5 stations / 86 steps/ 14 script lines
Neurological examination
The longest exam in the book, cut into the order you perform it. The cranial nerve map and the myotome cards below carry the same content as the checklists, one nerve or one muscle at a time.
0 of 86 steps
0/3Headache
- Onset“Does it come on suddenly and reach maximum intensity within seconds?”Sudden severe headache suggests intracranial hemorrhage.Early morning headache suggests a space-occupying lesion.
- Location, triggers, provoking and relieving factors, quality (throbbing, stabbing, tight band, steady pressure), auras (flashing lights, zig-zag lines, scotoma), severity, frequency, timing.
- Neurological symptoms: diplopia, dizziness, gait imbalance, tingling, numbness, weakness.
0/2Loss of consciousness
- Syncope is a transient global fall in cerebral perfusion, vasovagal (common) or cardiogenic; premonitory darkening of vision, seeing stars, light-headedness.Unlike a seizure: no post-ictal lethargy or confusion, no epileptic aura such as a rising epigastric sensation.Vasovagal syncope almost always happens upright; a faint while lying flat points to the heart.
- Ask about body position before the episode, collateral observations (jerks, tongue biting, incontinence), duration, awareness, timing.
0/6Aphasia and dysarthria
- Dysarthria is impaired articulation with language spared: nasal or slurred speech from the muscles, their nerves, or the junction.
- Aphasia is a disturbance of language, with high localizing value to the dominant hemisphere or a left middle cerebral artery stroke; classify by fluency, comprehension, repetition and naming.Motor (Broca): slow, laborious, non-fluent, nouns and verbs only, comprehension spared.Sensory (Wernicke): fluent but empty or out of context, poor comprehension.Paraphasic errors: semantic (similar meaning) or phonemic (similar sound).
- Spontaneous speech“Can you tell me what brings you to the hospital?”
- Comprehension“Can you point to the floor? Can you point to the entrance of this room? Can you take this paper with your right hand, fold it in half, and place it on the floor?”
- Repetition“Can you repeat the phrase: no ifs, ands, or buts? Can you repeat: the Prime Minister lives in Ottawa?”
- Naming“Can you name this object? And this part of it?”
0/2Weakness and tremor
- Proximal weakness: combing hair, brushing teeth, rising from a chair, reaching overhead. Distal: opening jars, using tools, picking up small objects, tripping on the toes.Sudden unilateral weakness with slurred speech: central (stroke).Bilateral proximal: myopathy.Bilateral distal with numbness and tingling: peripheral neuropathy.Asymmetric progressive wasting with bulbar symptoms and no sensory loss: anterior horn cell disease.Fatigable, fluctuating weakness: neuromuscular junction.
- Tremor: rest versus action; ask about thyroid, liver, kidney disease, caffeine, alcohol, medications (beta-agonists, lithium, amphetamines).Rest tremor, unilateral, pill-rolling 4 to 7 Hz that fades with movement: Parkinson disease.Action tremor: postural (holding a posture) or kinetic (a task). Intention tremor worsens approaching the target, often perpendicular to the movement: cerebellar.
0/3Dizziness, numbness, ataxia
- Dizziness“What do you mean by dizzy: spinning, feeling faint, or unsteady on your feet?”Vertigo is an illusion of movement, commonly peripheral. Ask about nausea, hearing change, tinnitus, ear fullness, chest pain, palpitations, slurred speech, facial weakness, ataxia, diplopia.
- Numbness: dermatomal or peripheral distribution, unilateral or bilateral, sudden or gradual, constant or intermittent, spreading, face or trunk involved.Paresthesia is pins and needles; dysesthesia is unpleasant paresthesia; allodynia is pain from a non-noxious stimulus; hyperalgesia is heightened pain.Perioral and hand paresthesia for minutes suggests hyperventilation.
- Ataxia: incoordination not due to weakness; cerebellar or sensory (posterior column or polyneuropathy). Ask about tasks (writing, feeding), drugs, alcohol, falling consistently to one side.Sensory ataxia is worse in the dark, comes with sensory symptoms, and the patient watches their limbs.
0/2Memory loss
- Dementia is impairment in two or more cognitive domains severe enough to impair daily function; often brought by loved ones; the patient may minimize.
- Listen for attention and recall as they tell the story“You mentioned difficulties with your memory. Can you give me some specific examples? What is today's date? What did you have for dinner last night? Do you have trouble following a conversation or the plot of a show? Have you ever got lost in familiar places?”
18 steps left in this station.
Cranial nerve map
I to XII, one at a time
CN I Olfactory
Smell.
How to test
- 1A non-irritating recognizable scent, one nostril occluded, eyes closed; repeat on the other side.
Finding and lesion
- Unilateral anosmiaOlfactory bulb or tract lesion, deviated septum, blocked nasal passage
- Bilateral anosmiaCribriform plate damage, rhinitis, heavy smoking, cocaine, Parkinson disease
Power, proximal to distal
Say the instruction, then check the roots
- 1
Deltoid
shoulder abduction
- 2
Biceps
elbow flexion, forearm supinated
- 3
Triceps
elbow extension
- 4
Flexor carpi radialis
wrist flexion
- 5
Extensor carpi radialis
wrist extension
- 6
Finger flexors
finger flexion
- 7
Extensor digitorum communis
finger extension
- 8
Abductor pollicis brevis
thumb abduction
- 9
Extensor pollicis longus
thumb extension
- 10
Adductor pollicis
thumb adduction
- 11
First dorsal interosseous
index finger abduction
Reflexes and roots
- Biceps (C5, C6): Thumb over the tendon in the cubital fossa; strike the thumb.
- Brachioradialis (C5, C6): Fingers over the tendon at the distal dorsolateral forearm; strike the fingers.
- Triceps (C7, C8): Support the arm, everything relaxed; strike the tendon just proximal to the elbow.
- Finger flexors (C7, C8): Your fingers against their curled fingers; strike your own fingers.
- Patellar (L3, L4): Legs hanging free, or supine with your arm under the knees; strike the patellar tendon.
- Ankle (S1, S2): Slightly dorsiflex the foot; strike the Achilles tendon; kneeling on a chair helps.
MRC power scale
- 0No contraction
- 1Flicker or trace of contraction
- 2Active movement with gravity eliminated
- 3Active movement against gravity
- 4Active movement against gravity and resistance (4-, 4, 4+ for slight, moderate, strong)
- 5Normal power
Reflex grades
- 0Absent
- 1+Hypoactive
- 2+Normal
- 3+Hyperactive without clonus
- 4+Hyperactive with clonus
The headache
Ten headaches by character and timing, the features that travel with them, and what the examination and the first action look like.
| Row | Character and timing | Associated features | Examination and action |
|---|---|---|---|
| Migraine | Unilateral throbbing pain building over hours, lasting 4 to 72 hours, worse with activity; recurrent since the teens; triggers such as poor sleep, missed meals, menses, alcohol | Nausea, sensitivity to light and sound; an aura of shimmering lights or spreading numbness before the pain in a third | Normal examination; treat the attack early with a triptan, an anti-inflammatory and an antiemetic, and prevent when attacks are frequent |
| Tension-type | Bilateral pressing or tight band, mild to moderate, not worsened by routine activity, lasting hours to days; the commonest headache | No vomiting and at most one of light or sound sensitivity; stress, poor sleep, neck tightness | Pericranial tenderness only; simple analgesia on fewer than 10 days a month, and attention to sleep, stress and posture |
| Cluster | Excruciating strictly unilateral pain around one eye, 15 to 180 minutes, once to several times a day in bouts of weeks, often waking at the same time each night; mostly men who smoke | Same-side red watery eye, blocked or running nostril, drooping lid and small pupil; restless and pacing, unlike the still migraineur | High-flow oxygen and subcutaneous sumatriptan for the attack, verapamil to prevent |
| Medication overuse | A daily or near-daily dull headache in someone with a prior migraine or tension pattern who takes simple analgesics on 15 or more days a month, or triptans, opioids or combination products on 10 or more | Present on waking, briefly eased by the next dose; low mood, poor sleep | Normal examination; withdraw the overused drug and start a preventive; warn that it gets worse before it gets better |
| Subarachnoid hemorrhage | Thunderclap headache reaching maximal intensity within a minute, often with exertion or sex, 'the worst of my life'; sometimes a sentinel headache days before | Vomiting, neck stiffness, transient loss of consciousness, photophobia, a seizure | Meningism, sometimes a third nerve palsy or focal signs; non-contrast CT within 6 hours of onset, lumbar puncture for xanthochromia if the CT is negative later |
| Giant cell arteritis | A new headache over the temple in someone over 50, constant, worse at night; scalp tender when combing hair; the jaw tires when chewing | Transient visual loss or blurring, shoulder and hip girdle stiffness, weight loss, fever, sweats | A tender, thickened, pulseless temporal artery; ESR and CRP raised; high-dose steroids the same day and a temporal artery biopsy within two weeks |
| Raised intracranial pressure | A progressive headache over weeks, worse in the morning and on lying flat, coughing, straining or bending | Vomiting, drowsiness, new seizures, personality change, a focal deficit, visual obscurations | Papilledema, a sixth nerve palsy as a false localizing sign, focal signs; urgent imaging, and no lumbar puncture until a mass is excluded |
| Meningitis | Hours to a day of severe generalized headache with fever, at any age; rapid deterioration in the young and the immunosuppressed | Neck stiffness, photophobia, vomiting, drowsiness; a non-blanching rash with meningococcus | Fever and meningism (Kernig, Brudzinski), altered consciousness; blood cultures and antibiotics without delay, CT before lumbar puncture only for signs of raised pressure or focal deficits |
| Idiopathic intracranial hypertension | A daily headache in a young woman with obesity, worse on waking and with straining; recent weight gain or a new drug (tetracyclines, isotretinoin, vitamin A) | Pulsatile tinnitus, transient visual obscurations, double vision | Papilledema with normal imaging and a raised opening pressure on lumbar puncture; weight loss and acetazolamide, and the vision is protected above all |
| Trigeminal neuralgia | Seconds-long stabs of electric pain in one division of the face, many times a day, triggered by chewing, talking, washing or a breeze | Pain free between attacks, a refractory period after each, a trigger zone on the face | Normal examination (sensory loss or bilateral pain suggests a secondary cause and needs MRI); carbamazepine first line |
Types of aphasia
Fluency, comprehension, repetition, naming.
| Row | Fluency | Comprehension | Repetition | Naming |
|---|---|---|---|---|
| Broca | Impaired | Intact | Impaired | Impaired |
| Transcortical motor | Impaired | Intact | Intact | Impaired |
| Wernicke | Intact | Impaired | Impaired | Impaired |
| Transcortical sensory | Intact | Impaired | Intact | Impaired |
| Global | Impaired | Impaired | Impaired | Impaired |
| Transcortical mixed | Impaired | Impaired | Intact | Impaired |
| Conduction | Intact | Intact | Impaired | Impaired |
| Anomic | Intact | Intact | Intact | Impaired |
Abnormal gaits
| Row | Description |
|---|---|
| Spastic | Affected leg extended at hip, knee and ankle, foot dragging and toes scraping, circumduction from the hip; arm adducted and flexed at elbow, wrist and fingers. |
| Cerebellar ataxic | Wide-based stance and gait, staggering, cannot tandem walk; scanning dysarthria, dysmetria, dysdiadochokinesia. |
| Parkinsonian | Stooped, slow, shuffling with short strides and reduced arm swing; rest tremor visible; hesitancy, festination, en bloc turns. |
| Sensory ataxic | High steppage gait, feet thrown out and slapping down heel first, watching the feet; Romberg positive. |
Patterns of weakness
| Row | Likely localization |
|---|---|
| Sudden unilateral limb weakness with slurred speech | Central, for example stroke |
| Bilateral proximal weakness | Myopathy |
| Bilateral distal weakness with numbness and tingling | Peripheral neuropathy |
| Asymmetric progressive weakness and wasting with bulbar symptoms, no sensory loss | Anterior horn cell disease |
| Fluctuating, fatigable weakness | Neuromuscular junction disorder |
Eye movement and pupil findings
| Row | Lesion |
|---|---|
| Eye down and out with ptosis and a dilated pupil | CN III with pupil involvement, typically compressive |
| Ptosis and down-and-out eye, pupil spared | CN III sparing the pupil, typically ischemic |
| Ptosis, miosis, anhidrosis | Horner syndrome, ipsilateral sympathetic pathway |
| Difficulty looking down and in, contralateral head tilt | CN IV palsy |
| Difficulty looking laterally | CN VI palsy |
| Ipsilateral adduction failure with nystagmus of the abducting eye | Internuclear ophthalmoplegia, medial longitudinal fasciculus |
Rinne and Weber
| Row | Rinne (affected ear) | Weber |
|---|---|---|
| Normal | Air conduction louder than bone | No lateralization |
| Conductive loss (otitis media) | Bone conduction louder than air | Lateralizes to the affected ear |
| Sensorineural loss (CN VIII lesion) | Air louder than bone (normal) | Lateralizes to the unaffected ear |
Recall quiz
Which cranial nerve?
A finding is described; name the nerve it implicates.
Score 0 / 12Streak 0
Shuffling the deck...
Demonstration videos are embedded from their creators’ own YouTube channels (Geeky Medics and Stanford Medicine 25) and remain theirs; each frame credits the channel and links out to it.