Learning guides for Neurologic Examination

Prepare the needed equipment:

▪ Reflex Hammer
▪ Wooden handed Cotton Swabs and cylindrical pieces of cotton
Getting Ready:
▪ Establish rapport with the patient
▪ Explain the procedure to the patient
▪ Encourage the patient to tell you if any pain or embarrassment is caused by the examination
▪ Ask the patient to expose the area of examination
▪ Compare opposite sides
▪ Compare distal and proximal sites
▪ Record findings at the end of the procedure
▪ Wash hands and maintain proper infection prevention practices.

Clinical Learning Guide

Mental Status Examination (MSE)
STEP/TASK CASES
Getting Ready:
1. Prepare the needed equipment
2. Assure that the patient can pay attention. The MSE can not be done in patients with
coma, or aphasia or non-fluent in the language of the examiner
3. Before conducting the MSE, take careful medical and psychiatric history
4. Always explain to the patient what are you going to do
A. Appearance:
Look at the general appearance of the patient
B. Movements: Observe :
▪ Gait ▪ Eye contact
▪ Posture ▪ Facial expressions
▪ Coordinated movement
C. Level of Alertness and Mental state:
1. Is the patient conscious? If not, can s/he be aroused? Apply Glasgow Coma Score .
Mental status (the child's level of awareness and interaction with the environment) may be assessed by
watching the infant interact with the parent, or by asking the older child to follow directions or answer
questions appropriately.
The older child will also be observed for clear speech and making sense while talking. This is usually done by
your child's healthcare provider just by observing the child during normal interactions.
E. Speech: (taking age in consideration)
1. Observe the patient while talking
2. Comment on the following:
▪ Ability to produce sounds
▪ Volume of the voice
▪ Speed of speech
▪ Appropriateness and clarity of the answers
F. Remember to look for:
1. Remember to examine the back
F2. remember to look for neurocutaneous stigmata
F.3. Remember to look for dysmorphic features.
 Clinical Learning Guide
Neurological Examination of the Sensory
Function
STEP/TASK CASES
Getting Ready:
Prepare the needed equipment:
• pin with large head.
• Cylindrical pieces of cotton
• Paper clip
General Considerations:
• Always explain to the patient what are you going to do
• Ask the patient to expose both upper and lower limbs and most of the trunk
• Unless otherwise specified, the patient's eyes should be closed during the test
• Compare symmetrical areas on the two sides of the body
• Also compare distal and proximal areas of the extremities
• When you detect an area of sensory loss map out its boundaries in detail.
• Record findings
1. Superficial sensation
A. Pain
1. Use a suitable object to test "sharp" or "dull" sensation ( an object that has a sharp part
and a dull part as a sharp pin with large head
2. Test the following areas:
a. Shoulders (C4)
b. Inner and outer aspects of the forearms (C6 and T1)
c. Thumbs and little fingers (C6 and C8)
d. Front of both thighs (L2)
e. Medial and lateral aspect of both calves (L4 and L5)
f. Little toes (S1)
3. Compare both sides
6. Compare from above down (sensory level)
7. Examine around the trunk or limb in levels
B. Touch
1. Use a fine cylindrical piece of cotton or your fingers to touch the skin lightly
2. Follow the same steps done for pain.
C. Temperature
1. Often omitted if pain sensation is normal
2. Apply two test tubes, one cold 10° C (or metallic pen) and one hot 45° C (or side of the
examiner hand)
3. Follow the same steps done for pain.
2. Deep sensation
A. Pressure Sense
1. Apply palm pressure by squeezing the muscles of the arm, forearm, thigh and calf.
2. Ask about sense of deep pressure
B. Vibration Sense
1. Strike the tuning fork (128Hz) and place it over the patient’s forehead to teach the
patient about the sense of vibration.
2. Apply the vibrating tuning fork over bony prominences
3. Ask the patient to tell you if the vibration is felt.
4. Stop the fork, reapply and ask if the patient still feels a vibration.
C. Joint sense
▪ Joint movement:
1. Hold the patient’s toe between your thumb and index fingers
2. Teach the patient the different positions of the toe.
3. Ask patient to close the eyes, then move the toe up and down and ask the patient to
differentiate whether you moved the thumb
4. If the sense of movement is impaired, move proximally to test the ankle joint
5. Test the fingers in a similar fashion
6. If indicated, examine the metacarpophalangeal joints, wrists, and elbows
▪ Joint position:
1. Grasp the patient's big toe and hold it away from the other toes to avoid friction
2. Show the patient "up" and "down."
3. With the patient's eyes closed ask the patient to identify the direction you move the toe
4. If sense of position is impaired, move proximally to test the ankle joint
5. Test the fingers in a similar fashion
6. If indicated, move proximally to the metacarpophalangeal joints, wrists, and elbows
3. Cortical Sensation:
A. Tactile Localization
• Ask the patient to localize one point of pin prick
B. Tactile Discrimination
1. Use an opened paper clip to touch the patient's finger pads in two places simultaneously
2. Alternate irregularly with one point touch
3. Ask the patient to identify "one" or "two."
4. Find the minimal distance at which the patient can discriminate
C. Stereogenesis
1. Ask the patient to close eyes
2. Place a familiar object in the patient's hand (coin, paper clip, pencil, etc.)
3. Ask the patient to tell you what it is
 Clinical Learning Guide
Neurological Examination of the
Motor Function

STEP/TASK CASES
Getting Ready:
Prepare the needed equipment:
• Reflex hammer
General Considerations:
• Always explain to the patient what are you going to do
• Ask the patient to expose both upper and lower limbs and most of the trunk
• Compare symmetrical areas on the two sides of the body
• Also compare distal and proximal areas of the extremities
• When you detect an area of sensory loss map out its boundaries in detail.
• Record findings
1. Examination of the muscle state:
1. Observe the size of the muscle
2. Observe any involuntary movement or fasciculation
3. Observe symmetry between left and right, and proximal and distal muscles
2. Examination of the muscle tone:
1. Ask the patient to relax
2. Flex and extend the patient's fingers, wrist, elbow, and shoulder.
3. Flex and extend patient's ankle, knee & hip. There is normally a small, continuous
resistance to passive movement
4. Observe for decreased (flaccid) or increased (rigid/spastic) tone
3. Examination of the muscle power:
1. Test strength by having the patient move against your resistance
2. Examine power of muscle around all joints
3. Grade the power: (if asked)
a. As (0/5) if there is no muscle movement
b. As (1/5) if there is visible muscle movement,
c. but no movement at the joint
d. As (2/5) if there is movement at the joint, but
e. not against gravity
f. As (3/5) if there is movement against gravity,
g. but not against added resistance
h. As (4/5) if there is movement against resistance, but less than normal
i. As (5/5) if there is normal strength
4. If proximal weakness:
4.1.Look for Gower sign
4.2.Look for winging of scapula
5. Deep reflexes (NOT the nerve supply)
1. Ensure that the patient is relaxed and positioned properly before starting
2. Reflex response depends on the force of your stimulus.
3. Reflexes can be reinforced by having the patient perform isometric contraction of other
muscles (clenched teeth)
4. Grade reflex:
• as (0) if it is absent
• as 1+ or + if it is hypoactive
• as 2+ or ++ if it is normal
• as 3+ or +++ if it is hyperactive without clonus
• as 4+ or ++++ if it is hyperactive with clonus
5. A. The brachioradialis reflex (C5,6)
1. Have the patient rest the forearm on the abdomen or lap
2. Strike the radius about 1-2 inches above the wrist
3. Watch for flexion and supination of the forearm
5. B. The triceps reflex (C6,7)
1. Support the upper arm and let the patient's forearm hang free
2. Strike the triceps tendon above the elbow with the broad side of the hammer
3. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close
to the chest
4. Watch for contraction of the triceps
5. C. The biceps reflex (C5,6)
1. The patient's arm should be partially flexed at the elbow (120 degree) with the palm
down
2. Place your left index finger firmly on the biceps tendon
3. Strike your finger with the reflex hammer
4. You should feel the response even if you can't see it
5. D. The knee jerk reflex (L2, L3, L4)
1. Ask the patient to allow the leg to hang down, or to cross the leg to be examined over
the other leg (thighs must be exposd).
2. Alternatively, Support the half bent knee on your left arm, while the patient is supine
3. Tap the tendon of the quadriceps muscle just below the patella with the hammer
4. Note contraction of the quadriceps and extension of the knee
5. E. The ankle jerk reflex (S1, S2)
1. Put ankle over the other leg with slight ankle dorsiflexion and eversion (with the other
hand).
2. With the hammer in the other hand & swing it to hit the Achilles tendon
3. Watch and feel for plantar flexion at the ankle
5. F Hip adductor reflex (L2-4)
1. The proximal thigh must be readily palpated, free of restrictive clothing
2. Position the patient in supine with the hip to be examined in about 45
degrees of flexion and slight abduction; the leg is supported by a pillow or the
clinician.
3. Stand to the side of the patient at the level of the proximal to mid-thigh.
4. Place your second and third fingers over the medial epicondyle of the femur
5. Allow the reflex hammer to swing loosely between your thumb and
forefinger through a 45 to 60 degree arc.
6. Strike your fingers, with the broad end of the reflex hammer.
7. Palpate and visually observe the response to the provided stimulus (i.e., hip
adduction); you should be able to palpate a response even if you cannot see it.

6. Superficial reflexes
1. Insure that the patient is relaxed before starting
2. Reflex response depends on the force of your stimulus. Use no more force than you need
to provoke a definite response
3. Reflexes can be reinforced by having the patient perform isometric contraction of other
muscles (clenched teeth)
4. Use a blunt object such as a key or tongue blade
6. A. The abdominal skin reflex (T8, T9, T10, T11, T12)
1. Strike the abdominal skin rapidly and not too hard with a needle from the side to the
middle at three levels
2. Note the contractions of the abdominal muscles and deviation of the umbilicus towards
the stimulus (degree and symmetry).
6. B. The cremastric reflex (L1, 2) (for male patients only)
1. Undress the male patient and instruct him to lie Down in the supine position
2. Strike the skin of the upper thigh longitudinally with a needle
3. Note elevation of the scrotum
6. C. The Planter reflex (S1, 2)
1. Expose the patient’s feet
2. Press the lower leg against the table.
3. With a blunt object strike the lateral edge of the sole of the foot from the heel to the base
of big toe, heavily, steadily and slowly
4. Note movement of the toes, normally flexion (withdrawal)
5. Extension of the big toe with fanning of the other toes is abnormal. This is referred to as
a positive Babinski.
6. Consider other maneuvers in special situations.
7. In case of hyperreflexia look for pathologic reflexes:
7.1 The ankle clonus (S1, S2)
Support the knee in a partly flexed position
With the patient relaxed, quickly dorsiflex the foot
Observe for rhythmic oscillations of the patient's foot
7.2. Patella clonus - less common than ankle clonus
1. The examiner holds the patient's patella between thumb and index finger - rest other
hand - left - on top of patient's quadriceps
2. Sharply pull down patella - if clonus is present then there is sustained rhythmical
contraction of quadriceps as long as the examiner maintains downward pressure on the
patella
7.3. Hoffmann sign
The examiner flicks the nail of the middle finger downward while loosely holding the
patient's hand, allowing it to flick upward reflexively.

The sign is positive when there is quick flexion and adduction of the thumb and/or index
finger on the same hand.

8. Primitive reflexes
8.1. The asymmetric tonic neck reflex
is performed by manual rotation of the infant’s head to one side. The infant will extend its
arm to the side of the rotated face and flex the contralateral arm.
Onset at 35 weeks gestation and disappears by three months
8.2. The Moro reflex
The infant experiences the sensation of falling when the arms are released, resulting in
abduction at the shoulder and extension at the elbow with the spreading of the fingers,
followed by immediate flexion of the upper extremities and an audible cry.
The reflex develops by 28 weeks gestation and disappears by six months
8.3. The grasping reflex
It can be elicited by providing sustained pressure on the palmar aspect of the hand,
resulting in flexion of the patient’s fingers grasping the object providing the pressure.
This reflex develops by 28 weeks gestation and disappears by six months

7. Tests for coordination

7. A. Standing
• Check whether the patient stands straight
• Check whether he could remain straight with eyes opened
• Check whether he could remain straight with eyes closed
7. B. Walking
• Ask the patient to walk across the room, turn and come back
• Walk heel-to-toe in a straight line
• Walk on his\her toes in a straight line
• Walk on his\her heels in a straight line
• Hop in place on each foot
• Do a shallow knee bend
• Rise from a sitting position
7. C. Diadocokinesia
• Ask the patient to do pronation and supination as rapidly as possible
7.D. Finger-to-nose test
• Ask the patient to stretch one arm out
• Ask the patient to close his\her eyes
• Ask the patient to bring the index finger to the tip of the nose
7. E. knee-heel test
• Ask the patient to close his eyes
• Ask the patient to place the heel of one foot on the knee of other leg
• Ask the patient to slide the heel down from the knee to the instep of the leg.

Adductor reflex patellar clonus patellar refelex hoffman

 Clinical Learning Guide
Examination of the Cranial Nerves

STEP/TASK CASES
Getting Ready:
Prepare the needed equipment :
1. Reflex Hammer
2. 128 and 512 (or 1024) Hz tuning Forks
3. A Snellen Eye Chart or Pocket Vision Card
4. Pen Light or Otoscope
5. Wooden Handled Cotton Swabs
6. Non-pungent material in a tube (coffee)
7. Paper clips
8. Tongue depressor
9. Sharp & blunt objects
10. Salt, acetic acid & sugar
General Consideration:
• Always explain to the patient what are you going to do
• Report findings
• Always consider left to right symmetry
• Consider proximal vs. distal deficits
A. Olfactory nerves (may not be possible in very young, comatosed or MR)
1. Describe the procedure to the patient
2. Insure that the nasal airway is patent
3. Tell the patient to close both eyes
4. Close patient's nostril one at a time
5. Bring a tube with non-pungent material to the nostril
6. Ask the patient to sniff
7. Ask the patient to identify if there is a smell or not; If he identifies a smell inquire about
its nature
8. Do the same for the other nostril
B. Optic nerve
Organize your approach into five procedures:
• Visual acuity
• Visual field
• Pupillary reflex
• Convergence reflex
• Fundus examination
B.1. Visual Acuity
1. Allow the patient to use their glasses or contact lens if available
2. Position the patient 6 meters in front of the Snellen eye chart
3. Have the patient cover one eye at a time with a card
4. Ask the patient to identify direction of the opening of the letter "C" from larger to
smaller letters until they can go no further
5. Record the smallest line the patient reads successfully
6. Repeat with the other eye.

B.2.Test color vision:

1. Use color chart.
2. Ask patient to identify the colors
B.3. Visual Field (both doctor and patient without glasses)
1. Stand 50 cm in front of the patient and at the same level
2. Ask the patient to look directly and fix his eyes into your eyes
3. Cover non-tested eyes
4. Use small object (or index finger) and place it half distance between you and the patient
and beyond limits of field of vision
5. Advance the object (while moving) from outwards inwards
6. Test the four quadrants (upper nasal, lower nasal, upper temporal, and lower temporal)
7. Repeat for the other eye
8. Record your findings
B.4. Pupillary Reflex
1. Dim the room lights as necessary
2. Ask the patient to look into the distance
3. Shine a bright light obliquely into each pupil in turn
4. Look for the change of pupil size in the same eye
(direct reflex)
5. Look for the change of pupil size in the other eye
(consensual reflex)
6. Record pupil size in mm and any asymmetry
or irregularity
B.5. Convergence Reflex
1. Hold your finger about 10 cm from the patient's nose
2. Ask the patient to alternate looking into the distance and at your finger
3. Observe the pupillary response in each eye
4. Observe convergence in both eyes
B.6. Fundus examination (See the specific Learning guide)
C. Oculomotor, trochlear and abducent nerves
Organize your approach into four procedures:
• Cover test
• Uncover test and examination for nystagmus
• Pupillary reflex (if not done before)
• Convergence reflex (if not done before)
C.1. Cover test
1. Tell the patient to look at a distant fixation point
2. Cover one eye at a time
3. Remove the cover rapidly
4. Notice any movement of the eye
5. Repeat in the other eye
C.2. Uncover test, and test for nystagmus
1. Stand or sit one to two meters in front of the patient
2. Ask the patient to follow your finger with his\her eyes without moving their head in the
six cardinal directions using a cross or "H" pattern
3. Pause during upward and lateral gaze to check for nystagmus
4. Comment on movement and presence of
Nystagmus
D. Trigeminal nerve
Organize your approach into three categories:
• Motor
• Sensory
• Reflexes
D.1. Motor
1. Ask the patient to clench his teeth
2. Palpate the temporalis and massetter muscles bilaterally
3. Move jaw to the contralateral side against resistance (ptrygoid) and compare both sides
4. Ask the patient to open his/her mouth then against resistance from your hands placed
below the chin
5. Notice any deviation of the mandible
D.2. Sensory
Test for pain, temperature, and light touch
1. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides
2. Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull"
3. Test the three divisions for temperature sensation with a tuning fork heated or cooled by
water
4. Test the three divisions for sensation to light touch using a wisp of cotton
D.3. Reflexes
D.3.a Corneal Reflex
1. Ask the patient to look up and away
2. From the other side, touch the cornea lightly with a fine wisp of cotton
3. Look for the normal blink reaction of both eyes
4. Repeat on the other side
N.B. Use of contact lens may decrease this response
D.3.b Jaw jerk
1. Ask patient to hang the jaw freely (while eyes are closed ).
2. Place your left index finger on the chin of the
Patient
3. Tap your finger by a hammer
4. Look for jaw closure
E. Facial nerve
Organize your approach into two procedures:
• Motor
• Sensory
E.1. Motor
1. Ask the patient to sit down and relax
2. Inspect the face for symmetry
3. Ask Patient to do the following, note any lag,
weakness, or asymmetry:
a. Raise eyebrows
b. Wrinkle forehead
c. Close both eyes tightly against resistance
d. Smile
e. Frown
f. Show teeth
g. Blow his cheeks

E.2. Sensory
1. Teach the patient to respond to the stimuli by moving hands.
2. Ask patient to protrude his tongue while eyes are closed
3. Apply wet salt, vinegar or sugar solution in the anterior part of the tongue
4. Instruct the patient not to withdraw tongue unless he/she identifies the substance
F. Acoustic nerve
Organize your approach into three procedures:
• Voice test
• Rhinne test
• Weber's test
F.1. Voice test
1. Stand beside the patient at a distance of about 50 cm
2. Whisper at very low voice
3. Ask the patient to repeat what is said
4. Use watch tick or finger friction sound
Alternatively
5. Compare both sides
F.2. Rinne test
1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork against the mastoid bone behind the ear.
4. When the patient no longer hears the sound, hold the end of the fork near the patient's
ear and comment.
5. Repeat on the other ear
F.3. Weber test
1. Use a 512 Hz or 1024 Hz tuning fork
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork firmly on top of
the patient's head.
4. Ask the patient where the sound appears
to be coming from
G. Glossopharyngeal and vagus nerves
G.1 Comment on voice
1. Listen to the patient while speaking freely
2. Comment on the voice changes
G.2 Deglutition
1. Give the patient a cup of water
2. Ask him/her to swallow it
3. Comment on swallowing
G.3 Palatal reflex
1. Prepare two tongue depressors and torch
2. Place the torch over one tongue depressor in
Your right hand
3. Advance the torch with the tongue depressor in the patient mouth so that you press the
tongue and see the pharynx clearly
4. Notice the position of the uvula if it is central or deviated to one side
5. With the other tongue depressor in your left hand touch the inferior surface of the uvula,
then to its right and its left sides
5. Comment if there is elevation of the uvula and the shift to right or left
G.4 Gag reflex
1. Repeat steps 1, 2, and 3 as in palatal reflex
2. With the other tongue depressor in your left hand touch the posterior pharyngeal wall
3. Comment if the patient gags or not
H. Accessory nerve
1. Stand behind the patient while he is sitting on a chair
2. look for atrophy or asymmetry of the trapezius muscles
3. Place your hands over both shoulders
4. Ask the patient to elevate shoulders against resistance, and palpate the trapezius in both
sides
5. Place your hands so that the right hand is pushing
the right side of the patient mandible, and the left
hand is palpating the patient's right sterno-
mastoid muscle
6. Ask the patient to push against you right hand and test the muscle for contour, power
and or atrophy
7. Replace hands, to test for the other sternomastoid muscle
8. Report your findings
I. Hypoglossal nerve
1. Observe the tongue as it lies in the mouth
2. Ask the patient to protrude the tongue and observe deviation
3. Place your finger over the patient's cheek, and
Ask him\her to press against by his tongue.