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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Neurologic exam.

Mahsa Shahrokhi ; Ria Monica D. Asuncion .

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Last Update: January 16, 2023 .

• Definition/Introduction

The neurological examination is an assessment tool to determine a patient's neurologic function. It is beneficial in a variety of ways as it allows the localization of neurologic diseases and helps in ruling in or ruling out differential diagnoses. Neurological diseases can present a myriad of ways, including cognitive/behavioral, visual, motor, and sensory symptoms. Certain red flags during examination allow early detection of life-threatening neurologic diseases and recognize disorders that may negatively impact the quality of life. [1]

The neurologic examination is useful in both ambulatory and emergency settings. It provides the physician a tool to recognize neurologic involvement in certain disease states, and thereby allow proper work-up and treatment for these patients. It is also beneficial in intensive care units, particularly in monitoring neurologic sequelae of diseases like strokes, intracranial tumors, and traumatic brain injury. [2] [3]  In emergent settings, rapid assessment of the severity of an injury and neurologic involvement is crucial and leads to fast decision-making in patient management, as well as improvement of patient survival rates. [4]

• Issues of Concern

The neurological exam can be intimidating and challenging to perform for most physicians. It is particularly challenging to perform in certain age groups like infants, younger children, and older uncooperative adults. [5]  In the examination of a pediatric patient, proper diagnoses begin with understanding which specific age groups are prone to developing certain disease processes. It is also important to keep in mind that the manifestation of certain neurologic illnesses can be vastly different in children and adults.

The assessment of how a patient feels about their symptoms can provide a better insight into their quality of life. [6]  

Physicians encounter an extensive range of patients with different illnesses daily. These can range from relatively benign to life-threatening conditions. This range of potentials highlights the importance of a physician's ability to recognize red flags early on in the disease processes. These red flags are picked up in history or during a neurological examination. A good example would be a patient who presents with chronic headaches, which can be a benign condition like migraine or life-threatening like a tumor. The presence of nausea and vomiting in the patient's history may still be present in migraines or may be a sign of increased intracranial pressure. An abnormal neurological examination can then direct the physician to the diagnosis (e.g., ataxic gait in this patient points to a cerebellar lesion). The physician can then refer the patient for appropriate diagnostic imaging and direct the management. [7]  

Recognizing red flags can be challenging for physicians, particularly when it comes to neurologically related disorders. The complexity of the neurologic examination, the interpretation of results, and the correlation to the neuroaxis are often challenging. This fact highlights the need for increased awareness of what constitutes a proper neurological examination and what each specific finding suggests. It is also important to note that some positive results, especially in isolation, can be a normal variant.

A neurological examination should also be tailored and focused on specific disease presentations. Certain maneuvers can be incorporated to increase the sensitivity of an exam for a certain symptom; an elderly patient with memory deficits will require a more in-depth cognitive assessment than a young patient with ptosis.

• Clinical Significance

A basic neurologic examination can be performed rapidly with practice. The presence of an abnormal result usually warrants further investigation and referrals to specific specialties. It helps to recognize and therefore manage diseases earlier in their course. A complete neurologic examination should contain an assessment of sensorium, cognition, cranial nerves, motor, sensory, cerebellar, gait, reflexes, meningeal irritation, and long tract signs. Specific scales are useful to improve interobserver variability.

Glasgow Coma Scale

The Glasgow coma scale (GCS) is a standard to determine the level of awareness in trauma or critically ill patients who present with impaired consciousness. It is a 15 point scale that gives a general idea of the extent of brain injury. [12] The GCS is divided and scored according to eye-opening, verbal response, and motor response. The eye-opening response is scored as spontaneous – 4, opens to verbal command – 3, opens to pain – 2, and no response – 1. The verbal response is scored as oriented – 5, confused – 4, inappropriate responses – 3, incomprehensible sounds – 2, and no response – 1. The motor response is scored as obeys commands – 6, spontaneous movement or localizes to painful stimuli – 5, withdrawal from pain – 4, abnormal flexion (decorticate) – 3, abnormal extension (decerebrate) – 2, and no response – 1. The scores are added and classified as follows: Minor brain injury – 13 to 15 points, moderate brain injury- 9 to 12 points, and severe brain injury- 3 to 8 points. [8]

Mental Status

The mental status examination begins during the interview. Assessment of the patient's cognitive abilities such as language usage, chronology in the recollection of events, and significance of answers will give a clinician a general feel of the patient's condition. A quick mental status exam may involve asking for orientation to time, place, and person. A healthy patient is recognized to be "awake," "alert" (responding appropriately), and "oriented" (aware of self, place, and time). If disorientation or memory lapses (especially in the elderly) are present, a mini-mental status examination can be done. This will assess further the patient's orientation, registration, attention, recall, language, repetition, complex commands, and visuospatial function. Any abnormality in a specific function may warrant further investigation that is not covered by this article. Abnormalities in these areas can point to lesions in specific areas of the cortex (e.g., difficulty in repetition may involve the arcuate fasciculus of the dominant hemisphere—the pathway between Wernicke's area and Broca's area). Mood and affect also require assessment. [9]

Cranial Nerves 

The cranial nerves innervate the structures in the head and neck. The olfactory nerve and optic nerve exit from the cerebrum. The cranial nerves 3 to 12 exit from the brainstem. Abnormality in cranial nerve function helps in localizing the lesion to a specific level of the brain or brainstem. Cranial nerves have motor, sensory and autonomic functions. It is important to note that, in general, a singular cranial nerve deficit points to a lesion of the peripheral nerve. A lesion in the brainstem, being a busy structure, will involve multiple cranial nerve deficits, as well as motor and sensory tracts to the extremities.

Olfactory nerve (Cranial nerve I) - This is the least tested of cranial nerves in the clinical setting. To test function involves the assessment of the patient's sense of smell. Start with one nostril while covering the opposing nostril to allow for proper detection of any abnormal findings. Do this for both sides. The most common causes of anosmia, the loss of smell, are the following: infections, allergies, or nasal polyps. Other causes include trauma (fracture of the cribriform plate), Parkinson disease, lesions at the base of the skull (meningioma), or rare genetic conditions. [10]

Optic nerve (Cranial nerve II) – Assessment of the optic nerve function includes a test for visual acuity and visual fields. Each eye is tested separately. Most problems with visual acuity are ophthalmologic in origin; however, damage to this nerve, like pseudobulbar neuritis or pressure from a pituitary tumor, can present with monocular blindness and visual field cuts. The extent of involvement will depend on what they can see during the examination as compared to the baseline. [11] Furthermore, the pupillary light reflex can be tested by shining a light directly into the eye. The afferent limb of this reflex is found on the optic nerve; the sensory input. Shining a light on one eye should show a constriction of the pupils on both eyes. The failure of the pupils to constrict could indicate either an optic nerve lesion, a lesion of the efferent limb (oculomotor nerve), or any lesion along the pathway. A dilated pupil that is unresponsive to light may indicate a lesion on the efferent limb of the pathway, while a constricted pupil can point to a lesion on the cervical sympathetic chain. A fundoscopic examination is also done to visualize the optic disk. Abnormalities like papilledema or retinal hemorrhages are red flags that can point to life-threatening conditions like increased intracranial pressure and subarachnoid hemorrhage. [12]

Oculomotor, trochlear, and abducens nerves (Cranial nerve III, IV, and VI)  are the nerves for extraocular muscle movement. Assessment involves drawing an invisible "H" in front of the patient and asking the patient to follow with their eyes. Abnormal findings present as disconjugate gaze or double vision. The involvement of the third cranial nerve by compression (aneurysm of the posterior communicating artery) leads to dilated pupil, ptosis, and eyes looking outward and downward. Lateral rectus palsy is due to the involvement of the sixth cranial nerve; it can be a false localizing sign in increased intracranial pressure (bilateral lateral rectus palsy). The involvement of the pathways in the brainstem (e.g., lacunar infarct, multiple sclerosis) can lead to internuclear ophthalmoplegia. This condition occurs when the medial longitudinal fasciculus (MLF), a heavily myelinated pathway that allows for coordinated horizontal gaze, is damaged. [13]

Trigeminal nerve (Cranial nerve V)   – this nerve supplies the sensation to the face, the motor nucleus is responsible for biting and chewing. Assessment of this nerve involves asking the patient to clench their jaw and test for the sensation of the ophthalmic, maxillary, and mandibular branches. Therefore, a weakness of the muscle of mastication or sensory deficit on the ipsilateral side suggests its involvement. This is also the afferent pathway for the blink reflex (the efferent pathway being the facial nerve). A corneal reflex is usually performed in comatose patients to assess brainstem function. An absence in an awake patient may point to a localized lesion affecting either the trigeminal nerve the facial nerve or both. [14]

The facial nerve (Cranial nerve VII) supplies the muscles of facial expression, stapedius muscle, and taste to the anterior two- of the tongue. Assessment of this nerve involves asking the patient to move their facial muscles by asking them to raise their eyebrows, close their eyes tightly, smile, and blow up their cheeks. The location of weakness in facial muscles can differentiate between peripheral or central involvement. A weakness with the movement of the entire right side of the face is indicative of either a peripheral lesion or damage to the facial nucleus on the ipsilateral side, like in Bell's palsy or a pontine infarct. A weakness of the lower half of the face with sparing of the forehead is suggestive of a lesion above and contralateral to the facial nerve (stroke involving the motor cortex). This is because the forehead has innervation from both the left and right sides of the motor cortex.  [15] Damage to the facial nerve can also present with hyperacusis and loss of taste to the anterior 2/3 of the tongue.

The vestibulocochlear nerve (Cranial nerve VIII) supplies functions in hearing and equilibrium. Gross assessment of function can be done by whispering words behind the patient, rubbing fingers or hair together close to the ear, and asking if the patient can hear. If a hearing deficit is established, doing a Weber and Rinne test can differentiate sensorineural from conductive hearing loss. A normal Rinne exam will exhibit air conduction (AC) greater than bone conduction (BC). A conductive hearing loss will show BC greater than AC. In patients with sensorineural hearing loss, AC will be greater than BC, but for a shorter duration when compared to a normal subject. A normal Weber test shows hearing the sound/vibration equally in both ears. A conductive hearing loss will lateralize the sound to the abnormal ear while a sensorineural hearing loss will lateralize to the normal ear. [16]

The glossopharyngeal and vagus nerves (Cranial nerve IX and X) innervate the pharynx and posterior third of the tongue. The vagus nerve innervates the pharynx, larynx, and gastrointestinal tract motility and function. Assessment of these nerves includes listening as the patient talks, watching out for hoarseness, or nasal speech. The patient can also be asked to swallow some water and observed for coughing or gurgling speech, which may indicate weakness of the muscles involving swallowing. Ask the patient to open the mouth and say "ah," and observe the palatal arch for asymmetry. The deviation of the uvula to one side indicates a vagal nerve lesion on the opposite side. [17]

The spinal accessory nerve (Cranial nerve XI) innervates the muscles of the thorax, back, and shoulders. Assessment involves asking the patient to turn their head to the side against resistance and shrug their shoulders. The weakness of the sternocleidomastoid or atrophy of the trapezius muscle may indicate involvement. [18]

The hypoglossal nerve (Cranial nerve XII) innervates the motor component of the tongue. Assessment involves inspection of the tongue in the relaxed position inside the mouth, the presence of increased corrugation and fasciculations may indicate a lower motor neuron involvement. Also, ask the patient to stick out the tongue, the deviation to one side is indicative of a lesion on the same side. [19]

The inspection of the muscles is the first step in doing the motor examination. Any visible scars, deformities, fasciculations, and asymmetry (swelling or atrophy) should be noted. This is followed by palpation to assess for mass lesions or tenderness if present.

The range of motion (ROM) is used to assess tone and helps localize injury or disease to the joints or muscles. On doing the passive ROM, the physician check's for flaccidity, spasticity, and rigidity. The active ROM can give a clue to strength and pain-related causes of decreased range. The presence of spasticity or flaccidity can help differentiate an upper motor neuron from a lower motor neuron cause of weakness, while the presence of cogwheel rigidity points to a specific disease like Parkinsonism. [20]

Finally, the assessment of muscle strength is done. The manual muscle testing is scored as follows: [21] [22] 0 - None: No visible or palpable contraction, 1 - Trace: Visible or palpable contraction (only slight), 2 - Poor:  Full ROM with gravity eliminated, 3 - Fair: Full ROM against gravity, 4 - Good: Full ROM against gravity with moderate resistance, and 5 - Normal: Full ROM against gravity with maximum resistance. 

Assessment of muscle strength should occur in an orderly fashion. Testing should be done to differentiate proximal from distal muscle weakness, as well as compare the left and right sides. The location of the weakness concerning other neurologic deficits can help differentiate a cortical lesion (hemiplegia from a stroke), from a brainstem lesion (crossed deficits from an MS plaque), from a spinal cord lesion (presence of dermatomal level), from a peripheral nerve lesion (neuropathy or radiculopathy), and a muscular disease (myasthenia gravis). 

Sensory Exam

The sensory exam involves the assessment of patient-reported symptoms that includes a diminished or exaggerated perception of sensation. Modalities tested include pain, temperature, vibration, and position sense. The location and pattern of sensory deficits are also helpful in localization. Pain sensation is assessed by using a sterile pin and test for sharpness or dullness. A tuning fork can be used to evaluate vibration sense. A piece of cotton can serve to assess for light touch, while the assessment for position sense can be done by testing the distal phalanx and asking the patient the position of the digit with eyes closed. An abnormal sensation can involve the sensory cortex, the thalamus, the brainstem, the spinal cord, and the peripheral nerves. Cortical lesions present with diminished sensation on the contralateral side, spinal cord lesions present as a sensory level, radiculopathies involve a specific dermatome, and neuropathies can have a glove and stocking distribution. [23]

The assessment of a patient's gait can be as simple as watching the patient walk into the room. It is essential to keep in mind that gait changes can be brought about by several factors, including weakness, neuropathies, arthritic changes, excess weight, and pain. A specific gait disorder that is recognized can point to a particular disease process or neurologic involvement.

Assessment of the gait involves observing the stance, the stride, the balance, and the heel strike. Balance and strength could have further evaluation by asking the patient to walk on their tiptoes or heels and walking in tandem (the heel of the front foot touching the toe of the back foot in a straight line). Recognition of an extensive list of different gaits linked to various pathologies is crucial in the early detection of neurological diseases. [24]  Assessment of the gait also allows an understanding of a patient's level of functioning. [25]  

Some common abnormal gait recognized include: [24]  

• Antalgic gait - altered gait due to pain, such as "limping." 
• Paretic gait - due to partial paralysis/weakness (e.g., steppage gait)
• Spastic gait - due to stiffness of the limbs
• Ataxic gait - broad-based and uncoordinated gait, might be due to cerebellar or sensory involvement.
• Hypokinetic - shuffling and slow gait, might be due to basal ganglia involvement.
• Dyskinetic - disturbance due to involuntary movements like dystonia or athetosis

Deep Tendon Reflexes                                            

The assessment of the deep tendon reflexes can be done by tapping a specific tendon with a reflex hammer and observing for a reflex muscle contraction. These tests a specific spinal cord level (biceps C5-C6, triceps C7, knees L3-L4, ankles S1-S2) and help in localizing the level of a lesion. Reflexes are scored as follows: 0 - absent, 1+ - trace, 2+ - normal, 3+ - brisk, 4+ - nonsustained clonus, and 5+ - sustained clonus.

Decreased deep tendon reflex is usually suggestive of a lower motor neuron lesion, like radiculopathy, but may also occur in spinal shock. On the other hand, the presence of hyperreflexia and clonus points to an upper motor neuron lesion. [26] [27]

Other reflexes include the Babinski reflex and the Hoffman reflex. The Babinski reflex involves stimulation of the lateral plantar aspect of the foot, the presence of an upgoing big toe indicates a positive result. Variations of this reflex include Chaddock reflex - stimulation of the lateral aspect of the foot, Oppenheim reflex - stroking the anterior and medial tibia downward, and Gordon reflex - squeezing the calf muscle; the presence of the upgoing big toe indicates a positive response. On the upper extremity, a Hoffman reflex can be done by flicking the distal digit of the middle finger with the positive response being the involuntary flexion of the other fingers, including the thumb. A positive Hoffman reflex indicates cervical cord involvement. A positive response in these tests helps differentiate an upper motor lesion from a lower motor lesion.

Meningeal Signs

The presence of meningeal signs reflects an irritation of the meninges. Maneuvers include assessment of nuchal rigidity by passive flexion of the patient's neck, and the presence of pain and resistance indicates a positive result. Other maneuvers include the Kernig sign, where a passive extension of the knee while the leg is flexed at the hip in a supine patient causes pain, and the Brudzinki sign, where passive neck flexion causes reflex knee flexion in the supine position. [28]  The usual causes of meningeal irritation include CNS infections and subarachnoid hemorrhage.

It is crucial to remember that when examining a patient, a focused physical and neurologic exam is complementary to a detailed history and is key in achieving proper diagnoses. [29]  

• Nursing, Allied Health, and Interprofessional Team Interventions

Although a full neurological examination with its specific maneuvers and domains is within the comfort zone of neurologists, it is an essential tool in the arsenal of primary care physicians. Localizing a disease to the neuroaxis will assist them in the appropriate management and referral to appropriate specialties. Also, basic neurologic assessment should be a point of emphasis for other health care professionals, especially in areas with a high likelihood of seeing neurologic cases such as in emergency rooms, intensive care units, and post-operative monitoring. [30]  

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Disclosure: Mahsa Shahrokhi declares no relevant financial relationships with ineligible companies.

Disclosure: Ria Monica Asuncion declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Shahrokhi M, Asuncion RMD. Neurologic Exam. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Neurological examination

  Neurological examination

The neurological examination  and questions for medical student exams, finals, OSCEs and MRCP PACES

Introduction (WIIPPPE)

• W ash your hands
• I ntroduce yourself (name and position)
• I dentity of patient (confirm name and date of birth)
• P ermission (consent and explain examination: “I’m going to examine your arms and legs in various differnent ways, I’ll talk you through it as I go. Is that OK?”)
• Should be able to see hands to deltoid (upper limb) and toes to upper thigh (lower limb)
• Unable to see your hand (neglect, blindness)
• Unable to lift their hand to shake yours (paralysis, weakness)
• Unable to easily release your hand (myotonic dystrophy)
• Explain that you’ll take a step back to look at them properly
• Wheelchair, walking stick (mobility issues)
• Catheter bag (possible spinal issues)
• Spirometer (respiratory dysfunction e.g. in Guillain-Barre syndrome)
• Evident syndrome
• Asymmetry in positioning (unilateral weakness)
• Muscle atrophy
• Fasciculations

Upper Limbs

Closer inspection.

• Start by observing each muscle group looking for  size , shape and symmetry
• Atrophy occurs in unused muscle groups
• Hypertorphy (provided not due to deliberate exercise) is usually indicative of compensation of one muscle group for the loss of function in another muscle group, such as seen in muscular dystrophies
• Fasciculations are often best seen in the deltoid in the upper limb. They may be elicited by gently flicking the muscle if there is a clinical suspicion
• Muscle tone is its resistance to passive stretching
• Move each joint of the limb in a purposeful but non-predictable manner
• The wrist often gives the most information. Supinate and pronate the hand, slowly and then briskly
• Tone will either be decreased ( hypotonia ) which can occur in lower motor neuron lesions or increased ( hypertonia ) classical of upper motor neuron lesions
• Spacticity is often described as “ clasp knife ” as resistance will change throughout movement
• Rigidity is an extrapyramidal pathway (e.g. Parkinson’s) issue and is knows as “ lead pipe ” rigidity. When tremor is superimposed it is described as “ cog-wheel ” rigidity
• Power is rated on a scale of 0 to 5 according to the Medical Research Council (MRC)
• 5 – Full Strength
• 4 – Movement against partial resistance
• 3 – Movement against gravity
• 2 – Movement with gravity eliminated
• 1 – Feeble contractions
• 0 – Absent voluntary contraction
• Note that when time is short, full examination of each muscle group may not be possible. In such cases, you can test grip power by asking the patient to squeeze your index and middle finger. You can also ask the patient to pull you towards them and push you away. This covers basic proximal and distal muscle strength
• The table below  gives the general scheme for examination of power in the upper limb including a general overview of relevant basic anatomy. This is often performed with the patient sitting up in bed

Testing power in the upper limbs

• Ensure a reflex is in fact absent by reinforcing the reflex arc. To reinforce, ask the patient to clench their teeth or grasp hands together and pull apart just as you strike with the tendon hammer ( Jendrassik’s manoeuvre )
• Hold the tendon hammer near the tapered tip and let the rubber head fall onto the tendon being tested (the movement is in the wrist). The weight of the tendon hammer head will define the force with which the tendon is struck rather that the strength of the examiner. If the reflex is brisk, the ‘briskness’ can be quantified by repeating the reflex but holding the hammer closer and closer to the head (thus exerting less and less force). Briskness is thus defined as a change in the threshold of the reflex response and not the speed or size of the response
• In the acute setting, if no tendon hammer is available then a stethoscope can be used as a rough stand-in – just do not do this in front of a neurologist!

Video on how to test reflexes in the upper limbs

• These are often written as + , ++ or +++ respectively
• To test the biceps reflex ask the patient to place their hands on their abdomen and let their arms relax. Place a finger over the biceps tendon in the antecubital fossa and strike your finger with the tendon hammer
• To assess the triceps reflex hold the hand/wrist on the abdomen with the elbow in a 90 degree angle and strike the triceps tendon just above the olecranon
• Test the supinator reflex (brachoradialis muscle) by placing two fingers at the level of the distal radius and striking your fingers with the tendon hammer
• Compare left to right before moving on to the next muscle group

Coordination

• In assessing coordination you are testing fine motor skills modulated by higher centres in the brain (i.e. basal ganglia, cerebellum). There are two basic methods of testing coordination in the upper limbs: the finger-nose test and dysdiadochokinesis
• Ask the patient to touch their nose with an index finger. Hold your finger at arms-length distance from the patient and ask them to use the same finger to touch your finger. Then ask them to move between their nose and your finger as quickly and  accurately as possible. Then repeat the same instructions with the other index finger. Look for past pointing and intention tremor
• Ask the patient to clap their right hand on the palm of their left hand,then alternate clapping with the palm and dorsum of the right hand. It always helps to demonstrate this
• Then switch hands (clap their left hand on their right hand.) Disorganisation in this alternating movement indicates dysfunction in the cerebellum or associated circuitry. An additional test of coordination is to ask the patient to oppose finger and thumb repeatedly as fast as possible. Slowing of the frequency and amplitude of this movement is a useful sign of bradykinesia

Lower Limbs

• There are three techniques to use when assessing tone of the lower limbs.
• For the first, have the leg fully relaxed, hold the knee to fix the leg to the bed and roll the thigh left and right repeatedly . In a patient with normal tone the foot will flop in the opposite direction as the way the knee is moved. However in the presence of increased tone the foot will remain in line with the knee
• In the second technique put your hand under the knee (at the popliteal fossa) and sharply pull the knee up . In a patient with normal tone, the heel will remain on the bed, but with increased tone the foot will leave the bed
• The third technique is the test for ankle clonus . The presence of greater than five beats of clonus (or sustained rhythmical contraction while the tendon is stretched) indicates increased tone
• The same principles of examination apply in the lower limbs as in the upper limbs
• The table below contains  the instructions for testing power in the legs, which is done with the patient lying down. Test each side individually before moving to the next muscle group

Testing power in the lower limbs

• Place your hand underneath the knee and slightly flex the knee for the patellar reflex then strike the patellar tendon just above the tibial tuberosity
•  For the ankle jerk, bend the knee and open the leg out, flex the foot slightly and strike the Achilles tendon looking for plantarflexion
• Finally the Babinski reflex or plantar response: use a smooth but rigid instrument and apply steady pressure starting at the heel and moving towards the big toe (never use the sharp end of a tendon hammer)
• Do not scratch the sole of the foot so hard as to leave a visible mark on the skin. Watch the toes for upward or downward movement (predominantly the big toe)
• Upper motor neuron lesions will cause the big toe to dorsiflex (an ‘upgoing plantar’), and the other toes spread out
• Positioning and comparison between left and right again, are key. You must have the muscle group being tested relaxed in order to see the contraction
•  Knowing the nerve roots that supply each muscle group and reflex being tested will help identify the location (level) at which the motor nervous system is affected. For example if the ankle reflex is brisk but the patellar reflex is normal then the lesion must lie in the spinal cord at L3/4
• Below the level of the lesion there are upper motor neuron signs (brisk reflex) and at the level there may be lower motor neuron signs (loss of the reflex) or no change in reflex. In addition the patient will have decreased power in the muscles groups below L3/4 and thus will have weakness of dorsi- or plantar flexion of the foot
• Ask the patient to “place your left heel on your right knee. Then slide your heel down your shin to the ankle. Now lift your foot in the air and place your heel back on the knee. Slide your heel once again down to your ankle. Please repeat this movement”
• Look for the heel sliding off the shin as the patient tries to slide it down towards the ankle. If this is difficult another technique is to ask the patient to tap their foot  repeatedly on your hand
• Remember that coordination can be affected by weakness and lack of sensory perception and may necessarily indicate a lesion in the basal ganglia or cerebellum. This is especially true in the lower limbs where a patient may have sensory loss in the stocking distribution, such as in diabetes
• The patient will also be unable to walk heel-to-toe, a more sensitive test of ataxia
• Classically seen in extra-pyramidal disease
• May be indicative of inner ear disorder
• Ocurs in foot drop, a person will lift their foot far above the ground in order to avoid catching their toes on the ground while walking. The patient will also have difficulty walking on their heels

Video on gait disturbances

Romberg’s Test

• Romberg’s test is a method of assessing propioception and can be positive in sensory ataxia (peripheral neuropathy) and in tabes dorsalis caused by syphilis (affecting the sensory pathways of the spinal cord).
• Ask the patient to stand with their feet close together and stretch out their arms. Make sure you position the patient so that if they did fall you can catch them or that they fall onto a bed. After giving reassurance that you will catch them if they fall, ask the patient to close their eyes.
• In a positive Romberg’s test the patient will fall with their eyes closed but not with their eyes open, as the visual input that was compensating for the lack of propioceptive input is removed.
• In cerebellar dysfunction the patient will be just as unsteady with their eyes open as closed.

Sensation: Upper and Lower Limbs

• There are three principals in testing sensation:  compare left to right, compare distal areas to proximal areas and finally test dermatomes (when indicated)
• It can be helpful to ask the patient if they have any numbness or tingling
• Start by touching the patient’s upper chest lightly with your finger or a piece of cotton wool and ask them if it feels like a finger/cotton touching them
• Ask them to close their eyes and each time you touch their limb ask them which side you have touched, left or right. Ask them if it feels the same on both sides .
• Outer shoulder/regimental badge area: axillary nerve C6
• Outer forearm: lateral cutaneous C5
• Thumb: median nerve C6
• Middle finger: median nerve C7
• Little finger: ulnar nerve C8
• Back of the hand – radial side: radialnerve C5-T1
• Medial antecubital fossa: medial cutaneous T1
•  Inner thigh: upper L1, mid L2
• Medial side of knee: L3
• Medial malleolus: L4
• Big toe: L5
• Popliteal fossa: S2
• Anal sensation/tone needs to be tested if concern about spinal cord lesions: S3 and S4
• In determining the sensory level remember that the pain and temperature pathways decussate at the level of entry at the spinal cord (spinothalamic tract) while the pathways for fine touch and propioception ascend the spinal cord and decussate at the level of the brain stem (dorsal columns)

Other sensory modalities

• To test sensation thoroughly the above routine should be repeated, testing the rest of the sensory modalities
• Alternate using the sharp and blunt ends of the neurotip)
• Can be tested with the metal tuning fork as it tends to be cold
• Tested on a bony prominence looking for when the patient stops feeling the vibration
• Start at the most distal joint in the limb, such as the distal interphalageal joint. Place your fingers on either side of the digit to isolate the joint. Move the joint upwards and say “this is up” and then move the joint down and say “this is down”. Ask the patient to then close their eyes and tell you which way they feel you are moving their joint. If they are unable to tell you move to the next more proximal joint.
• Beware of the subjective nature of the sensory exam. If you suspect that the patient is giving spurious answers, or trying to disguise a lack of sensation, instruct them to close their eyes and ask them which side you are touching without touching them at all. Patches of sensory loss that do not follow a dermatomal or nerve distribution are likely to be non-organic in aetiology.

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Approach to the Neurologic Patient

, MD, MSc, University of Ottawa

Physical Examination and Testing

Patients with neurologic symptoms are approached in a stepwise manner termed the neurologic method, which consists of the following:

Identifying the anatomic location of the lesion or lesions causing symptoms

Identifying the pathophysiology involved

Generating a differential diagnosis

Selecting specific, appropriate tests

Identifying the anatomy and pathophysiology of the lesion through careful history-taking and an accurate neurologic examination Introduction to the Neurologic Examination The purpose of the neurologic examination is to establish whether the patient’s brain, special senses, spinal cord, peripheral nerves, and muscle and skin receptors are functioning normally... read more markedly narrows the differential diagnosis and thus the number of tests needed. The history is important in identifying the likely site of neurologic dysfunction, and the neurologic examination is used to corroborate the suspected location. This approach should not be replaced by reflex ordering of CT, MRI, and other laboratory testing; doing so leads to error and unnecessary cost.

To identify the anatomic location, the examiner considers questions such as

Are all the symptoms and signs referable to a single lesion in the nervous system or to multiple lesions?

Is the central or peripheral nervous system involved, or are both involved?

Specific parts of the nervous system to be considered include the cerebral cortex, subcortical white matter, basal ganglia, thalamus, cerebellum, brain stem, spinal cord, brachial or lumbosacral plexus, peripheral nerves, neuromuscular junction, and muscle.

Once the location of the lesion is identified, categories of pathophysiologic causes are considered; they include those originating primarily in the nervous system and those originating elsewhere in the body and affecting the nervous system secondarily (eg, vascular, infectious, immune-mediated). General categories of causes for neurologic disorders include the following:

Degenerative

Toxic-metabolic

Immune-mediated

When appropriately applied, the neurologic method provides an orderly approach to even the most complex case, and clinicians are far less likely to be fooled by neurologic mimicry—eg, when symptoms of an acute stroke are actually due to a brain tumor or when rapidly ascending paralysis suggesting Guillain-Barré syndrome is actually due to spinal cord compression.

The history is the most important part of the neurologic evaluation. Patients should be put at ease and allowed to tell their story in their own words. Usually, a clinician can quickly determine whether a reliable history can be obtained or whether a family member should be interviewed instead.

History of present illness should include asking the patient about the following:

The quality, intensity, distribution, duration, and frequency of each symptom (questions should be specific)

The duration of symptoms to differentiate between acute, subacute, and chronic (including congenital) conditions

The circumstances that aggravate and attenuate the symptom

The effectiveness of past treatments

The order in which symptoms occur to help identify the cause

Symptoms not directly related to the nervous system, which suggest a generalized or systemic condition

Specific disabilities, described quantitatively (eg, walking at most 7.6 meters [25 feet] before needing to stop to rest) and their effect on the patient's daily routine.

Family history is important because migraine and many metabolic, muscle, nerve, and neurodegenerative disorders are inherited.

Social, occupational, and travel history provides information about unusual infections and exposure to toxins and parasites.

Sometimes neurologic symptoms and signs are functional, reflecting a psychiatric disorder. Typically, such symptoms and signs do not conform to the rules of anatomy and physiology, and the patient may be depressed or unusually frightened. However, functional and physical disorders sometimes coexist, and distinguishing them can be challenging.

A physical examination to evaluate all body systems is done, but the focus is on the nervous system ( neurologic examination Introduction to the Neurologic Examination The purpose of the neurologic examination is to establish whether the patient’s brain, special senses, spinal cord, peripheral nerves, and muscle and skin receptors are functioning normally... read more ). The neurologic examination, discussed in detail elsewhere in THE MANUAL, includes the following:

Mental status How to Assess Mental Status The mental status examination is used to evaluate the patient’s level of consciousness and the content of consciousness. Patients are considered alert if they are actively perceiving the world... read more

Motor system How to Assess the Motor System Motor weakness can be due to dysfunction in the corticospinal tract, basal ganglia, spine, peripheral nerves, or muscle. A careful examination of the motor system enables the clinician to localize... read more

Muscle strength How to Assess Muscle Strength Patients who report weakness may mean fatigue, clumsiness, or true muscle weakness. Thus, the examiner must define the precise character of symptoms, including exact location, time of occurrence... read more

Gait, stance, and coordination How to Assess Gait, Stance, and Coordination Normal gait, stance, and coordination require integrity of the motor, vestibular, cerebellar, and proprioceptive pathways (see also Movement and Cerebellar Disorders). Lesions in these pathways... read more

Sensation How to Assess Sensation Similar to the motor examination, the sensory examination is designed to localize dysfunction and help determine whether the problem is in the cerebral cortex, thalamus, sensory pathways in... read more

Reflexes How to Assess Reflexes (See also Introduction to the Neurologic Examination.) Deep tendon (muscle stretch) reflex testing evaluates afferent nerves, synaptic connections within the spinal cord, motor nerves, and descending... read more

Autonomic nervous system How to Assess the Autonomic Nervous System Assessment of the autonomic nervous system involves checking for the following: Postural hypotension Heart rate changes in response to the Valsalva maneuver Decreased or absent sweating Evidence... read more

In many situations, a cerebrovascular examination Cerebrovascular Examination In a patient presenting with acute stroke, radial pulse and BP in the 2 arms are compared to check for painless aortic dissection, which can occlude a carotid artery and cause stroke. The skin... read more also is done.

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How to Assess the Cranial Nerves

, MD, PhD, Albert Einstein Medical Center

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The cranial nerves originate in the brain stem. Abnormalities in their function suggest pathology in specific parts of the brain stem or along the cranial nerve's path outside the brain stem. For example, unilateral leg weakness with upper motor Amyotrophic Lateral Sclerosis (ALS) and Other Motor Neuron Diseases (MNDs) Amyotrophic lateral sclerosis and other motor neuron diseases are characterized by steady, relentless, progressive degeneration of corticospinal tracts, anterior horn cells, bulbar motor nuclei... read more signs may be due to pathology anywhere between the cerebral cortex and the lumbar spine. However, the presence of an abnormal cranial nerve sign strongly suggests that the observed weakness results from a problem in the brain stem. Specific combinations of cranial nerve signs may suggest pathology at specific locations around the base of the skull.

1st Cranial nerve

Smell, a function of the 1st (olfactory) cranial nerve, is usually evaluated only after head trauma or when lesions of the anterior fossa (eg, meningioma) are suspected or patients report abnormal smell or taste.

The patient is asked to identify odors (eg, soap, coffee, cloves) presented to each nostril while the other nostril is occluded. Alcohol, ammonia, and other irritants, which test the nociceptive receptors of the 5th (trigeminal) cranial nerve, are used only when malingering is suspected.

2nd Cranial nerve

For the 2nd (optic) cranial nerve, visual acuity is tested using a Snellen chart Visual acuity The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more for distance vision or a handheld chart for near vision; each eye is assessed individually, with the other eye covered.

Color perception is tested using standard pseudoisochromatic Ishihara Color vision testing The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more or Hardy-Rand-Ritter plates that have numbers or figures embedded in a field of specifically colored dots.

3rd, 4th, and 6th Cranial nerves

For the 3rd (ocolomotor), 4th (trochlear), and 6th (abducens) cranial nerves, eyes are observed for symmetry of movement, globe position, asymmetry or droop of the eyelids (ptosis), and twitches or flutters of globes or lids. Extraocular movements controlled by these nerves are tested by asking the patient to follow a moving target (eg, examiner’s finger, penlight) to all 4 quadrants (including across the midline) and toward the tip of the nose; this test can detect nystagmus and palsies of ocular muscles. Brief fine amplitude nystagmus at end-lateral gaze is normal.

Anisocoria or differences in pupillary size should be noted in a dimly lit room. The pupillary light response is tested for symmetry and briskness.

5th Cranial nerve

For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against the lower or lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the angle of the jaw should be examined; sparing of this area (innervated by spinal root C2) suggests a trigeminal deficit. A weak blink due to facial weakness (eg, 7th cranial nerve paralysis) should be distinguished from depressed or absent corneal sensation, which is common in contact lens wearers. A patient with facial weakness feels the cotton wisp normally on both sides, even though blink is decreased.

Trigeminal motor function is tested by palpating the masseter muscles while the patient clenches the teeth and by asking the patient to open the mouth against resistance. If a pterygoid muscle is weak, the jaw deviates to that side when the mouth is opened.

7th Cranial nerve

The 7th (facial) cranial nerve is evaluated by checking for hemifacial weakness. Asymmetry of facial movements is often more obvious during spontaneous conversation, especially when the patient smiles or, if obtunded, grimaces at a noxious stimulus; on the weakened side, the nasolabial fold is depressed and the palpebral fissure is widened. If the patient has only lower facial weakness (ie, furrowing of the forehead and eye closure are preserved), etiology of 7th nerve weakness is central rather than peripheral.

Taste in the anterior two thirds of the tongue can be tested with sweet, sour, salty, and bitter solutions applied with a cotton swab first on one side of the tongue, then on the other.

Hyperacusis, indicating weakness of the stapedius muscle, may be detected with a vibrating tuning fork held next to the ear.

8th Cranial nerve

Because the 8th (vestibulocochlear, acoustic, auditory) cranial nerve carries auditory and vestibular input, evaluation involves

Vestibular function tests

Vestibular function can be evaluated by testing for nystagmus Nystagmus Nystagmus is a rhythmic movement of the eyes that can have various causes. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected... read more . The presence and characteristics (eg, direction, duration, triggers) of nystagmus help identify vestibular disorders and sometimes differentiate central from peripheral vertigo. Vestibular nystagmus has 2 components:

A slow component caused by vestibular input

A quick, corrective component that causes movement in the opposite direction (called beating)

The direction of the nystagmus is defined by the direction of the quick component because it is easier to see. Nystagmus may be rotary, vertical, or horizontal and may occur spontaneously, with gaze, or with head motion.

When trying to differentiate central from peripheral causes of vertigo, the following guidelines are reliable and should be considered at the onset:

There are no central causes of unilateral hearing loss because peripheral sensory input from the 2 ears is combined virtually instantaneously as the peripheral nerves enter the pons.

There are no peripheral causes of CNS signs. If a CNS sign (eg, cerebellar ataxia) appears at the same time as the vertigo, the localization is virtually certain to be central.

Evaluation of vertigo using nystagmus testing is particularly useful in the following situations:

When patients are having vertigo during the examination

When patients have acute vestibular syndrome

When patients have episodic, positional vertigo

If patients have acute vertigo during the examination, nystagmus is usually apparent during inspection. However, visual fixation can suppress nystagmus. In such cases, the patient is asked to wear +30 diopter or Frenzel lenses to prevent visual fixation so that nystagmus, if present, can be observed. Clues that help differentiate central from peripheral vertigo in these patients include the following:

If nystagmus is absent with visual fixation but present with Frenzel lenses, it is probably peripheral.

If nystagmus changes direction (eg, from one side to the other when, for example, when the direction of gaze changes), it is probably central. However, absence of this finding does not exclude central causes.

If nystagmus is peripheral, the eyes beat away from the dysfunctional side.

When evaluating patients with acute vestibular syndrome (rapid onset of severe vertigo, nausea and vomiting, spontaneous nystagmus, and postural instability), the most important maneuver to help differentiate central vertigo from peripheral vertigo is the head thrust maneuver. With the patient sitting, the examiner holds the patient's head and asks the patient to focus on an object, such as the examiner's nose. The examiner then suddenly and rapidly turns the patient's head about 20° to the right or left. Normally, the eyes stay focused on the object (via the vestibular ocular reflex). Other findings are interpreted as follows:

If the eyes temporarily move away from the object and then a frontal corrective saccade returns the eyes to the object, nystagmus is probably peripheral (eg, vestibular neuronitis Vestibular Neuronitis Vestibular neuronitis causes a self-limited episode of vertigo, presumably due to inflammation of the vestibular division of the 8th cranial nerve; some vestibular dysfunction may persist. Sometimes... read more ). The vestibular apparatus on one side is dysfunctional. The faster the head is turned, the more obvious is the corrective saccade.

If the eyes stay focused on the object and there is no need for a corrective saccade, nystagmus is probably central (eg, cerebellar stroke).

A latency period of 5 to 10 seconds

Usually, vertical (upward-beating) nystagmus when the eyes are turned away from the affected ear and rotary nystagmus when the eyes are turned toward the affected ear

Nystagmus that fatigues when the Dix-Hallpike maneuver is repeated

In contrast, positional vertigo and nystagmus related to CNS dysfunction have no latency period and do not fatigue.

The Epley canalith repositioning maneuver (see figure ) can be done for both sides to help confirm the diagnosis of BPPV. If the patient has BPPV, there is a high probability (up to 90%) that the symptoms will disappear after the Epley maneuver, and results of a repeat Dix-Hallpike maneuver will then be negative.

9th and 10th Cranial nerves

The 9th (glossopharyngeal) and 10th (vagus) cranial nerves are usually evaluated together. Whether the palate elevates symmetrically when the patient says "ah" is noted. If one side is paretic, the uvula is lifted away from the paretic side. A tongue blade can be used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is observed; bilateral absence of the gag reflex is common among healthy people and may not be significant.

In an unresponsive, intubated patient, suctioning the endotracheal tube normally triggers coughing.

If hoarseness is noted, the vocal cords are inspected. Isolated hoarseness (with normal gag and palatal elevation) should prompt a search for lesions (eg, mediastinal lymphoma, aortic aneurysm) compressing the recurrent laryngeal nerve.

11th Cranial nerve

The 11th (spinal accessory) cranial nerve is evaluated by testing the muscles it supplies:

For the sternocleidomastoid, the patient is asked to turn the head against resistance supplied by the examiner’s hand while the examiner palpates the active muscle (opposite the turned head).

For the upper trapezius, the patient is asked to elevate the shoulders against resistance supplied by the examiner.

12th Cranial nerve

The 12th (hypoglossal) cranial nerve is evaluated by asking the patient to extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion).

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Free Neurology Essay Examples & Topics

Being a neurologist equates to countless hours of study, research, and work. If you find yourself interested in this field, you have to prepare to face many challenges along the way. Among these challenges are writing neurology essays and choosing what to write about. Thankfully, our experts have prepared an article to help you out.

Neurology and neuroscience are closely related subjects. However, there are distinctions between the two.

Neuroscience is a scientific area. More often than not, neuroscientists spend their days in a laboratory conducting research on the central nervous system.

Neurology is a branch of medicine, concerned with the diseases of the nervous system. People studying neurology are medical students who strive to obtain a medical license. They eventually become practicing doctors. One of the perks of being a neurologist is specialization. These doctors can have a specialty that they work with, such as epilepsy disorders or pediatric neurology.

Below, you will find both neuroscience and neurology essay topics. You will also find advice for writing academic papers. Finally, you can browse through free essay samples provided by students like yourself.

6 Top Tips on Neurologist Essay

To be successful with your neurologist essay, you should adhere to the standard academic style of writing. Here we have collected the tips that will make sure you are on the right path.

1. Brainstorm for ideas. This is one of the essential steps in any academic paper. By this point, you are probably bursting with neurology essay ideas. Putting them all down on paper will help you visualize your process.

2. Pick your topic. When your ideas are outlined in front of you, it is time to choose. Deciding what to go for can be tricky – you need to make sure the topic isn’t too narrow or broad. It is best to go with the area that is the most interesting to you personally. This way, research won’t be a burden, and the writing process will be more exciting.

3. Conduct research. When considering neurological essays, trustworthy sources are essential. Spend an extra hour browsing through books and journal articles. Depending on the scope of your work, you might want to consider interviews with known neurologists. Besides secondary sources, try to obtain primary ones.

4. Come up with a hypothesis. Once you have everything in order, start thinking about your thesis. In other words, draft a solid hypothesis long before writing. This will be the subject that you will discuss throughout your essay. Take your time with it, or let our thesis generator do that for you.

5. Outline your future paper. When you have your hypothesis, outlining your paper should become manageable. Base your introduction, body paragraphs, and conclusion around the thesis statement. Remember that your primary discussion points should be supported by the evidence you gathered in your research.

6. Draft your paper and revise. Most students forget that they can edit their paper as many times as necessary before submission. This can severely influence the quality of your assignment. Proofreading is one of the most fundamental elements of essay writing. Make sure to look over your paper at least once before submitting it.

25 Neurology & Neuroscience Essay Topics

Any essay begins with a carefully chosen topic. Fortunately, you can find hundreds of original ideas related to neuroscience and neurology. We have listed some of them below. Otherwise, you can try our topic generator – it will create more for you.

Feel free to browse through these ideas:

• The effects of Alzheimer’s on the emotional stability of older people.
• Neurosurgery as a cure for depression.
• The link between head injury and physical injury in athletes in professional boxing.
• Is neurology a good field to study human emotions and feelings?
• Brain development after post-traumatic stress.
• The effect of alcoholism on dopamine production in the human brain.
• Clinical neurology and the treatment of Parkinson’s disorder.
• Targeting of specific nerve centers in treatment of chronic pain.
• The impact of mental illness on brain chemistry from a neurosurgeon’s perspective.
• Chronic Fatigue Syndrome and its development in the human brain.
• Why I chose neurology: advantages and disadvantages of clinical neuroscience.
• The formation of irrational phobias and fears.
• The effect of insomnia on the development of cognitive brain functions.
• An analysis of the common methods of treatment for cerebral shaking palsy.
• The causes and cures for schizophrenia in young adults.
• Is brain death completely irreversible? A discussion on the future of neurological theory.
• The link between IQ and brain development in young adults.
• Pros and cons of marijuana use in neurology units in hospitals.
• The interaction of neurons and their impact on mental health.
• The extent of available medicine for neurological disorders.
• The algorithms in brain functions and their link to intelligence in humans.
• A critical examination of treatment for terminal cancer of the brain.
• Frontal lobe and parietal lobe – different impacts on the development of multilingual skills.
• The influence of the Internet on human memory functions.
• Long-time drug use and its effect on human brain development.

We hope that these ideas managed to inspire you. If you need extra guidance, feel free to check out our neurology essay samples below.

Thank you for reading!

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The Neurologic Exam, Step-by-step

This case-based review will help you assess beyond each patient’s visual presentation and uncover key clinical signs of neurologic dysfunction..

By Ashley Kay Maglione, OD, and Kelly Seidler, OD

B ecause the eye is an extension of the brain, a neurologic examination can be a crucial diagnostic tool. The neuro exam allows you to assess structures neighboring those that are important to vision and can help determine the level of urgency for a patient’s ocular findings such as visual field defects, cranial neuropathies, double vision, optic neuropathy, ptosis, pupillary abnormalities and loss of vision. It may increase your clinical suspicion for underlying etiologies, including stroke, space-occupying lesion and demyelinating disease, among others. 

Incorporating the neurologic exam into your tool box will help you provide exceptional care to your patients. Here we show you how and provide several case examples.

The Five-step Exam

As important as the neurologic exam is, it doesn’t take advanced technology to perform, and the tools are readily available in an optometric office. Clinicians can tackle the neurologic examination by breaking it into five sections:

1. Mental status. Many practitioners assess mental status at the beginning of the exam and, for healthy patents, write “A&Ox3,” representing A lert and O riented to (1) person, (2) place and (3) time. If the patient is answering your questions inappropriately and seems confused or disoriented, you may choose to perform a mini mental status exam (MMSE). This questionnaire is designed to assess different aspects of cognitive function, including orientation, recall and language. The MMSE is quick and requires no training, although it may not detect mild cognitive decline. 1

2. Cranial nerve testing. You will already have tested four of the 12 cranial nerves (CNs) during your routine eye exam: II, III, IV and VI. Before you tackle your first neurologic exam, we recommend you review the anatomical locations and pathways of the cranial nerves. 

Cranial nerve testing can provide strong localizing data for a lesion. For example, if multiple cranial nerves are affected, the clinician can consider where cranial nerves share a common space, such as within the cavernous sinus (recall that CN III, IV, VI, the ophthalmic division of the trigeminal nerve, or V 1 , and the maxillary division of the trigeminal nerve, or V 2 , course here) or the superior orbital fissure (which contains CN III, IV, VI and the frontal, lacrimal and nasociliary branches of the trigeminal nerve). Table 1 reviews CN functions and outlines how to test for any dysfunction during a neurologic examination. Here is a brief review of the clinical applications of testing each cranial nerve: 2

CN I: This nerve is often not tested unless a frontal tumor is suspected, such as in Foster-Kennedy syndrome, which is characterized by pallor of one optic nerve due to compression and edema of the contralateral nerve due to increased intracranial pressure. 

CN II: This afferent nerve is assessed during visual acuity, color vision, pupil testing with the swinging flashlight test for afferent pupillary defect and visual field testing (see “ Beyond Visual Field Testing” ).

CN III: This is routinely tested with extraocular motility. It innervates the levator palpebrae superioris (elevation of the upper eyelid) as well as four of the six extraocular muscles and is involved in elevation, depression and adduction of the eye. It is also involved in pupillary constriction. A pupil-involved CN III palsy is more concerning for an aneurysm because pupillary fibers travel on the external surface of the nerve and are subject to compression

CN IV: This is also routinely tested with extraocular motility. It innervates the superior oblique muscle involved in depression of the adducted eye, as well as intorsion. Cover testing in multiple positions of gaze demonstrates a hyper deviation worse on contralateral gaze and ipsilateral head tilt.

CN V: Reduced sensation in the distributions of V 1 and V 2 may indicate a cavernous sinus lesion, especially in cases of CN III, IV and/or VI dysfunction.

CN VI: Routinely tested with extraocular motility, CN VI innervates the lateral rectus muscle which abducts the eye. Abduction deficits may be found in cases of increased intracranial pressure.

CN VII: This is a helpful test when you note facial asymmetry or an abduction deficit. An upper motor neuron lesion of CN VII (such as a stroke) will spare the forehead and indicates damage in the cerebrum. A lower motor neuron will affect the entire half of the face. 

CN VIII: In a patient with an abduction deficit, it is important to test hearing due to the close relationship of cranial nerves VI, VII and VIII in the cerebellopontine angle. A patient with an abduction deficit and hearing loss on one side would localize to this region and would be concerning for a lesion such as an acoustic neuroma. Unilateral hearing loss is rarely due to a central lesion within the brain due to the extensive crossing of the auditory pathway.

CN VIII is also involved in the vestibular system, which is responsible for balance, proprioception and eye movements, including the vestibulo-ocular reflex. Disruption to this system can manifest clinically as nystagmus which may be seen in conditions such as Meniere’s disease. 

CN IX and X: These are not examined separately; their close anatomic relationship rarely results in isolated lesions. Dysfunction of these nerves or the structures that they innervate may be indicated by dysphonia, dysphagia or dyspnea. Pay special attention to CN IX and X in patients with diplopia, ptosis or both, as they may be involved in myasthenia gravis, therefore raising clinical suspicion for disease of the neuromuscular junction. 

CN XI: Upper motor neuron lesions will relatively spare the sternocleidomastoid muscle function and comparatively affect the trapezius muscle function more. This is also important to test in cases suspicious for myasthenia gravis.

CN XII: The tongue will deviate to the contralateral side of an upper motor neuron lesion and to the ipsilateral side with a lower motor neuron lesion. Tongue atrophy is a sign of a lower motor neuron lesion.  

Cranial nerve testing clinical case. A poorly controlled diabetes patient presented with diplopia and an abduction deficit (75% of normal capability) concerning for a CN VI palsy. Neurologic examination revealed a subtle ipsilateral facial palsy that we could have easily missed with observation alone. All other testing of cranial nerve functions was normal. Despite the patient’s vasculopathic risk factor of poorly controlled diabetes, the concurrent CN VII palsy raised suspicion for an alternative etiology. Given the close association between cranial nerves VI and VII within the pons and as they exit the brainstem, simultaneous dysfunction suggests a lesion in that region. We referred the patient for additional testing, including an MRI of the brain, which resulted in the diagnosis of metastatic cancer and referral to oncology for further evaluation.

3. Motor/reflex examination.   This begins with observation. You should first look for any involuntary movement such as tremors suggestive of basal ganglia disease (e.g, Parkinson’s) or muscle atrophy. Next, check for weakness of the upper and lower extremities by asking the patient to flex, extend, abduct and adduct their arms and legs against resistance. Compare the strength and ability of each muscle group with the contralateral side, looking for any asymmetry ( Figure 1 ). 

Weakness may be subtle and can be further elucidated with specific tasks. Ask a patient to hold both arms out in front of them with their palms facing upward and close their eyes. A slow, downward drift and pronation of one arm suggests weakness. Additionally, check fine movements by asking the patient to rapidly tap a finger or alternate their hand in a palm-up, palm-down fashion. Deep tendon reflexes may be diminished, such as in patients with Adie’s tonic pupil, or abnormally increased, such as in patients with multiple sclerosis. 3

Motor/reflex examination case. A 66-year-old patient presented emergently with complaints of double vision. The patient had poorly controlled diabetes and blood pressure was elevated at the time of the exam. The patient denied any associated neurologic symptoms such as weakness, paresthesia or headache. Examination revealed a right abduction deficit concerning for a CN VI palsy, but the eye examination was otherwise normal. A neurologic exam revealed a previously unknown upper extremity, left-sided weakness. All other aspects of the neurologic exam were normal. An abduction deficit with contralateral weakness is concerning for a lesion in the brainstem, specifically referred to as Raymond’s syndrome. The patient was referred immediately to the hospital where neuroimaging revealed an infarction of the right ventral pons. 

These first two cases discussed highlight the importance of performing a neurologic examination on patients with diplopia. The presence of additional neurologic symptoms (cranial neuropathy and weakness) that the patient may or may not be aware of should prompt you to pursue a more urgent work-up. If this patient had been evaluated from purely an ophthalmic standpoint, the CN VI palsy may have been presumed ischemic or vasculopathic, given the poor control of systemic disease. However, the discovery of a concurrent new-onset neurologic symptom raised significant concern and warranted immediate neuroimaging. While a cranial nerve palsy may be secondary to vasculopathic risk factors, it is important to consider that a diagnosis of exclusion. 

4. Coordination/gait. The first indication of cerebellar dysfunction may be observed as the patient walks to the exam room. Those with the condition may exhibit an ataxic, or clumsy, gait. You can also ask the patient to walk heel-to-toe in a straight line. Wheelchair-bound patients can slide their heel along their contralateral shin toward their foot. Inability to perform any of these tasks indicates potential cerebellar dysfunction or intoxication. 

The presence or absence of ataxia may also be detected by asking the patient to quickly touch their finger from their nose to your fingertip an arm’s length away. Any hesitation, overshoot or undershoot, shaking or difficulty when they are about to touch your finger may indicate ataxia. Stand far enough away so that these patients have to fully extend their arm to reach your finger. You can move your finger to different areas to increase difficulty.

To assess rapid alternating movements, ask the patient to tap the palm of their hand on their leg repeatedly and quickly. Then ask them to flip their hand from palm to the back of the hand on their leg. Inability to do so is known as dysdiadokinesia and is often a sign of cerebellar disease, including stroke and atrophy.

The classic ocular manifestation of cerebellar dysfunction is nystagmus, with other potential ocular complications such as abnormal pursuits and optokinetic response. However, nystagmus is not only caused by cerebellar disease and can be due to vestibular dysfunction as well as other etiologies such as albinism and medication use (such as anti-seizure medications). Therefore, performing a neurologic exam on patients with nystagmus and paying special attention to their coordination and gait can help increase or decrease your clinical suspicion for a lesion within the cerebellum.

Coordination/gait case. A 31-year-old woman presented with complaints of glare and reduced vision. Her best-corrected visual acuity was 20/25- OD and 20/100 OS. She demonstrated a 0.3 log unit relevant afferent pupillary defect of the left eye and reduced color vision (12/14 Ishihara plates OD, 3/14 Ishihara plates OS) ( Figures 2 and 3 ). Fundus examination revealed bilateral temporal pallor OS>OD ( Figure 4 ). A neurologic exam revealed tandem gait ataxia and a positive Romberg test, suggestive of cerebellar dysfunction. She also demonstrated fine motor weakness affecting the left hand more than the right. Records of recent lab work demonstrated significant vitamin B12 and folate deficiencies, which supported a nutritional optic neuropathy diagnosis.

This case highlights how a neuro exam helps to refine your differential diagnosis of an optic neuropathy. Potential causes of bitemporal pallor include inflammatory, infectious, nutritional and toxic conditions. Anemia is a common early symptom of vitamin B 12 deficiency, while neurologic symptoms are typically found later. Neurologic symptoms arise due to demyelination and can include cerebellar ataxia and limb weakness. 4,5 In this case, our neurological findings helped narrow our differential and avoid additional tests such as laboratory testing and neuroimaging.

5. General sensory exam. Pain, temperature, proprioception, two-point touch, light touch, pressure and vibratory sense are all general sensations. The stimulus travels from the site of stimulation to the cerebral cortex. Depending on the sensation, the pathway decussates, or crosses, the midline in either the low medulla or spinal cord. Lesions below the decussation cause ipsilateral loss of sensation. In general, lesions within the brainstem or the brain cause contralateral loss of sensation.

We recommend integrating tests of sensation with other elements of the neurologic exam. While the patient has their arms outstretched with closed eyes to test for pronator drift, lightly touch the backside of one of their hands and ask them to identify which hand was touched. Touch one hand, then the other and then both simultaneously while asking the patient to note any asymmetry. You may also touch a cool transilluminator on each of the patient’s arms to assess for asymmetry in temperature sensation.

Proprioception can be assessed by asking the patient to stand with their feet touching, known as the Romberg test. Patients can usually keep their balance with their eyes open due to visual cues; however, if they are unable to maintain their balance with their eyes closed—a positive test—they may have loss of proprioception. This test may also indicate cerebellar dysfunction. 

Sensory exam case. A 62-year-old male presented with tearing affecting the left eye more than the right, a left-sided, non-congruous, homonymous hemianopia and intermittent diplopia. He reported a history of a hemorrhagic stroke affecting the right side of his brainstem. Neuro exam revealed left-sided weakness of the left upper and lower extremities. He also demonstrated notable sensory defects and a left-sided facial palsy that was not grossly evident by observation alone. By correlating our findings with the anatomical location of the stroke, we attributed his presentation to the prior stroke of the right pons, therefore avoiding any further testing or work-up. His previous MRI report was remarkable for gliosis involving the right optic tract, which corresponded with his visual field defect.

These cases highlight many important clinical implications of the neurologic exam, hopefully inspiring you to incorporate it into your practitioner’s toolbox. Ultimately, a neurology consult is often indicated, but an in-office screening may help narrow a list of differentials to help develop a sense of urgency. With practice, the neurologic exam can be performed and interpreted quickly and efficiently, with significant implication for patient care. 

Dr. Maglione is an assistant professor at the Pennsylvania College of Optometry at Salus University and clinical instructor in the primary care and neuro-ophthalmic disease services at The Eye Institute.

Dr. Seidler graduated from the Pennsylvania College of Optometry at Salus University. She is currently completing a two-year advanced residency program at The Eye Institute in neuro-ophthalmic disease.

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Home » Feature » How to Pass the Neuro-Psychiatric Exam: 2023 Guide

How to Pass the Neuro-Psychiatric Exam: 2023 Guide

The  Neuro-Psychiatric Examination tests the mental stability, adaptability, and psychological functioning of applicants before they are recruited into service. The purpose of the exam is to filter applicants if they are really suitable for the uniformed services of the government. It is one of the most decisive parts of the recruitment process in the PNP , BFP, BJMP, BuCor , and all the branches of the AFP. In fact,  only 25% of the applicants pass the Neuro-Psychiatric exam, making it the most dreaded part of the application process.

The  Neuro-Psychiatric Exam is comprised of two parts- the written and the personal interview. It includes a 35-item Aptitude (Adaptation) Test,  Guilford Zimmerman Temperament Survey , Applicant Risk Profiler, The Industrial Sentence Completion Test, Work Environment Preference Schedule (WEPS), Hand Test, and the “Drawing”. Sounds scary, right? Well, here are some tips and pieces of advice to help you pass this crucial part of your application. Please read on.

6 Important Tips to Pass the Neuro-Psychiatric Exam

To help you succeed in passing the Neuro-Psychiatric Exam, we recommend a book called Neuro-Psychiatric Exam Guide for Police (PNP), Fire (BFP), BJMP, Coast Guard & AFP Applicants . It is available in Shopee and can be paid via the COD option.

Are you still searching for ways how to successfully hurdle this important part of your application? Check these important tips on how to pass the Neuro-Psychiatric Exam like a boss.

1. Follow instructions

In every exam, following the instructions is as important as knowing the right answer to every question. Knowing how to follow instructions is a good indicator that you will be a good policeman, fireman, jail officer, or soldier as these services require utmost compliance with instructions. When you are told to write your name in block capitals, do it exactly as you are told.

Neuro-psychiatric examinations often involve complex tasks and assessments that require careful observation and attention to detail. Whether it’s reading a passage and answering questions or completing a visual puzzle, make sure you take the time to thoroughly understand the instructions and the requirements of each task. Paying attention to details can help you avoid careless mistakes and demonstrate your ability to analyze information accurately.

2. Manage your time during the exam

As I’ve said earlier, the Aptitude, or what we call the IQ test is composed of 35 questions. You have to answer all these questions in just 15 minutes. That means you only have about two minutes to answer each item. The proctors are strict regarding the time limit, so never think that they will give you a time extension. Develop a strategy to allocate your time wisely, ensuring that you devote sufficient time to each section while leaving enough time for reviewing and double-checking your answers. The trick is to answer the easy questions first, then go back to the difficult ones in case you still have time. This way, you can maximize the time and increase your chances of completing the test.

Practicing under timed conditions beforehand can help you become more comfortable with the time constraints and improve your efficiency during the actual exam.

3.  Be consistent with your answers

Be mindful of your answers to every question of the exam. Always remember your answer to a particular question because you will be asked similar and related questions in the next following items. You have to be consistent with your answers. Remembering and providing consistent information throughout the examination demonstrates your attentiveness and reliability. In contrast, inconsistent answers may indicate that you are untruthful and just telling lies. By remaining consistent, you will enhance your chances of passing the examination successfully.

4. Learn how to draw

When I say learn how to draw, it does not mean you have to be like Michaelangelo or Da Vinci. If you are told to draw people, do not draw stick figures. Instead, focus on basic human anatomy and proportionality. Draw people with complete parts like ears, eyes, hairs, fingers, etc. Pay attention to details such as body posture, facial expressions, and gestures, as they can provide valuable insights into the individual’s emotional state. Make evident distinctions between males and females e.g., mustache for males and long hair for females. After that, you describe each drawing or make a story out of it in 4-5 sentences.

Remember that the purpose of drawing in this context is not to showcase artistic talent, but rather to communicate information and convey observations accurately. Some of the concepts included here are tricky, and everything being drawn could mean something to the psychologists. Therefore, be careful.

5. Hone your English skills

Sometimes, the exam may include essay exercises. The purpose is to evaluate the incident reporting skills of the applicants. Practice your English writing skills, be precise, and pay attention to the grammar rules. Remember, clear and concise communication is crucial in showcasing your knowledge and competence in the neuro-psychiatric examination.

6. Prepare for the interview

The final part of the exam is the one-on-one interview with a psychologist to assess how you will present yourself under pressure. Answer all the questions with wit, consistency, and fluency. Do not make unnecessary body and hand movements or gestures during the interview. Maintain a calm and composed demeanor throughout the process. Remember to take deep breaths, maintain eye contact, and listen attentively to the interviewer’s questions before formulating your responses. Be honest about your limitations and strengths, as this will demonstrate self-awareness and authenticity. Be snappy and stand firm when talking. Lastly, always be humble.

To wrap it up

The neuro-psychiatric test wants to know if you have the mindset of an average person. Do not pretend that you are an extraordinary one and just be yourself. Be consistent in your answers, bring out the good in yourself, and do not show any violence in your words. Lastly, never leave anything unanswered. Those unanswered questions might determine the result of the neuro-psych whether you are RECOMMENDED or NOT RECOMMENDED. Good luck and may the odds be in your favor.

I usually told my former students and friends and those who are asking some pieces of advice from me before they take their exams these things mentioned above. I emphasized on consistency of answers, I used to work in a Psych department. Also, be descriptive on your drawings and you need to be able to explain what you have drawn. Most of those who ask help from me are now policemen, seeing them around in town and thanking me makes me happy at least. I agree with the author. So have confidence, be ready and be prepared, be humble and …  Read more »

I just hope I can pass the neuro-psychiatric exam for PNP soon. In god’s perfect timing. please lord let the light be in me.

Do i need to be honest even though i have a lot of negativism and lack of confidence .

ff, I lied in my neuro exam too.

How many months/year Neuro exam expire.. or how.long its validity

very nice advice

It is good for me to review my self

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EBN - European Board of Neurology Examination

General information.

The European Board Examination in Neurology is considered to be a tool for the assessment of neurological training and for boosting its standards. It is an important step towards further harmonisation in European neurology.

Successful candidates from all over the world are conferred the title "Fellow of the European Board of Neurology (FEBN)"

The exam is unified based on European Training Requirements in Neurology and EAN Guidelines . It consists of a step 1 written part testing (handling) knowledge, and a step 2 oral part testing other competencies from the CanMEDS roles.

The exam was held in 2009 for the very first time and since then 850 candidates passed the exam.

Joint Education Board

The European Board Examination in Neurology is a joint assignment of both EAN and UEMS SN/EBN via the Joint Education Board (JEB) . Since establishing the JEB, cooperation in this regard is conducted via the board and has a designed framework.

EBN Exam 2024

16th European Board Examination in Neurology 2024

The EBN Exam exists of two partial exams (written and oral) and both will be held  ONLINE  only.

Oral exam : 31 May & 1 June 2024  (Friday/Saturday) Written exam: 7 June 2024  (Friday)

Deadlines: Early bird application deadline: January 15, 2024 Final application deadline: March 01, 2024 Deadline for submitting workpieces (CAT, Essay) for the oral examination: March 5, 2024

Please find more information about the EBN Exam and the Application Process on the Website of UEMS-SN:  UEMS Section of Neurology - European Board Examination (uems-neuroboard.org)

Discounts and Funding

EAN RRFS, Full and Corresponding members, who participate in the exam, receive 20% discount on their congress registration.

All other exam participants and examiners receive a 10% discount off their congress registration fee.

JEB Examination Committee

In order to effectively organise the continually thriving exam, the Examination Committee has been established. This committee is a working group of the Joint Education Board that will coordinate and conduct all activities concerning the exam, from collecting and supervising questions to management of the examination on-site. The nomination is for at least two years.

Composition of the Examination Committee:

Dr. david garcía azorín (uems-sn/ebn) , valladolid, spain   , prof. pablo irimia-sieira (ean), pamplona, spain  , dr francesco di lorenzo (ean), rome, italy  , prof. massimiliano filosto (ean), gussago brescia, italy  , prof. jan b.m. kuks (uems-sn/ebn), groningen, the netherlands, dr. deborah mcintyre (uems-sn/ebn), luxembourg, louxembourg  , dr. tim counihan (uems-sn/ebn), galway, ireland  , ean eqtf representative, hana brozova, prague, czech republic, fellows of the ebn exam.

Find out more