What is the typical order of a neurological examination?

Order of Neurological Examination

The neurological examination should follow a systematic sequence: (1) level of consciousness assessment, (2) cranial nerve examination, (3) motor function testing, (4) sensory function evaluation, (5) coordination and cerebellar testing, and (6) reflex assessment. 1

1. Level of Consciousness Assessment (First)

Begin by evaluating the patient's alertness and orientation, as this establishes baseline mental status and determines the patient's ability to cooperate with subsequent testing 1:

• Assess alertness using the Glasgow Coma Scale components: eye opening, verbal response, and motor response 1
• Evaluate orientation by asking about person, place, and time 1
• Test ability to follow commands by asking the patient to open/close eyes and grip/release hand 1
• Document standardized scores such as the Glasgow Coma Scale for trauma patients or altered consciousness 1

This initial assessment is critical because it determines how reliably you can interpret all subsequent examination findings 2.

2. Cranial Nerve Assessment (Second)

After establishing consciousness level, systematically test all 12 cranial nerves 1:

• CN I: Assess smell (optional in routine examination) 1
• CN II: Check visual acuity and visual fields using confrontation testing 1
• CN III, IV, VI: Evaluate pupillary size, reactivity, and eye movements 1
• CN V: Test facial sensation in all three divisions and jaw strength 1
• CN VII: Assess facial symmetry and movement 1
• CN VIII: Evaluate hearing 1
• CN IX, X: Test gag reflex and palatal elevation 2
• CN XI: Assess shoulder shrug and head turning 2
• CN XII: Evaluate tongue protrusion and movement 2

The cranial nerve examination is performed early because it requires patient cooperation and provides critical information about brainstem function 2.

3. Motor Function Assessment (Third)

Motor testing follows cranial nerves and includes both strength and tone evaluation 1:

• Test for pronator drift: Have patients extend arms at 90° (seated) or 45° (supine) for 10 seconds 1
• Assess leg strength: Ask patients to raise legs 30° and hold for 5 seconds 1
• Evaluate strength in major muscle groups using the 0-5 scale 1
• Assess muscle tone through passive range of motion 1
• Check for abnormal movements such as tremor, myoclonus, or asterixis 1

Motor examination is positioned here because it requires active patient participation and builds upon the mental status assessment 1.

4. Sensory Function Assessment (Fourth)

Sensory testing is performed after motor examination because it is more subjective and requires sustained patient attention 1:

• Test light touch in all extremities 1
• Assess pain/temperature sensation using pinprick 1
• Evaluate vibration using a tuning fork 1
• Test proprioception (joint position sense) 1
• Compare symmetry between sides throughout 1

Sensory examination comes later in the sequence because it is the most subjective component and patients may fatigue during prolonged testing 3.

5. Coordination and Cerebellar Function (Fifth)

Cerebellar testing requires the patient to have adequate strength and sensory function already documented 1:

• Test finger-to-nose movements to detect ataxia 1
• Assess heel-to-shin movements 1
• Evaluate rapid alternating movements 1
• Test gait and balance if the patient is able to stand and walk 1

This component is performed near the end because it integrates multiple neurological systems and requires the patient to be mobile 1.

6. Reflex Testing (Last)

Reflexes are tested last because they are objective findings that do not require patient cooperation 1:

• Check deep tendon reflexes: biceps, triceps, brachioradialis, patellar, Achilles 1
• Test for pathological reflexes including Babinski sign 1
• Grade reflexes using the standard 0-4+ scale 2

Reflex testing concludes the examination because it provides objective data even in uncooperative or obtunded patients 1.

Special Considerations for Specific Contexts

In acute stroke settings, use the NIH Stroke Scale (NIHSS) as the standardized assessment tool, which follows a similar but abbreviated sequence focusing on consciousness, visual fields, gaze, motor function, sensation, speech, and language 2, 1.

In critically ill patients, perform more frequent assessments every 1-4 hours based on acute brain injury risk 2. Serial examinations should occur at 6,24, and 72 hours after admission 4.

In patients on sedation or paralytics, focus on brainstem reflexes (pupillary light response, oculocephalic, corneal, and cough/gag reflexes) since motor and sensory testing will be unreliable 2.

Common Pitfalls to Avoid

• Never perform incomplete motor testing – always assess both sides for comparison 1
• Account for systemic factors that may affect neurological status, including hypotension, hypoxemia, medications (especially sedatives), and metabolic derangements 1, 4
• Recognize that initial examinations may be unreliable due to patient factors such as uncooperativeness, intoxication, or cognitive impairment 1
• Always repeat examinations to detect neurological deterioration, as a single assessment provides limited information 1
• Document baseline status before any intervention (such as ECMO cannulation) and perform serial evaluations throughout treatment 2