Pupils & Eye Movement Tests CN II · III · IV · VI · VIII
Swinging Flashlight Test (RAPD — Relative Afferent Pupillary Defect)
CN II afferent
Patient
Dim lighting. Ask patient to fixate on distant point. Both pupils should be equal at baseline.
Technique
Swing a bright pen torch from eye to eye, spending ~2–3 seconds on each. Watch the illuminated eye for dilation.
Normal
Both pupils constrict equally when light is shone. No dilation on swing.
Positive
Affected eye dilates when light swings onto it (pupil appears to run away from the light). This is a RAPD (Marcus Gunn pupil).
+ RAPD = optic nerve or severe retinal disease on ipsilateral side. Key sign in optic neuritis (MS), compressive optic neuropathy, ischaemic optic neuropathy, severe glaucoma.
Note
RAPD cannot occur from a lens or vitreous problem alone. Abnormal consensual reflex with normal direct = CN III palsy (efferent defect, not RAPD).
H-Pattern Eye Movement Test
CN III · IV · VI
Technique
Hold finger ~50cm from patient's face. Move in a large "H" shape: right, right-up, right-down, return centre, left, left-up, left-down. Ask patient to report diplopia; watch for restricted movement or nystagmus. Test each eye separately if needed.
CN III
Failure of: medial gaze (medial rectus), up-gaze (SR, IO), down-gaze in abduction (IR). Eye rests "down and out".
CN IV
Failure of intorsion + depression in adduction (superior oblique). Worst looking down-and-in. Patient tilts head away from lesion to compensate.
CN VI
Failure of abduction (lateral rectus). Eye cannot move outward. Horizontal diplopia, worse on looking to affected side.
Nystagmus on lateral gaze: fast phase direction = direction called. Peripheral: horizontal/rotatory, fatigable. Central: vertical, direction-changing, non-fatigable = POSTERIOR FOSSA.
Convergence Test
CN III bilateral + midbrain
Technique
Bring finger slowly towards patient's nose from ~50cm. Eyes should converge and pupils constrict (near response triad: convergence, accommodation, miosis).
Positive
One or both eyes fail to converge, or no pupillary constriction.
Impaired convergence + absent vertical gaze = Parinaud's syndrome (dorsal midbrain lesion: pineal tumour, hydrocephalus). Light-near dissociation (Argyll Robertson pupil) = neurosyphilis, DM.
Pupil Reactions — Systematic Assessment
Critical prehospital
Technique
Assess: size (mm), shape, equality (anisocoria), direct reflex, consensual reflex, and accommodation.
- Unilateral fixed dilated (mydriasis): CN III compression — PComm aneurysm, uncal herniation. EMERGENCY.
- Bilateral fixed dilated: Brainstem death, severe hypoxia, atropine/sympathomimetics, post-ictal, deep anaesthesia.
- Bilateral pinpoint (miosis): Opioid toxicity, pontine haemorrhage, Horner's (partial miosis).
- Horner's syndrome: Miosis + ptosis + anhidrosis (enophthalmos apparent). Ipsilateral sympathetic chain. Causes: Pancoast, carotid dissection, lateral medullary, thoracic cord.
- Anisocoria <1mm: Physiological (20% population).
- Spared pupil CN III: Diabetic mononeuropathy — pupillomotor fibres are on outside of nerve, spared by microvascular ischaemia. Less urgent but needs imaging.
Meningeal Irritation Tests SAH · Meningitis · Encephalitis
Context: These tests detect meningism — irritation of the meninges by blood (SAH), infection, or inflammation. A negative test does NOT exclude SAH or meningitis — sensitivity is moderate. Clinical suspicion drives management.
Kernig's Sign
Meningism
Position
Patient supine. Flex hip and knee to 90°.
Technique
With hip held at 90° flexion, attempt to extend the knee.
Normal
Full passive knee extension achievable (>135°) without pain.
+ Kernig's = inability to extend knee beyond ~135° due to pain/spasm in hamstrings. Suggests meningeal irritation. Bilateral = more significant.
Mechanism
Inflamed meninges stretch when nerve roots are tensioned — hamstrings contract to resist this. Also positive in severe hamstring injury/sciatica (non-specific).
Brudzinski's Sign
Meningism
Position
Patient supine, hands behind head (or your hand supporting occiput).
Technique
Flex the neck briskly — bring chin toward chest.
Normal
No involuntary movement of lower limbs.
+ Brudzinski's = involuntary flexion of both hips and knees when neck is flexed. Patient "curls up". Suggests meningeal irritation.
Mechanism
Neck flexion stretches the inflamed meninges. Reflex hip/knee flexion reduces tension on lumbosacral roots. Same meningeal irritation principle as Kernig's.
Nuchal Rigidity (Neck Stiffness)
Critical sign
Technique
With patient supine, gently try to flex the neck — chin to chest. Also assess lateral rotation. Note resistance, guarding, pain.
Distinguish from
Cervical spondylosis (slow restriction, all movements), torticollis (lateral, muscular), cervical spine injury (do not test if trauma suspected).
+ Nuchal rigidity = resistance to flexion. In combination with photophobia and headache = meningism triad. Any one of the three should raise suspicion.
Prehospital
Absent in ~30% of bacterial meningitis cases — do not be falsely reassured. Non-blanching rash (petechiae/purpura) + any fever = IM benzylpenicillin before transport (if no penicillin allergy).
Jolt Accentuation Test
Higher sensitivity for meningism
Technique
Ask the patient to turn their head horizontally at ~2–3 rotations per second (like shaking "no" rapidly).
+ Jolt accentuation = worsening of headache with head rotation. Reported sensitivity ~97% for meningitis, though evidence base is limited. Useful early screening when classic signs absent.
Coordination & Cerebellar Tests Cerebellum · Dorsal columns · Vestibular
Cerebellar signs: DANIISH — Dysdiadochokinesia, Ataxia (gait/limb), Nystagmus, Intention tremor, Impaired finger-nose, Slurred speech (dysarthria/scanning speech), Hypotonia. Ipsilateral to cerebellar lesion.
Finger-Nose Test
Cerebellar
Technique
Hold your finger ~50cm from patient's face. Ask them to touch their nose then your finger alternately, moving your finger between attempts. Observe trajectory, speed, accuracy.
Normal
Smooth, accurate, no tremor.
+ Intention tremor = tremor that worsens as target approached. Overshooting (past-pointing/dysmetria) = cerebellar ipsilateral. Worse eyes closed + no cerebellar signs = sensory ataxia (dorsal column).
Heel-Shin Test
Cerebellar lower limb
Technique
Patient supine. Ask them to place one heel on the opposite knee and slide it smoothly down the shin to the ankle. Repeat both sides.
Normal
Smooth, straight, controlled slide.
+ = Heel deviates laterally off the shin, jerky or inaccurate movement = ipsilateral cerebellar ataxia. Compare sides. Also impaired in proprioceptive loss.
Dysdiadochokinesia Test (Rapid Alternating Movement)
Cerebellar
Technique
Ask patient to rapidly pronate and supinate one hand on their opposite palm. Or: rapidly tap thumb to index finger. Compare sides.
+ Dysdiadochokinesia = slow, irregular, clumsy alternating movements. Ipsilateral cerebellar lesion. Parkinson's gives bradykinesia (slow but rhythmic). UMN gives slowness with spasticity.
Romberg's Test
Sensory ataxia vs cerebellar
Technique
Patient stands with feet together, arms at sides. Observe 30 seconds. Then ask to close eyes — observe for 30 seconds. Stand close to catch patient.
Normal
Maintains balance with eyes open AND eyes closed (may sway slightly).
+ Romberg = stable eyes open but falls/markedly unsteady eyes closed = dorsal column / proprioceptive loss (sensory ataxia). Patient relies on vision to compensate. Causes: B12 deficiency, tabes dorsalis, MS, peripheral neuropathy.
Unsteady with eyes OPEN = cerebellar (Romberg negative — visual input doesn't help cerebellar ataxia).
Pronator Drift Test
Subtle UMN
Technique
Patient extends both arms in front, palms up (supinated), fingers spread, eyes closed. Hold for 10–15 seconds. Watch for downward drift and/or pronation of one arm.
Variations
Tap the arms downward — the weak arm will drift more after perturbation. Can also observe with eyes open first then closed.
+ Pronator drift = arm drifts down AND pronates (rotates inward). Contralateral UMN lesion. This is often the most sensitive sign of mild pyramidal weakness — may be positive before formal power testing reveals deficit. Also used in NIHSS.
Reflex Tests — Technique & Interpretation UMN · LMN · Roots
Always reinforce if absent (Jendrassik manoeuvre: patient interlocks fingers and pulls hands apart as you test). Grade reflexes 0 (absent), + (reduced), ++ (normal), +++ (brisk), ++++ (clonus).
Plantar Reflex (Babinski Sign)
Key UMN sign
Technique
Use a blunt object (key, orange stick, thumbnail). Stroke firmly along the lateral sole from heel toward little toe, then curve medially across the ball of the foot. Observe the big toe.
Normal
Plantar flexion of big toe (toe curls down). Flexor response = normal.
+ Babinski = big toe extends (dorsiflexes, points up) ± fanning of other toes. Extensor plantar = UMN lesion. Normal in infants under ~18 months (immature corticospinal tracts).
Variants
Chaddock: stroke lateral malleolus. Oppenheim: firm pressure down tibial crest. Gordon: squeeze calf. All elicit same extensor response if UMN lesion present.
Clonus
UMN — sustained
Ankle clonus
Flex knee slightly. Quickly dorsiflex the foot and maintain pressure. Observe for rhythmic beats of plantar flexion/dorsiflexion.
Patellar clonus
Push patella sharply downward and hold. Observe for rhythmic oscillation.
+ Clonus (≥5 beats) = UMN lesion. Sustained clonus is pathological. A few beats can be normal in anxious patients. Cervical myelopathy, spinal cord lesion, severe cortical UMN damage.
Hoffman's Sign
Upper limb UMN
Technique
Hold patient's middle finger loosely. Flick the fingernail downward (or flick tip of middle finger downward rapidly). Watch thumb and index finger.
+ Hoffman's = reflex flexion/adduction of thumb and flexion of index finger after flick. Upper limb equivalent of Babinski. Suggests UMN lesion above C5/C6. Cervical myelopathy, cord compression.
Note
Can be bilateral in anxious/hyperreflexic patients. Asymmetric = more significant.
Corneal Reflex (CN V afferent — CN VII efferent)
Brainstem integrity
Technique
Approach from the side (avoid visual threat triggering blink). Touch the cornea (not sclera or eyelashes) with a wisp of cotton wool. Observe blink in both eyes.
Normal
Both eyes blink. Direct (ipsilateral) and consensual (contralateral) response.
+ Absent direct only = CN VII lesion (efferent — motor) ipsilateral. + Absent both when touching one side = CN V lesion (afferent — sensory) ipsilateral. Absent both sides = severe brainstem dysfunction.
Prehospital
Loss of corneal reflex in reduced GCS = deep coma, pontine pathology. Contact lens wearers may have reduced sensitivity — test both eyes.
Gag Reflex (CN IX afferent — CN X efferent)
Airway relevance
Technique
Using a tongue depressor or gloved finger, gently touch the posterior pharyngeal wall on each side. Observe for gag and note symmetry of palate elevation.
Normal
Bilateral gag. Uvula rises midline. Note: up to 20% of normal adults have reduced or absent gag — absence alone is not pathological.
+ Asymmetric gag or absent on one side only = IX or X lesion. Absent gag + reduced consciousness = aspiration risk. Watch for pooling secretions, nasal regurgitation, hoarse voice (suggesting impaired laryngeal protection).
Vestibular & Hearing Tests CN VIII · Vertigo differentiation
Dix-Hallpike Test
BPPV diagnosis
Setup
Patient sitting upright on bed. Turn head 45° to side being tested. Warn patient of likely vertigo.
- 1Quickly lower patient to supine with head hanging ~30° below horizontal (support head throughout).
- 2Head remains rotated 45° to tested side. Observe eyes for nystagmus for 30–60 seconds.
- 3Ask about vertigo. Return to sitting and observe again for reversal nystagmus.
- 4Repeat for other side after 1 minute.
+ BPPV = delayed onset nystagmus (2–5 second latency), geotropic (toward ground/ear-down), upbeating + torsional, fatigable with repetition, associated with rotational vertigo. Positive on the side of the affected ear.
Negative = no nystagmus. Central cause (posterior fossa tumour, MS, stroke) = immediate onset, non-fatigable, may be purely vertical. HINTS exam distinguishes these.
Contraindications
Suspected cervical instability, recent cervical surgery, severe carotid stenosis — do not perform.
HINTS Exam (Head Impulse, Nystagmus, Test of Skew)
Stroke vs peripheral vertigo
HINTS has higher sensitivity for posterior circulation stroke than early MRI DWI in the first 24–48h. A "reassuring HINTS" (peripheral pattern) has high NPV for stroke. Requires training to interpret reliably.
H — Head Impulse
Hold patient's head, focus on nose. Rapidly rotate head 10–15° to one side. Watch for corrective saccade.
N — Nystagmus
Observe direction and type. Unidirectional vs bidirectional vs vertical.
T — Test of Skew
Cover-uncover test: cover one eye, then rapidly uncover. Observe for vertical refixation movement (skew deviation).
| Component | PERIPHERAL (safe) | CENTRAL (stroke/tumour) |
|---|---|---|
| Head Impulse | + Catch-up saccade (abnormal impulse test) = peripheral | Normal head impulse (no saccade) = DANGER |
| Nystagmus | Unidirectional, horizontal-torsional, beats away from lesion | Direction-changing OR purely vertical OR bidirectional |
| Skew | No vertical skew deviation | + Vertical skew (one eye higher than other) = central |
Central pattern on ANY component of HINTS = treat as posterior circulation stroke. Even one abnormal component overrides others.
Rinne's Test
Conductive vs SNHL
Technique
Strike 512Hz tuning fork. Place base on mastoid process (bone conduction). When patient can no longer hear it, hold fork near external auditory meatus (air conduction).
Normal (Rinne positive) = air conduction > bone conduction after mastoid silent. Normal or sensorineural hearing loss.
Rinne negative = bone > air. Conductive hearing loss on that side (wax, otosclerosis, middle ear effusion, perforated TM, ossicular chain damage).
Weber's Test
Lateralisation
Technique
Strike 512Hz tuning fork, place base on forehead midline or vertex. Ask: "Which side is louder, or is it the same?"
Normal = heard equally both sides (or midline). No lateralisation in symmetric hearing.
Lateralises to: affected side in conductive loss (masking effect lost). Better/unaffected side in sensorineural loss. Use with Rinne to classify type and side of loss.
Spine & Nerve Root Tests Disc · Myelopathy · Cauda equina
Straight Leg Raise (SLR) (Lasègue's Test)
L4–S1 nerve root
Technique
Patient supine. Passively raise the extended leg by the heel, slowly, watching the face. Stop when pain occurs. Note the angle.
Normal
Hamstring tightness at 70–90°. No nerve pain.
+ SLR = radicular pain (down leg in dermatomal distribution, not just back or hamstring) at <60–70°. L4/L5/S1 nerve root irritation — usually from disc prolapse. The more acute the angle, the more significant.
Bowstring sign
At point of pain, flex the knee slightly (relieving tension) then press on the popliteal fossa — reproduces pain. Confirms nerve root irritation.
Crossed SLR
Raising the unaffected leg reproduces pain in the affected leg. Highly specific for large central disc prolapse.
Femoral Nerve Stretch Test (Prone Knee Bend)
L2–L4 nerve root
Technique
Patient prone. Flex the knee to 90°. Passively extend the hip (lifting the knee off the bed). Alternatively, just flex the knee passively with patient prone.
+ = Pain radiating down anterior thigh (femoral dermatomal distribution) = upper lumbar nerve root irritation (L2/L3/L4). High lumbar disc prolapse. Less common than L4/5 or L5/S1.
Spurling's Test (Foraminal Compression Test)
Cervical radiculopathy
Technique
Patient seated. Laterally flex head toward affected side. Apply gentle downward axial pressure on the vertex.
+ Spurling's = reproduction of ipsilateral arm/hand radicular pain or paraesthesia. Cervical nerve root compression (foraminal narrowing from osteophyte or disc). High specificity for cervical radiculopathy.
Caution
Do not perform if cervical instability, fracture, or severe myelopathy suspected.
L'Hermitte's Sign
Cervical myelopathy · MS
Technique
Ask patient to flex the neck (chin to chest). This is often reported spontaneously rather than elicited.
+ L'Hermitte's = electric shock-like sensation down the spine and/or limbs on neck flexion. Pathognomonic of posterior column irritation in the cervical cord. Strongly associated with MS, also cervical myelopathy (spondylosis), B12 deficiency, Chiari, radiation myelopathy.
Lhermitte's Saddle Sensation Check
Cauda equina
Technique
Ask about and test sensation over the perianal area, inner thighs, perineum, scrotum/labia, posterior upper thighs (S3–S5 distribution).
Also ask
Urinary hesitancy/retention/incontinence, faecal incontinence, loss of erection, reduced sensation during intercourse.
+ = Any saddle numbness + bladder/bowel dysfunction in context of back pain/leg neurology = CAUDA EQUINA SYNDROME. Same-day emergency MRI. PR to assess anal tone only if trained and appropriate.
Upper vs Lower Cervical Cord Signs
Myelopathy screen
Screen for
Gait disturbance, hand clumsiness (dropping things, poor dexterity), urinary urgency, hyperreflexia, Hoffman's sign, bilateral Babinski, clonus.
Inverted reflex
Tapping biceps tendon → finger flexion (not elbow flexion) = C5/6 cord + C5/6 LMN lesion simultaneously = cervical myelopathy at that level.
+ Myelopathy signs = urgent MRI cervical spine. Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in adults over 50.
Peripheral Nerve Tests Entrapment · Compression · Tension
Tinel's Sign
Nerve compression/regeneration
Technique
Lightly tap over the suspected compressed nerve with two fingers at the point of entrapment.
Key sites
Wrist (median — carpal tunnel), elbow medial epicondyle (ulnar — cubital tunnel), fibular head (common peroneal), tarsal tunnel (tibial).
+ Tinel's = tingling or electric sensation radiating distally in the nerve's territory on tapping. Suggests nerve compression or regeneration at that site. Not highly sensitive alone — use with clinical context.
Phalen's Test
Carpal tunnel (median)
Technique
Patient holds both wrists in maximal flexion (dorsum of hands together, pointing downward) for 60 seconds. Alternatively: reverse Phalen's = maximal extension.
+ Phalen's = onset or worsening of paraesthesia/numbness in median nerve distribution (thumb, index, middle, lateral ring finger) within 60 seconds. Carpal tunnel syndrome. Sensitivity ~75%, specificity ~47%.
Compare
Durkan's (direct carpal compression): press directly over carpal tunnel for 30 seconds. Higher sensitivity/specificity than Phalen's or Tinel's alone.
Froment's Sign
Ulnar nerve (adductor pollicis)
Technique
Ask patient to hold a piece of paper between thumb and index finger on each side. Try to pull paper away.
+ Froment's = patient flexes the thumb IP joint (using FPL, median nerve) to compensate for weak adductor pollicis (ulnar nerve). "Paper sign" — thumb bends at IP joint. Ulnar nerve lesion (cubital tunnel, Guyon's canal, deep ulnar branch).
Wartenberg's Sign
Ulnar nerve (interossei)
Technique
Ask patient to hold all fingers adducted (pressed together). Observe little finger.
+ Wartenberg's = little finger abducts spontaneously (cannot be held adducted). Weak 3rd palmar interosseus (ulnar). Often accompanies claw hand deformity. Ulnar nerve pathology.
Peripheral Nerve Motor Tests — Quick Reference
Upper limb screen
| Nerve | Test movement | Loss gives | Sensation lost |
|---|---|---|---|
| Median | Thumb opposition (touch little finger base) | Thenar wasting, "ape thumb", benediction hand | Lat. 3½ fingers (palm), index pulp |
| Ulnar | Finger abduction (spread fingers against resistance) | Hypothenar wasting, claw hand (ring/little), Froment's | Med. 1½ fingers + medial palm |
| Radial | Wrist extension against gravity | Wrist drop, finger drop | Dorsum 1st web space (small variable area) |
| Axillary | Shoulder abduction 0–90° (deltoid) | Deltoid wasting, weak abduction | Regimental badge (lateral shoulder) |
| Musculocutaneous | Elbow flexion supinated (biceps) | Weak supinated flexion; pronated (brachioradialis/radial) preserved | Lateral forearm (LACN) |
Neurological Acronyms & Mnemonics A–Z reference
AVPUConscious level — rapid assessment
GCS equivalent: A=15, V=~12, P=~8, U=3. AVPU is rapid; GCS is more granular. Use GCS for ongoing monitoring.
GCSGlasgow Coma Scale
Score /15. ≤8 = severe, intubation threshold. Score the best response. Document as E/V/M not just total.
FASTStroke screen — public & clinical
FAST misses ~14% strokes — particularly posterior circulation. FAST-ED adds Eye deviation and Denial/neglect for large vessel occlusion screening. BE-FAST adds Balance and Eyes.
BE-FASTExtended stroke screen (posterior circulation)
NIHSSNational Institutes of Health Stroke Scale
Score 0–42. 0=normal, 1–4=minor, 5–15=moderate, 16–20=moderate-severe, 21–42=severe. ≥6 suggests large vessel occlusion (thrombectomy candidate). Used for thrombolysis eligibility.
HINTSPosterior circulation stroke screen in acute vertigo
Central (dangerous) = Normal head impulse + Direction-changing nystagmus + Skew deviation. Any central feature = treat as stroke. Superior to early DWI MRI in first 24–48h.
DANIISHCerebellar signs
All cerebellar signs are IPSILATERAL to the lesion. Mnemonic: cerebellar = same side as lesion (unlike cortical). DANISH is the same without the extra I.
RAPDRelative Afferent Pupillary Defect (Marcus Gunn)
Affected pupil dilates when light swings to it. Indicates optic nerve or severe retinal disease on that side. Cannot occur from anterior segment disease alone.
PERLAPupil documentation
Document size in mm both sides (e.g. "PERLA 3mm bilaterally"). Always document if unequal or unreactive — don't just write PERLA if it's abnormal.
MRC ScaleMedical Research Council Power Grading
4- = barely against resistance, 4 = moderate, 4+ = strong but less than normal. Document by muscle group and side.
LOAFMedian nerve intrinsic hand muscles
All other hand intrinsics = ulnar nerve. LOAF = median. Wasting of thenar eminence (APB most reliable) = median nerve lesion (carpal tunnel most common).
AEIOU-TIPSCauses of altered consciousness
Systematic differential for any patient with reduced GCS or confused state. Always check BM first — hypoglycaemia is reversible and easily missed.
Additional Mnemonics & Acronyms
SIADHSyndrome of Inappropriate ADH — neurological cause of hyponatraemia
Causes: SAH, meningitis, encephalitis, head injury, cerebral tumour. Presents with confusion, seizures, coma. Na <125 = severe. Treat with fluid restriction ± hypertonic saline (HDU/ITU). Rapid correction = central pontine myelinolysis.
ROSIERRecognition of Stroke in the Emergency Room
Score: Asymmetric facial weakness (+1), arm weakness (+1), leg weakness (+1), speech disturbance (+1), visual field defect (+1). Seizure at onset (−1), loss of consciousness (−1). Score ≥1 = probable stroke. Used in ED triage.
ABCD²TIA stroke risk scoring
Score 0–7. ≥4 = high 2-day stroke risk (~4%). ≥6 = very high. Replaced by imaging in current UK guidelines (NICE 2023) — all TIAs should have same-day specialist assessment regardless of score.
MELAS · MERRFMitochondrial neurological syndromes (for completeness)
MELAS = Mitochondrial Encephalopathy, Lactic Acidosis, Stroke-like episodes. MERRF = Myoclonic Epilepsy with Ragged Red Fibres. Rare but pattern: young patient, maternal inheritance, stroke + metabolic + myopathy. Prehospital: treat presentations acutely.
WHODASCN mnemonic type reminder
Some Say Marry Money But My Brother Says Big Brains Matter More: CN I=S, II=S, III=M, IV=M, V=B, VI=M, VII=B, VIII=S, IX=B, X=B, XI=M, XII=M
OH OH OH…CN name order mnemonic
Oh Oh Oh To Touch And Feel Very Good Vaginas And Hmm: Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal. (Multiple versions exist — pick one and stick with it.)