Physical examination maneuver

Physical Exam

HINTS Exam

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Video coming September 2026

How to Perform

Perform three bedside steps in a patient who has continuous spontaneous nystagmus. First, the horizontal head-impulse test: with the patient fixating your nose, turn the head abruptly a small amount to each side and watch for a corrective catch-up saccade. Second, observe the nystagmus with the eyes in primary position and in gaze to each side, noting the direction of the fast phase and whether it stays the same or changes with gaze direction. Third, the test of skew: perform an alternating cover test, covering and uncovering each eye in turn, and watch for a vertical corrective movement of the eye as it is uncovered.

How to Interpret

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References

  • Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev. 2023 Nov 2;11(11):CD015089. doi:10.1002/14651858.CD015089.pub2. PMID 37916744. PMC10620998. Cochrane diagnostic-test-accuracy review; bivariate pooling; composite estimate from the 8-study advanced-imaging-reference subgroup (n=1146).
  • Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510.

Related Bedside Tests

🎬Video coming Sept 2026
Alternate Cover Test (Test of Skew)
aka Cross-cover test
Rule in:IEPeripheral Vestibular Dysfunction, IEPosterior Circulation Stroke
Rule out:IEPeripheral Vestibular Dysfunction, IEPosterior Circulation Stroke
🎬Video coming Sept 2026
Head Impulse Test
aka Head thrust test; Halmagyi test
Rule in:HPosterior Circulation Stroke, SHPeripheral Vestibular Dysfunction
Rule out:HPeripheral Vestibular Dysfunction, HPosterior Circulation Stroke
🎬Video coming Sept 2026
Nystagmus Characterization
Rule in:IEPeripheral Vestibular Dysfunction, IEPosterior Circulation Stroke
Rule out:IEPeripheral Vestibular Dysfunction, IEPosterior Circulation Stroke
🎬Video coming Sept 2026
Dix-Hallpike Maneuver
Rule in:IECentral Vestibular Lesion, IEPosterior Canal BPPV
Rule out:IECentral Vestibular Lesion, IEPosterior Canal BPPV
🎬Video coming Sept 2026
Pupillary Light Reaction
Rule in:IEAnticholinergic Toxicity, IECholinergic Toxicity, IECranial Nerve III Palsy +7 more
Rule out:IEAnticholinergic Toxicity, IECholinergic Toxicity, IECranial Nerve III Palsy +7 more
🎬Video coming Sept 2026
Gait Assessment
Rule in:IEAcute Neurologic Event or Severe Pain, IEAlcohol-related Cerebellar Degeneration, IEBilateral Hip Arthritis or Disease +20 more
Rule out:IEAcute Neurologic Event or Severe Pain, IEAlcohol-related Cerebellar Degeneration, IEBilateral Hip Arthritis or Disease +20 more