Neurological Exam
Cranial Nerve Assessment
CN 1: Olfactory
Ask patient to close their eyes and cover one nostril. Have them identify a smell (e.g. alcohol wipe). Repeat with other nostril.
CN 2: Optic
Visual acuity
Use an eye chart. Ask patient to cover one eye and read the lowest line possible. Have patient close other eye and read the same line backwards.
Rosenbaum eye chart: 14 inches away
Snellen eye chart: 6 feet away
Visual Fields
Have patient cover one eye and look at your nose. Mirror the patient by closing your own eye on the same side which will allow you to separate your hands until they reach the edge of your visual field. Have the patient point at the wiggling finger, testing all four quadrants. Repeat for other eye.
CN 3/4/6: Oculomotor/Trochlear/Abducens
Pupillary Response
Dim the room lights and ask the patient to fixate on a distant point. Use the otoscope light at an angle into each of the patient's eyes to assess direct pupillary constriction. Check to insure both eyes have consensual response.
Extra-Ocular Movements
Ask patient to follow your finger without moving your head. Move finger in shape of an "H", centered to the patient's midline at eye level.
CN 5: Trigeminal
Muscles of Mastication
Place fingers bilaterally on temporomandibular joint and ask patient to clench their jaw and then relax.
Facial sensation
Have patient close their eyes and run your finger gently on their forehead, cheeks, and chin. Check that they feel the same sensation on both sides.
CN 7: Facial
Check the patient can raise their eyebrows. Next, ask patient to close their eyes and resist you trying to open them.
CN 8: Vestibulocochlear
Have patient close their eyes and rub your fingers together near the side of their head. Insure the patient can hear the sound. Assess bilaterally.
CN 9/10: Glossopharyngeal/Vagus
These nerves are not assessed as part of the OSCE general education
Ask patient to open their mouth and stick out their tongue. Use a light source and tongue depressor and ask patient to say "Ah".
CN 11: Spinal Accessory
Trapezius muscle
Have patient shrug their shoulders. Ask patient to resist you pushing down on them.
Sternocleidomastoid (neck turn)
Have patient turn their head to one side. Ask patient to resist pushing their head the opposite directly. Repeat for other side.
CN 12: Hypoglossal
This nerve is not assessed as part of the OSCE general education
Have patient stick tongue out straight and move it from side to side. Ask patient to resist pressure to the side of their cheek with their tongue.
Sensory Assessment
Light touch
Lightly sweep the following locations and insure they feel the same bilaterally.
- Upper arms
- Distal portion of finger
- Upper legs
- Distal portion of big toe
Temperature
Using the tuning fork, touch the following locations and insure they feel the same bilaterally.
- Upper arms
- Distal portion of finger
- Upper legs
- Distal portion of big toe
Vibration
Strike the tuning fork and touch the stem to the distal interphalangeal joint of the pointer finger and the interphalangeal joint of the big toe. Insure they feel the same bilaterally.
Proprioception (feet only)
Isolate the joint and hold their toe. Lift it up and down and ask if they can feel the difference in direction. Ask patient to close their eyes and respond if you are moving the toe up and down.
Motor Assessment
Muscle bulk
Palpate their muscles in upper and lower extremities, checking for atrophy. Compliment gainz as necessary.
Muscle tone
Ask patient to relax arms and legs. Passively move the following joints:
- Shoulders
- Elbows
- Wrists
- Fingers
- Hips
- Knees
- Ankles
Muscle strength
Shoulder
Ask patient to raise arms to the side. Check abduction by asking patient to resist pressure down. Check adduction by asking patient to resist pressure up.
Elbow
Ask patient to raise arms to their front with elbows pointing out. Check flexion by asking to resist pulling motion. Check extension by asking to resist pushing motion.
Wrist
Ask patient to make a stop gesture with both arms. Check extension by asking to resist pushing hands down. Check flexion by asking to resist pushing hands up.
Hands
Ask patient to grab your fingers on both hands. Assess flexion by asking to resist pulling away.
Ask patient to spread their fingers apart. Assess abduction by resisting pushing each finger together.
Thumbs
Ask patient to hold their thumb to their pinky. Ask patient to resist pulling their thumb out. Check both sides.
Hip
Ask patient to raise their leg. Assess flexion by asking to resist pushing down. Check both sides.
Have them lower their leg. Assess extension by asking to resist pulling up. Check both sides.
Knee
Ask patient to straighten leg. Assess extension by asking to resist pushing down. Check both sides.
Have them lower their leg. Assess flexion by asking to resist pulling forward. Check both sides.
Ankle
Have patient point foot upwards. Assess dorsiflexion by asking to resist pushing down on the foot. Check both sides.
Have patient point their feet downwards. Assess plantarflexion by asking to resist pulling up. Check both sides.
Big toe
Have patient point their big toe upwards. Hold the big toe by the most proximal joint to the foot (metatarsophalangeal). Assess dorsiflexion by resisting pushing up. Check both sides.
Reflexes Assessment
Reflexes are assessed on a 4 point scale, with 0 being no response and 4 being normal. For each of the following locations, achieve a loose pendulum motion by holding the reflex hammer using the thumb and forefinger. Assess both bilaterally and symmetrically.
Biceps
Locate bicep tendon by placing thumb on location and rocking patients hand back and forth. Strike the thumb with pointy end of hammer.
Brachioradialis
Can be located by asking patient to roll their thumb around. Strike mid-forearm on radial side.
Triceps
Strike right above the elbow.
Patellar
Strike right below the kneecap.
Achilles
Dorsiflex foot before striking.
Plantar (Babinski)
Use side of hammer stem to stroke from the bottom lateral side of the foot in an arc towards the ball of the foot.
Cerebellum
Depth
Hold up your hand. Ask patient to take index finger and touch their nose and then your fingertips. Test both sides and all four quadrants. Allow for full arm extension.
Signal speed
Ask patient to take their hand and flip it back and forth as quickly as possible. Repeat for other side.
Ask patient to tap their foot on your hand as quickly as possible. Repeat for other side.
Leg accuracy
Ask patient to take their heel and place it on their opposite knee and slide it down their shin and back. Repeat for other side.
Gait
Ask patient to walk across the room and back. Ask them to do the same on their toes and then on their heels. Next, ask them to perform a tandem walk one foot in front of the other in a line.
Romberg
Ask patient to place feet together with hands to the side. Have them close their eyes for 10 seconds. Make sure you position yourself to catch them if they fall.