Guide to Performing a Neurological Exam
A neurological exam includes checking a patient’s memory and concentration, vision,
hearing, balance, coordination, and reflexes.
Mental Status Examination
With a head trauma, the exam usually begins with an assessment of cognitive
functioning, or how well the patient is thinking. The physician will:
1. Ask the patient a few simple questions, to determine his/her basic cognitive
status (e.g., “Where do you live?” or “What day is it?”).
2. Ask the patient to count backwards from 10, or name the months in reverse,
starting with December, to assess ability to perform simple mental tasks.
3. Ask the patient to repeat a short list of items, to assess level of attention or focus.
4. Ask the patient for information regarding the incident or injury, to assess shortterm memory (e.g., “What were you doing when you fell?”).
5. Ask the patient to recount an event that happened a few days ago, to assess
longer-term memory.
6. Ask the patient to repeat the short list of items, to assess immediate recall
memory.
7. Ask the patient to perform a simple task, such as “touch your right ear with your
left hand and cross your legs” to assess ability to follow simple commands.
8. Place several common small objects in the patient’s hand, one at a time, and ask
him/her to identify each with eyes closed, to asses ability to process sensory
information.
If the patient has trouble with any of these tasks, a referral to a neurologist is
recommended.
Cranial Nerves Examination
The cranial nerves are twelve sets of nerves that connect the brain to various parts of the
head and neck. Physicians can test the proper functioning of each nerve by asking the
patient to perform simple tasks, because each nerve controls a different body function.
How many nerves are tested depends on what type of disorder is suspected.
1. To test the Olfactory nerve, which controls the sense of smell, ask the patient to
identify several items with distinct odors (with eyes closed), such as coffee or
soap.
2. To test the Optic nerve, which controls vision and sensitivity to light, ask the
patient to read an eye chart, alternating eyes. Then ask the patient to look
straight ahead, cover each eye in turn, and specify when s/he can no longer see
the physician’s finger as it moves past the patient’s head.
Finally, examine the patient’s eyes with an ophthalmoscope, observing the optic
disc, physiological cup, retinal vessels and fovea. Note the pulsations of the optic
vessels, and check for a blurring of the optic disc margin and a change in the
optic disc's color from its normal yellowish orange.
3. To test the Oculomotor nerve, which controls movement of the eyes and dilation
of pupils in response to light, ask the patient to follow an object with his/her
eyes. Observe the size of each pupil. Then shine the light from a pen light or the
ophthalmoscope into the patient’s pupils and note the rate of constriction of the
pupils.
4. To test the Trochlear nerve, which controls movement of the eyes downward and
inward, ask the patient to follow the light with his/her eyes at various levels.
5. To test the Trigeminal nerve, which controls facial sensation and chewing, touch
various parts of the face with a pin and a cotton swab to assess awareness of
sensations. Touch the patient’s cornea in each eye to assess corneal reflex (patient
should blink).
6. To test the Abducens nerve, which controls lateral eye movement, ask the patient
to look sideways, left and right.
7. To test the Facial nerve, which controls facial expressions and taste in the front of
the tongue, ask the patient to smile, open his/her mouth and grimace, and close
the eyes tightly. Attempt to open the patient’s eyes while closed. Test the
patient’s taste using sweet, salty, and bitter substances.
8. To test the Acoustic nerve, which controls hearing and balance, use the tuning
fork and ask the patient to identify the location of various sounds (with eyes
closed). The Weber test involves striking the tuning fork on your palm and then
placing it on the patient’s head to make certain s/he can hear it equally in both
ears. To assess balance, ask the patient to walk in a straight line.
9, 10. To test the Glossopharyngeal and Vagus nerves, which together control
swallowing, gag reflex, and speech, ask the patient to swallow. Protrude the
tongue with a tongue depressor, ask the patient to say, “Ahh,” and note the
movement of the palate, using a light for better visibility. Use the depressor to
test the gag reflex by touching the pharynx (the back of the mouth) on both the
left and right sides.
11.
To test the Accessory nerve, which controls the ability to shrug the shoulders and
turn the neck, ask the patient to perform these motions while you attempt to
prevent them by pushing down on the shoulders or against the side of the head.
12.. To test the Hypoglossal nerve, which controls the ability to move the tongue, ask
the patient to stick out the tongue and move it side to side.
Motor Nerves Examination
Motor nerves carry instructions from the brains to voluntary muscles – those we move
using a conscious thought. A paralysis or weakness in a muscle could be the result of an
injury to a motor nerve.
The spinal column has four sections, each of which controls a different part of the body.

The Cervical region, C1 through C8, controls the neck, head, shoulder, and arm
regions.

The Thoracic region, T1 through T12, controls the upper back, torso, and part of
the arms.

The Upper Lumbar region, L1 through L5, controls the hips and legs.

The Sacral region, S1 through S5, controls the groin, toes, and some parts of the
legs.
For each muscle group, examine the patient for the appearance of the muscle (wasted,
highly developed, normal); the tone of the muscle (flaccid, clonic, normal); and the
strength of the muscle group. Test for asymmetry in any muscle group.
Cervical and Thoracic Regions
1. To test the deltoids (innervated by the C5 nerve), ask the patient to push up the
arms while you attempt to push them down.
2. To test upper motor strength, ask the patient to extend both arms, palms up, and
hold the position for at least 10 seconds with eyes closed.
3. To test the biceps muscle, controlled by the C5 and C6 nerves, ask the patient to
flex each arm while you push down, holding the wrist from above.
4. To test the triceps muscle, controlled by the C6 and C7 nerves, ask the patient to
push each arm down while you push up, holding the wrist from below.
5. To test the wrist extenders, controlled by the C6 and C7 nerves, ask the patient to
extend the wrist upward (palm up) for each arm while you push down.
6. To test the finger flexion, controlled by the C8 nerve, ask the patient to grip your
finger and not let go while you try to remove your fingers from the grasp.
7. To test finger fanning or abduction, controlled by the T1 nerve, ask the patient to
fan out the fingers and resist your attempt to compress them.
8. To test the thumb opposition, controlled by the C8 and T1 nerves, ask the patient
to touch each thumb to the pinky. Ask the patient to push against your finger with
each thumb.
Upper Lumbar and Sacral Regions
1. To test hip flexion and the iliopsoas muscles, controlled by the L2 and L3 nerves,
ask the patient to lie down raise each leg while you push down.
2. To test hip adduction (i.e., moving a body part towards the central axis of the
body), controlled by the L2, L3, and L4 nerves, ask the patient to push the legs
together while you push outwards on the inner thighs.
3. To test hip abduction (i.e., moving a body part away from central axis of the
body) and the gluteus maximus and gluteus minimus muscles, controlled by the
L4, L5, and S1 nerves, ask the patient to push the legs out while you push
inwards on the outer thighs.
4. To test hip extension and the gluteus maximus muscle, controlled by the L4 and
L5 nerves, ask the patient to push each leg down while you push up, holding the
leg from underneath.
5. To test knee extension and the quadriceps muscles, controlled by the L3 and L4
nerves, place one hand under the knee and the other on top of the lower leg and
ask the patient push up from the knee.
6. To test knee flexion and the hamstring muscles, controlled by the L5 and S1
nerves, place one hand on top of the knee and the other under the lower leg ask
the patient push up, pulling the leg towards the buttocks.
7. To test dorsiflexion of the ankle, controlled by the L4 and L5 nerves, ask the
patient to pull the foot towards the head while you push down.
8. To test plantar flexion of the ankle and the gastrocnemius and soleus muscles,
controlled by the S1 and S2 nerves, ask the patient to push the foot down (“step
on the gas pedal”) while you push up.
9. To test the motor ability of the toe and the extensor halucis longus muscle,
controlled by the L5 nerve, ask the patient to push the toe up while you push
down.
Sensory Nerves Examination
Sensory nerves carry instructions to the brain about sensory events occurring to the
body, such as touch, temperature, positions, shapes of objects, etc. Each nerve carries
information from a different part of the body to a different receptor on the spinal
column. Reduced sensory perceptions could indicate damage to a sensory nerve.
Physicians usually concentrate on that part of the body where the patient feels
numbness, tingling, or pain.
1. Ask the patient to lie down and close the eyes. Using both a pin (from a safety pin)
and a brush, touch the patient in the following areas and ask him/her to identify
which object is touching these 13 parts of the body:

posterior aspect of the shoulders (C4)

lateral aspect of the upper arms (C5)

medial aspect of the lower arms (T1)

tip of the thumb (C6)

tip of the middle finger (C7)

tip of the pinky finger (C8)

thorax, nipple level (T5)

thorax, umbilical level (T10)

upper part of the upper leg (L2)

lower-medial part of the upper leg (L3)

medial lower leg (L4)

lateral lower leg (L5)

sole of foot (S1)
Each test indicates whether there is damage to the corresponding spinal cord nerve. If
any body area indicates a loss of sensory perception, use the tuning fork to test for
awareness of vibrations, and also test for temperature awareness.
Deep Tendon Reflex Examination
Use a rubber hammer to test reflexes in all four extremities.
1. To test the biceps and brachioradialis reflexes, controlled by the C5 and C6
nerves, place your thumb on the biceps tendon (inside of elbow) and tap your
thumb with the hammer.
2. To test the triceps reflex, controlled by the C7 and, mainly, C7 nerves, hold the
patient’s arm and tap the triceps tendon (just above elbow on back of arm).
3. To test the quadriceps reflex (the knee jerk reflex), controlled by the L3 and,
mainly, L4 nerves, tap the patient’s leg just below the knee.
4. To test the ankle reflex, controlled by the S1 nerve, hold the foot in a relaxed
position and tap the Achilles’ tendon.
5. To test the plantar reflex (Babinksi’s sign), run a key or the end of the hammer
along the lateral side of the bottom of the foot, from heel to toe. The toes should
flex. If they extend and separate, this could indicate an upper motor neuron
lesion.