The 5-Minute Neurological Exam: A Cheat Sheet for Med Students

CLINICAL SKILLS • NEUROLOGY • EXAM GUIDE

Neurology is often feared because it seems complex. But a bedside neurological exam is simply a series of logical steps designed to localize the lesion. Master this systematic approach to impress your attendings and ace your OSCEs.

Before you touch the patient, observe. Are they awake? Are they moving all four limbs? Is their speech fluent? This initial "eyeball" test gives you 50% of the diagnosis before you even pull out your reflex hammer. Below is the structured framework you need.

1. Mental Status & Higher Functions

You don't need a full MMSE for every patient. Focus on the "A and O" and speech.

Quick Assessment Targets:

• Alertness: Is the patient awake?
• Orientation (x3): Person, Place, and Time.
• Speech: Is it fluent? Is comprehension intact? (Distinguish between Broca’s and Wernicke’s aphasia).

2. The Cranial Nerves (CN II-XII)

This is the most intimidating part for students. Break it down by function rather than memorizing the numbers in order.

Visual Pathway (CN II)

• Check Visual Acuity (near card).
• Visual Fields (confrontation test).
• Fundoscopy (papilledema?).

Eye Movements (CN III, IV, VI)

• Follow my finger (H-pattern).
• Look for Nystagmus.
• Check Pupils (PERRLA).

Face & Mouth (CN V, VII, XII)

• Sensory face (light touch).
• Smile/Frown (upper vs lower face).
• Stick out tongue (deviation?).

3. Motor and Sensory Exam

Localizing the lesion relies on comparing the left side to the right side. Look for asymmetry.

Motor System Key Points:

• Tone: Spasticity (upper motor neuron) vs Flaccidity (lower motor neuron).
• Power: Use the Medical Research Council (MRC) scale 0-5.
• Reflexes: Biceps, Triceps, Knee, Ankle. Grade 0-4.

Sensory System Key Points:

• Light touch (cotton wool).
• Pain (pin prick).
• Vibration and Proprioception (Dorsal columns).

4. Coordination (Cerebellar Function)

Cerebellar lesions cause clumsiness. Use these three bedside tests to uncover ataxia.

1. Finger-to-Nose Test: Look for intention tremor and dysmetria.
2. Heel-to-Shin Test: The patient slides their heel down their opposite shin. Look for ataxia.
3. Romberg Test: Ask patient to stand with feet together, eyes closed. Positive Romberg = loss of proprioception (dorsal columns).

Clinical Pearl for Exams

When presented with a neurological case, always localize the lesion first. Is it UMN or LMN? Is it Cortical, Subcortical, Spinal, or Peripheral? Once you localize the anatomy, the differential diagnosis becomes manageable.

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