Neurological Physical Exam Lab
Below are the elements of the physical exam that we will be performing today.
Opening the encounter
1. Introduction: Explain encounter, wash hands
Vital Signs
2. Measurement: Pulse rate (radial), RR, BP
General Appearance & Mental Status
3. Assessment: General appearance & Mental Status
General impressions of the patient’s level of consciousness (alert vs. lethargic or
obtunded) and appearance (grooming, overall health, level of distress, etc.).
Neurological Systems
CRANIAL NERVES
4. Assessment: Cranial Nerves V and VII (i.e., Masseter Contraction, facial sensation
V1/V2/V3, and facial muscles)
5. Screening: Gross hearing, Weber & Rinne tests (CN VIII) Screen for Olfaction (CN I) if
indicated.
6. Assessment: CN IX & X (Swallowing, palatal elevation)
7. Assessment: CN XII (Tongue extrusion)
8. Screening: Visual fields by confrontation; visual acuity if indicated (CN II)
9. Assessment: Extra-ocular muscle function (CN III, IV, & VI)
10. Assessment: Pupillary light response (CN II & III)
11. Assessment: CN XI (Shoulder shrug or SCM)
SENSORY & REFLEXES
12. Assessment: Deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and Achilles);
Assess Clonus.
The deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and Achilles) are
elicited & compared bilaterally. Reinforcement is used if reflexes are weak or absent.
13. Assessment: Plantar reflex (i.e., Babinski)
Plantar reflex is tested. Note upgoing, downgoing, withdrawal, or absent responses.
6. Assessment: Vibratory sense in all 4 extremities
Vibratory sense including cessation is evaluated distally in all extremities.
7. Assessment: Sensation in all 4 extremities (pain, light touch) (dermatomes and
stocking/glove).
Sensation including pain & light touch is assessed in all extremities. Assess for
differences between dermatomes & progress proximally to rule-out stocking/glove
losses.
1
9. Assessment: Proprioception in toes
Assess proprioception by isolating the great toe, grasping from the side. Move up and
down.
MOTOR FUNCTION
10. Assess: Strength (deltoid, biceps, triceps, quadriceps, hamstrings)
11. Assessment: Cerebellar function for both upper and lower extremities (i.e. rapid alternating
movements, finger-nose-finger, heel-knee-shin)
Both upper & lower extremities are evaluated bilaterally for cerebellar function (finger-tonose, heel-along-shin). Assess for dysdiadochokinesis (poor rapid alternating
movements).
12. Assessment: Romberg test and pronator drift
Romberg is done standing, with feet together. Pronator drift can be assessed at same
time.
13. Observation: Barefoot gait, station (stance)
Observe the barefoot gait and natural stance of the patient.
14. Observation: Heel walk, toe walk, and heel-to-toe walk
Assess the patient’s ability to walk heel-to-toe (tandem walk), heel walk, & toe walk.
Special maneuvers:
Brudzinski sign - involuntary lifting of legs when lifting a patient's head
Kernig sign – fully flex kee and hip. Subsequent extension of knee is painful.
Localization – ability to recognize where an object is making contact with the skin.
Two-point discrimination - the ability to discern that two nearby objects touching the skin are
truly two distinct points, not one.
Stereognosis – ability to recognise an object by using the sense of touch. Assesses cortical
function.
Graphesthesia – ability to recognize writing on the skin purely by the sensation of touch.
Assess cortical function.
Asterixis – a tremor of the wrist when the wrist is extended (dorsiflexion).
2