THE NEUROLOGICAL EXAMINATIONS

Full Cranial Nerve Examination:

• General Inspection:
  • Altered Level of Consciousness?
  • Patient Alert? Oriented to Person Place & Time?
  • Facial Asymmetry?
  • Evidence of Trauma?
  • Fasciculations/Tremors?
  • Muscle Wasting?
  • Speech Impediments (Dysphasia?/Dysarthria?/Dysphonia)
  • Ptosis?
  • Inability to Close the Eye?
  • Facial Muscle Wasting?
  • Facial Sweating?
• I – Olfactory:
  • “Have you noticed any change in smell or taste lately?”
• II – Optic:
  • “Have you noticed any changes in your vision lately?”
  • Obtain Corrected Visual Acuity in Each Eye Separately, then both eyes. (Snellen’s Chart)
  • Assess for Colour Blindness (Ishihara Charts)
  • 6 Point Visual Field Testing (confrontation position. Use hat pin and cover ipsilateral eyes)
  • Pupil Response to Light (Direct & Consensual + Swinging Torch Test)
  • Fundoscopy (Cataracts/Diabetic Retinopathy/Hypertensive Retinopathy)

• III – Occulomotor, IV – Trochlear & VI – Abducens:
  • “Keeping your head still, follow this hat pin with your eyes”
  • “Let me know if at any time you begin to see double”
  • Do the 6-speed gearbox positions
  • Asymmetrical Movement of the Eyes
  • Nystagmus (NB: This is a sign of Cerebellar Pathology – and always points to the side of the lesion)
  • Occulomotor: Superior Rectus, Medial Rectus, Inferior Rectus, Inferior Oblique
  • Trochlear: Superior Oblique
  • Abducens: Lateral Rectus

• V – Trigeminal:
  • “I’m going to be testing your facial sensation now using a sensory pin”
  • “First I’m going to test your “Sharp” (Pain) sensation, and this is what it feels like (on sternum)”
    • Pain: Ophthalmic Division, Maxillary Division, Mandibular Division
  • “next i’m going to test your “light touch” sensation, and this is what it feels like (on sternum)”
    • Light Touch (Cotton Wool): Ophthalmic Division, Maxillary Division, Mandibular Division.
  • “Ok now look straight ahead with your eyes wide open thankyou”
    • Corneal Reflex (Cotton wool): touch rolled cotton wool onto the corneas from the sides
  • “Next I’m going to test the motor function of the trigeminal nerve”
    • “Clench your jaw please” ➔ Feel the Masseter Muscle
    • “Open your jaw and resist me closing it” ➔ Pterygoids
    • “Just open your jaw halfway and relax, and I’m going to tap it with this” ➔ Jaw jerk reflex

• VII – Facial Nerve:
  • “Wrinkle your forehead and don’t let me flatten it”
  • “Close your eyes and don’t let me open them”
  • “Smile”
  • “Puff out your cheeks and don’t let me squash them”
  • (NB: UMN Lesions – you lose the Lower Quadrant of the face on the Contralateral Side)
  • (NB: LMN Lesions – you lose the Whole Half of the face on the Ipsilateral Side)

• VIII – Vestibulocochlear Nerve:
  • “Next I’m going to test your hearing and balance”
  • Romberg’s Test (“Stand feet together and close your eyes”)
  • Weber’s Test (“Tell me if you hear the sound more in one ear, or is it equal in both?”) – Comment on lateralisation. If it lateralises to one ear, then there is CONDUCTIVE DEAFNESS in that ear.
  • Rinne’s Test (“Tell me when you cannot hear the sound any more”) – then move the blades close to the ear canal – “Can you hear it now?”
  • Whisper Test (“No repeat what I whisper” – 69, 100) Whilst distracting the other ear with rubbing fingers.

• IX – Glossopharyngeal & X – Vagus:
  • “Open your mouth and say AH”
    • Look for asymmetrical elevation of the Uvula.
  • Mention that you’d also do the gag reflex.
  • “Can you say your name please” – Assess for Hoarseness
  • “Can you cough please” – Assess for bovine cough.
• XI – Accessory Nerve:
  • “Turn your head to the side and resist me moving it” (Contralateral Sternocleidomastoids)
  • “Shrug your shoulders and resist me pushing them down” (Trapezius)

• XII – Hypoglossal:
  • “Poke your tonge out as far as you can”
  • Assess for Asymmetry (The tongue will point to the side of the lesion)

“Thankyou that concludes my examination”

Focussed Cerebellar Examination:

• Introduction + Wash Hands + Consent
• General Inspection:
  • Patient Alert & Orientated?
  • Tremor? Fasciculations
  • Wasting?
  • Evidence of Head Injury?
• Speech:
  • Say “British Constitution” (Listen for Dysphasia, Dysarthria, Dysphonia)
• Horizontal Nystagmus:
  • Oscillations of the eyeball when looking from one side to the other.
  • NB: Nystagmus always points to the side of the cerebellar lesion.
• Standing Coordination:
  • Romberg’s Test – “Stand with feet together and close your eyes for me” – SUPPORT THE PATIENT:
    • Loss of balance with eyes closed = Proprioceptive Dysfunction (Dorsal Column)
    • Loss of balance with eyes open = Cerebellar Dysfunction

• • GAIT:
    • Walk Normally (Note any wide-based gait = Cerebellar Dysfunction)
  • Heel to toe Walking:
    • Inability to do this = Cerebellar Dysfunction
  • Pronator Drift – “Can you open your palms, raise your arms out to the front and close your eyes”:
    • Upward Drift = Cerebellar Dysfunction
    • Downward Drift = Pyramidal
  • Rebound – “Can you raise your arms out to the front as quick as you can and then stop them”:
    • Rebound = Cerebellar Dysfunction
  • Disdiodochokinesis:
    • “Clap your hands like this as fast as you can”
  • Finger nose Test (Past Pointing):
    • Touch your nose
    • Touch my finger

• Supine Coordination:
  • Heel-Shin Test:
    • “Place your heel on your knee and slide it down your shin…then lift off…then back to knee & repeat.”
    • 
  • Finger Toe Test (Past Pointing):
    • Touch My finger
    • Tough the bed
    • Etc.
  • Disdiodochokinesis:
    • “Tap my hands with your feet alternating as fast as you can.”
  • Clonus:
    • Flex the knee, externally rotate the hip, and Rapidly Dorsiflex (Sustained Rhythmic Contraction = Clonus = Cerebellar Dysfunction)
• Truncal Ataxia:
  • “Have a seat…Cross your arms…now stand up without using your hands”

“Thankyou that concludes my examination”

Focussed Upper Limb Neurological Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • “Can you please take your shirt off”
  • “Patient appears alert and oriented, and in no apparent pain or distress”
  • Wasting (LMN Lesion)?
  • Tremors (Parkinsons/Benign)? Fasciculations (LMN Lesion)?
  • Scars? Deformities?
  • Bruising? Injury?
  • Asymmetry?
  • “Are you left or right handed?”
• Vital Signs
• Motor Function:
  • Muscle Bulk/Wasting of:
    • Intrinsic Hand Muscles
    • Forearm
    • Biceps/Triceps
    • Shoulders
  • Tone – Hyertonia (UMN Lesion), Hypotonia (LMN Lesion), Cogwh./Leadpipe Rigidity (Parkinson’s):
    • Shoulder Abduction/Adduction
    • Shoulder Flextion/Extension
    • Elbow Flexion/Extension
    • Supination/Pronation
    • Wrist Flexion/Extension
    • Finger Flexion/Extension
  • Power – Graded 0➔5 (0=None; 1=Flicker; 2=Gravity Limited; 3=Gravity Unlimited; 4=Fatigue; 5=Full)
    • Shoulder Abduction (C5, C6) “Pick up sticks”
    • Shoulder Adduction (C7, C8) “Lay them straight”
    • Elbow Flexion (C5, C6) “Pick up sticks”
    • Elbow Extension (C7, C8) “lay them straight”
    • Wrist Flexion (C6, C7) “Point to heaven”
    • Wrist Extension (C7, C8) “lay them straight”
    • Grip Strength (C7, C8) “masterbate”
    • Finger Adduction & Abduction (C8, T1)
    • Thumb Opposition (C8, T1)
  • Reflexes – Hyperreflexia (UMN Lesion); Hyporeflexia (LMN Lesion):
    • Triceps Reflex (C6, C7)
    • Biceps Reflex (C5, C6)
    • Brachioradialis (C5, C6)
  • Coordination/Cerebellar Function:
    • Pronator Drift – “Can you open your palms, raise your arms out to the front and close your eyes” (Downward = Pyramidal; Upward = Cerebellar)
    • Rebound – “Keep your hands there & your eyes closed, and don’t let me move your arms” OR “Quickly raise your arms to the front and stop”.
    • Disdiodochokinesis – “Clap your hands like this as fast as you can”
    • Past-Pointing (Cerebellar Dysfunction) – “Touch your nose, Touch my finger”
• Sensory Function – (Standardise on Sternum first):
  • • • OVER ALL DERMATOMES:
        • C3 (Corporals Patch)
        • C4 (Corporals Patch)
        • C5 (Biceps)
        • C6 (Thumb)
        • C7 (Middle Finger)
        • C8 (Pinky)
        • T1 (Medial Forearm)
        • T2 (Medial Bicep)

• • 1. Pain (Spinothalamic)
    • EYES CLOSED
    • (Temperature – Not done)
  • 2. Vibration (Dorsal Column)
    • Start Distally ➔ Move Proximally
  • 3. Proprioception (Dorsal Column)
    • EYES CLOSED
  • 4. Light Touch (Both Pathways)
    • EYES CLOSED

“Thankyou that concludes my examination”

Focussed Lower Limb Neurological Examination:

• Introduction, Wash Hands, Consent,
• General Inspection:
  • Standing:
    • Muscle Wasting? (LMN)
    • Fasciculations? (LMN)
    • Scars? Deformities?
    • Injury?
    • Involuntary Movements?
  • GAIT – “Can you walk to the other end of the room, turn round, and walk back”. Look for:
    • Foot Drop L4 + L5 Lesion (Common Peroneal/Fibular Nerve Palsy)
    • Cannot Walk on Toes S1 Lesion.
    • Shuffling Gait (Parkinsons)
    • Wide Based Gait (Cerebellar)
    • Poor Heel-Toe Walking (Cerebellar)
  • Romberg’s Test – “Stand with feet together and close your eyes for me” – SUPPORT THE PATIENT:
    • Loss of balance with eyes closed = Proprioceptive Dysfunction (Dorsal Column)
    • Loss of balance with eyes open = Cerebellar Dysfunction
• Motor Function – On Examination Couch:
  • Muscle Bulk:
    • Feel for any wasting (LMN Lesion)
  • Tone – (Hypertonia = UMN Lesion; Hypotonia = LMN Lesion; Cog/Leadpipe Rigidity = Parkinson’s):
    • Hip Flexion
    • Knee Flexion & Extension
    • Ankle Flexion & Extension
    • Toe Flexion & Extension
  • Power:
    • Hip Flexion (L2, 3, 4) “Enforce the Law” (With Roundhouse Kick)
    • Hip Adduction (L2, 3, 4) “Enforce the Law” (With Roundhouse Kick)
    • Hip Abduction (L2, 3, 4) “Enforce the Law” (With Roundhouse Kick)
    • Hip Extension (L5, S1) + (S2) “Tense your bum”
    • Knee Extension (L3, L4) “Kick the Ball”
    • Knee Flexion (L5, S1) “Kick your bum”
    • Dorsiflexion (L4, L5) “Walk on Fire”
    • Plantar Flexion (S1) “Find your son”
  • Reflexes:
    • Patellar Tendon (L3, L4) “Kick the Ball”
    • Archilles Tendon (S1) “Find your son”
    • Plantar Reflex/(Babinski’s Positive if UMN Lesion)
  • Coordination/Cerebellar Function:
    • Disdiodocokinesis:
      • “Tap your feet against my hands as quickly as possible”
    • Finger-Toe Test (Past Pointing Test):
      • “touch my finger, touch the bed, touch my finger”
    • Heel-Shin Test:
      • Place your heel on your knee and slide it down your shin, lift off, and place back on knee…Repeat.
    • + Test for CLONUS (Cerebellar Dysfunction)

• Sensation:
  • OVER ALL DERMATOMES – With EYES CLOSED:
    • L1 Garter Band 1
    • L2 Garter Band 2
    • L3 Anterior Knee
    • L4 Medial Calf
    • L5 Lateral Calf
    • S1 Lateral Foot (little toe)
    • S2 Posterior Thigh

• • Pain
  • Vibration
  • Proprioception
  • Light Touch
• Special tests for Meningitis:
  • Kernig’s Sign – Neck pain on hip flexion & knee extension
  • Brudzinski’s Sign – Involuntary Hip Flexion & knee Extension on Neck Flexion
  • Neck Stiffness – Pain on Neck Flexion

“Thankyou that concludes my examination”

Happy Learning!!