.
• Romberg: feet touching, hands across chest, safe environment (bed behind, you in front), eyes closed.

Level up! Think about testing for a spinal sensory level when appropriate. Confirm with two modalities (temperature and pinprick).

Cerebellar examination

• Finger to nose (dysmetria) → ipsilateral cerebellar hemisphere
• Heel to shin (dysmetria) → ipsilateral cerebellar hemisphere
• Rapid alternating movements (dysdiadochokinesia) → ipsilateral cerebellar hemisphere
• Truncal, head titubation, ataxic gait → cerebellar vermis

Level up! The cerebellum can be tested many different ways. Think about incorporating unique tests like saccades, rebound, finger chase

Hemispheres → appendicular/limb ataxia, scanning speech

Vermis → truncal ataxia, gait ataxia

Flocculus → nystagmus (especially downbeat), impaired saccades/smooth pursuit, dysequilibrium

Gait examination

Observe and comment on:

• Stance
• Wide based, unsteady, “stomping” (ataxic)
• Stride
• Short, festinating steps (parkinsonism)
• High steppage (foot drop)
• Arm swing
• Lack of arm swing, presence of tremor, dystonic posturing
• Turns
• En-bloc turning (parkinsonism)
• Posture
• Stooped posture, camptocormia, kypho/scoliosis, lateropulsion

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Recognizable gait patterns in neurology

• Circumducting/hemiplegic gait: UMN gait, arm is flexed, leg is extended, foot is inverted, circumduction of leg to clear the paretic limb.
• Waddling gait: proximal muscle weakness gait
• Steppage gait: foot drop gait
• Shuffling gait: Parkinsonian gait with narrow base, short stride, decreased arm swing, en-bloc turning
• Cerebellar ataxic gait: Wide-based, leaning/veering to affected side
• Sensory ataxic gait: Wide-based, slapping feet on the ground/stomping

Picture of UMN hemiplegic, circumducting gait