The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.



Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5



Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area




Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1


A patient presents with a stab wound to the neck. You examine the wound and see a 1 cm laceration. The patient reports no other symptoms. How can we best identify injuries?


Through the neck run longitudinal blood vessels, nerves, as well as organs of the respiratory and gastrointestinal systems. The mechanism is important – what is the direction of the wound tract?


Below is a template of a thorough examination of penetrating neck trauma, with more detail on pertinent items. This is based on the 1997 article by Demetriades et al.


Airway: No subcutaneous emphysema, hoarseness, or stridor, no bubbling from wound

Esophagus: No odynophagia, no pharyngeal blood, no hematemesis

Vascular: Normal pulses, no bruit, no hematoma, no active bleeding


Motor/Sensory/Reflexes normal

Cranial nerves:

II – pupils equally reactive (no Horner’s syndrome)


V – normal facial sensation

VII – symmetrical facial movements

IX – normal soft palate

X – no hoarseness/dysphonia, normal cough

XI – symmetrical shoulder lift

XII – tongue midline

Brachial plexus:

normal radial, ulnar, median function of hand

musculocutaneous – normal forearm flexion

axillary  – normal arm abduction



In penetrating neck trauma, evaluate the airway and esophagus, in addition to the vascular and neurologic functions.


An example of a comprehensive coma exam in a patient with psychogenic coma:



-description – lying supine, well-dressed

-breathing pattern – normal

-breath odor – normal

Head atraumatic normocephalic


-eyes midline and conjugate without deviation

-pupils 2mm, equally reactive

-eyes squint to bright light

-fundoscopy – unable to perform due to eye movement

-purposeful movements detected

Oropharynx – mucus membranes moist

Neck – no meningismus

Chest cta bilat

Heart rrr no mrg

Abd soft, nt, no om

Extremities – warm, no atrophy

Neurologic examination:

Mental status:

-level of consciousness – unreactive

-no receptive or expressive language


-muscle tone normal, not atonic, not increased

-not following motor commands


-withdraws to pain in all 4 extremities


-DTRs symmetrical

-Babinski down bilaterally

Cranial nerves:

II – visual threat – blinks. Eye squints to bright light.

III, IV, VI – does not track.  Oculocephalic reflexes reveal intact motor movements.

V – corneal reflex intact, nares tickling provokes grimace

VII – supraorbital nerve compression yields symmetrical facial grimace

VIII – voice stimulation in ear provokes flinch

IX/X – gag reflex intact

XI/XII – not possible to reliably examine


Motor: purposeful movement to pain

Verbal – no response

Eyes – closed

Coma tests:

Cold calorics reveal nystagmus with fast phase away from the ice



Extraocular movements: intact and painless

Visual fields: intact

Lids/Lacrim: nl, no edema

Conjunctivae/sclera: nl, no injection

Cornea: clear, no ulcers, no uptake of fluorescein

Anterior chamber: clear

Pupils: equally round, reactive to light, no direct or consensual photophobia. No afferent pupillary defect

Fundoscopy: intact red reflex, sharp disc

Intraocular pressure:


Here is an outline of the neonatal neurologic examination followed by a listing of some reflexes that might be of value in demonstrating intact neurologic function.





CN II – responds to light

CN III/IV/VI – vestibulo-ocular reflexes intact to cardinal directions of gaze

CN V – rooting reflex intact

CN VII – facial symmetry during crying

CN VIII – responds to sound

CN IX/X/XII – normal sucking

CN XI – sternocleidomastoid movement noted



Tone normal in all 4 extremities, no hypotonia, no hypertonia. Spontaneously moves all extremities.



Symmetrical reflexes knee, ankle, biceps, triceps



Responds to touch in all 4 limbs





Primitive reflexes can be used to evaluate motor function in the neonate.  These are listed below:


Fetal position – After 36 weeks the fetus assumes a flexed position.  If the neonate is moved to extension, it will pull back to flexion. This lessons with time and is most present the first 48 hours after birth


Pull to sitting -the child will spontaneously open the eyes when pulled to a sitting position (


Walking reflex – stand the baby up and he or she will exhibit a walking reflex


Rooting reflex – scratch the cheek and the baby will root for a nipple


Suckling reflex – front of tongue latches on finger/nipple, back of tingue massages it, pharynx/esophagus pulls on the finger.


Fencing reflex – turn head to the side, that arm extends and the opposite arm flexes above the head


Moro startle reflex – an abrupt drop causes the arms to outstretch and flex forward.


Swimmer’s (Gallant)- hold baby prone, stroke spine on one side, that side will flex


Crawling reflex – place baby prone, will try to crawl briefly.


Rotation test – hold baby up, rotate to one side, baby will turn head to that side


Movement Muscle Nerve Nerve root Remarks
Thumb flexion IP FPL (flexor pollicis longus) Median (AIN branch) C8, T1
Finger flexion DIP 2/3 FDP (flexor digitorum profundus) Median (AIN branch) C8 In forearm the FDP is superficial to the FDS
Finger flexion DIP 3/4/5 FDP (flexor digitorum profundus) Ulnar C8 Digits 3,4,5 FDP are banded together.  Flexion of one flexes all. Hold the rest of the digit in extension during the exam
PIP flexion FDS (flexor digitorum superficialis) Median C7 Because FDP of digits 3-5 are linked, can examine one FDS by holding the other digits in extension.
Finger abduction Dorsal interossei Ulnar T1
Finger adduction Palmar interossei Ulnar T1
Thumb adduction ADP (Adductor Pollicis) Ulnar C8 Froment’s sign (pt holds paper tight between thumb and index, absent ADP, the distal thumb will flex)
Thumb palmar abduction APB (Abductor pollicis brevis) Median C8/T1 Also serves opposition.  Affected by carpal tunnel syndrome
Thumb radial abduction APL (Abductor pollicis longus) Radial (Posterior IO) C6C7 Unites with extensor pollicis brevis to form radial side of snuffbox
MCP extension digit 1 (thumb) EPL (extensor pollicis longus) Radial nerve (posterior interosseus branch) C7 On ulnar side of snuff box. Place hand on table, have patient lift thumb up
MCP extension digit 2 EI (extensor indicis proprius) Radial (deep radial) C7
MCP extension digits 2-5 EDC (extensor digitorum communis) Radial (deep radial) C7
MCP extension digit 5 EDM (extensor digiti minimi) Radial (posterior IO branch of deep radial) C7





Palpation – “extremity warm”


Color – “healthy pink”


Pulses – radial pulse normal


Capillary refill < 2 seconds








FPL distal thumb flexion 5/5


ADP thumb apposition 5/5


APB palmar abduction 5/5


APL radial abduction 5/5


EPL thumb dorsal extension 5/5






FDP distal phalanx flexion 5/5


FDS proximal phalanx flexion 5/5 (with DIP and other digits in extension)






EIP extension of forefinger proximal phalanx 5/5


EDC extension proximal phalanx 5/5


EDM extension 5th digit proximal phalanx 5/5






IO finger adduction/abduction 5/5






FCU wrist ulnar deviation 5/5


FCR wrist radial deviation 5/5


PL intact to palpation


ECRB wrist extension 5/5


ECU ulnar deviation/extension 5/5






ulnar – volar tip 5th digit nl


median – volar tip 2nd digit nl


radial – dorsal 1st webspace nl





Having a structured, systematic approach to the neurological mental status examination can greatly improve our diagnostic acumen.  Because this examination is long and complex, it helps to have a template. Unlike the mini-mental status examination, this template is organized by functional anatomy.



    1. Arousal – alert (lethargy = drifts off, obtunded = difficult to arouse, stupor = requires constant vigorous stimulation, coma = unarousable.  If you can’t remember this, just document what stimulation is necessary for arousal)
    2. Attention – counts the months backward, spells globe backward (a problem with attention means delirium, assuming no dementia)
    3. Orientation – year, month, date, situation
    1. Frontal – no kinetic apraxia (test rock, paper, scissor), no disinhibition (naming Fs)
    2. Temporal
      1. Memory – 5 minute recall (note whether memory jogging required)
      2. Language – Naming items nl, receptive and expressive language nl (can test visual comprehension with reading aloud).  Test writing if you are unclear on aphasia vrs dysarthria.
    3. Parietal
      1. Constructional praxis – nl copy of cube, nl clock drawing
      2. Right inferior parietal lobe (+/- left): Double simultaneous stimulation – can check visual, tactile
      3. Left parietal: math (subtracting 7 from 100 serially)



References: Strub and Black’s The Mental Status Examination in Neurology


Here is a template that helps one document encounters with psychiatric overtones.  I included pertinent negatives that help prompt one to use the right terms.  These can be deleted during actual encounters.  Although I hear many express less enthusiasm for psychiatric emergencies, I believe that being able to systematically assess a patient’s psychiatric state goes a long way toward understanding the difficult patient encounter.


Arousal: Alert

Attentiveness: fully attentive

Appearance: well-dressed and well-groomed

Attitude: cooperative, not guarded

Activity: calm, not restless, no abnormal movements, good eye contact

Orientation: Fully oriented

Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry

Affect: normal range, not restricted, flat, or labile

Verbal: nl expressive and receptive language function

Thought process: organized, goal-directed. Pt did not require redirection.

Thought content: no delusions, no suicidal/homicidal ideation

Perceptions: not responding to internal stimuli

Insight/Judgment: good insight, judgment appears to be good



References for this include Trzepacz’ excellent textbook, The Psychiatric Mental Status Examination.

NEURO EXAM TEMPLATE – comprehensive

Neuro template

Here is a neurological examination template with parenthetical explanations. This can be a helpful reminder.

Mental status:

General: alert, attentive, affect nl

Memory: nl repitition, short-term recall, remote memory (3 presidents)

Language: receptive and expressive language intact

Visuospatial: normal clock-drawing


Shoulder abduction (C5 – deltoid/supraspinatus) 5/5

Shoulder adduction 5/5

Elbow flexion (C5/C6 -biceps brachii – musculocutaneous nerve) 5/5

Elbow extension (C7 -triceps -radial nerve)  5/5

Wrist flexion (C7 – FCR/FCU – median/ulnar) 5/5

Wrist extension (C6 – ECR/ECU – radial nerve) 5/5

Finger adduction (T1-interossei-ulnar) 5/5

Thumb radial abduction (C7 – APL – radial nerve) 5/5

Thumb opposition (C8/T1 -opponens pollicis – median nerve) 5/5

Hip flexion (L1/L2 – iliopsoas muscle) 5/5

Hip extension (L5/S1 – gluteus maximus muscle) 5/5

Knee flexion (L5/S1 -hamstrings -sciatic nerve) 5/5

Knee extension (L3/L4 -quadriceps femoris muscle -femoral nerve) 5/5

Ankle dorsiflexion (L4/L5 -tibialis anterior muscle -deep peroneal nerve) 5/5

Ankle plantarflexion (S1 – gastrocnemius muscle -tibial nerve) 5/5

Ankle eversion (L5/S1 -peroneus longus/brevis – superficial peroneal nerve) 5/5

Ankle inversion (L4/L5 -tibialis posterior muscle – tibial nerve) 5/5

Extensor hallucis longus (L4/L5 – EHL/EDLs – deep peroneal nerve) 5/5

Flexor hallucis longus (S1 – FHL, FDLs – tibial nerve)  5/5


Lateral spinothalamic – pinprick, temperature nl

Dorsal columns – proprioception nl

Cortical – graphesthesia nl, proprioception nl


Biceps, triceps, brachioradialis, patellar, achilles nl and symmetric

Babinski nl

Cranial nerves:

ii – vision intact

iii,iv, vi – eomi

v – facial sensation symmetrical

vii – facial movement symmetrical

viii – audition intact

ix/x – oropharyngeal motor function nl

xi – shoulder shrug symmetrical

xii – tongue motor function nl


gait normal

finger to nose testing nl

heel to shin testing nl