Table 1.

Tips for Performing the Adult Neurologic Examination in a Telemedicine Visit^24,45

General Appearance	Inspection via Video
Vital signs∗	Possible if patient has home equipment for measurement of blood pressure, pulse, and weight
Mental status	Video observation •Ascertain if patient is alert and oriented to person, place, and time •Test immediate recall, recent and remote memory (3–5 items) •Montreal Cognitive Assessment (MoCA) BLIND (without visual items) •Assess mood, behavior, and affect
Speech	Evaluate fluency, comprehension (midline and cross-midline commands), naming, repetition, reading, and writing •Can use the National Institutes of Health Stroke Scale (NIHSS) standard materials (cookie jar picture, naming sheet, word list, and sentence list)
Cranial nerves	Visual fields∗: may be possible if patient has large screen or with assistance of another individual
	Extraocular movements: use video zoom function •Ask patient to look in 6 cardinal positions of gaze •Ask patient to fixate on camera and rotate head left and right for fixation •Assess for presence of nystagmus
	Fundoscopic examination∗: possible with smartphone app, FDA-approved applications include iExaminer, PaxosScope (DigiSight) •Look for pupil symmetry
	Visual acuity: assess ability to read newsprint with either eye
	Face: examine visually for symmetric movements, facial weakness •Look for strong eye closure, symmetrical facial movements (smile, puff cheeks, purse lips)
	Hearing: evaluate grossly if intact to voice, can have patient or tele-examiner test bilateral hearing by rubbing fingertips together near ears
	Palate: inspect for symmetric palate elevation, may be helpful to use video zoom function
	Shoulders: assess for symmetric shoulder shrug
	Tongue: Look for midline protrusion. Note asymmetry, deviation, hemiatrophy
Motor examination	Muscle bulk: assess visually via video
	Strength∗: hard to get full strength peripheral neuromuscular examination without tele-examiner present •Arms: Can assess for signs of mild weakness via pronator drift (Barré test), digiti quinti sign, barrel roll, finger taps •Legs: Can assess for signs of mild weakness via Mingazzini maneuver, ask patient to stand up from a chair without using their arms. Inquire about the ability to climb stairs.
	Tone∗: difficult to examine
	Abnormal movements∗: may be able to assess for bradykinesia, chorea etc. via video •Assess essential tremor via Parts A and B of the Clinical Rating Scale for Tremor (CRST)39, 40, 41 •Assess Parkinson disease motor symptoms via subscales 1, 2, and 3 of the Unified Parkinson's Disease Rating Scale (UPDRS)42 , 43
Sensory examination∗	Need help of a family member or tele-examiner •Can assess bilateral dermatomes for light touch, pin prick, and temperature if skilled examiner
Cerebellar examination	May need help of family member or tele-examiner •Gait and station testing: watch the patient stand on one leg, walk (normal gait and on heels and toes) •Rapid alternating hand movements, foot tapping •Instruct patient to demonstrate heel to shin
	Coordination: •To assess for dysmetria have patient extend arm fully then bring fingertip to touch their nose (finger-to-nose maneuver) •Perform Romberg test •Ask patient to walk in tandem
Reflexes∗	Difficult to assess without skilled examiner present •∗Deep tendon, plantar, Babinski reflexes if tele-examiner present

Limitations of the telemedicine neurologic examination
Comprehensive eye examination	•Cannot assess corneal reflex •May be difficult to assess visual fields
Neuromuscular examination	•Reflex testing may not be possible •Difficult to fully assess peripheral strength and grade subtle strength differences between sides of the body •Limited assessment of tone and rigidity •May be hard to detect subtle signs of Parkinson's disease: in particular rigidity and retropulsion pull testing44
Vestibular examination	•Cannot perform HINTs exam (Head Impulse, Nystagmus, Test-of-skew) for vestibular syndrome
Cerebellar examination	•Cannot perform Dix-Hallpike test for cerebellar infarction

FDA, Food and Drug Administration.

^∗Elements of the examination that may be more difficult to perform.