Neurological Examination Procedures
Screen in a fixed order
Mental status and cranial nerves when the complaint is cephalic, then motor grading (0–5), sensory testing by dermatome (light touch, pinprick, vibration, proprioception), reflexes (0 to 4+, with clonus), coordination (finger-to-nose, heel-to-shin, rapid alternating movements), station and gait, and meningeal signs when fever or sudden headache is present.
Upper versus lower motor neuron
Lower motor neuron findings - hyporeflexia, flaccidity, atrophy, fasciculations - localize to root or peripheral nerve. Upper motor neuron findings - hyperreflexia, spasticity, Babinski, Hoffman, clonus - localize to cord or brain. Bilateral symptoms, gait disturbance, clumsy hands, or bowel/bladder change in a patient with neck pain should raise suspicion of cervical myelopathy; that patient needs imaging and referral, not an adjustment.
Traps
Grading a 4+ reflex when 2+ is normal; testing light touch alone and missing a pinprick level; failing to test the contralateral side; dismissing a Babinski sign as age-related; confusing radicular pain (sharp, distal, dermatomal) with referred somatic pain (deep, aching, proximal).
Worked example
C6 radiculopathy: diminished biceps and brachioradialis reflexes, weakness of elbow flexion and wrist extension, sensory loss over the lateral forearm and thumb. C7 by contrast shows a diminished triceps reflex, weak wrist flexion, and middle-finger sensory loss.
Rule of thumb
Name the specific root or nerve you believe is involved, and state which findings support and which contradict it.