Neurological examination

• Limb motor examination  

  

  Mnemonic:

  • Observe The Patient Really F'ing Carefully.
  • Observation, Tone, Power, Reflexes, Function, Co-ordination.

  Observation

  Inspect carefully and for a good amount of time, moving around and crouching to make sure you properly look, including under feet and/or on both sides of hands (turn them over).

  Look for SWIFT:

  • Scarring, and ask if there's any you can't see.
  • Wasting
  • Involuntary movements.
  • Fasciculations: take time, look in plane.
  • Tremor

  Upper limb:

  • Ask if left or right handed.
  • Pronator drift: have them extend arms palms up, eyes closed. If there is an UMN lesion, contralateral pronation is stronger, causing pronation ± drift. If there is a cerebellar lesion, the contralateral arm may drift upwards.
  • Limb rebound: have them push their outstretched, upturned palms against your straight arm. If there is a cerebellar hemisphere lesion, the ipsilateral arm will jump up when you move your arm away.

  Tone

  First check there is no pain, then look for changes in tone by passively moving their limbs. Types of increased tone include:

  • Spasticity: velocity-dependant hypertonia, usually reflecting a corticospinal lesion. May lead to a fixed flexion deformity (aka contracture), and the clasp-knife response, whereby passive movement is initially rigid then suddenly gives.
  • Rigidity: general hypertonia throughout range of movement ('led-pipe'), possibly with an underlying tremor ('cogwheel'). Suggests extrapyramidal disease.

  Upper limb:

  • Have them relax their arm, then passively flex and extend all joints.
  • Holding their hand as if shaking it, pronate and supinate the forearm, slowly (rigidity) then quickly (spasticity: supinator catch).
  • Extrapyramidal signs at the wrist can be increased with distraction, by asking them to 'paint a fence' with the other hand.

  Lower limb:

  • Roll relaxed legs, rotating at the hip.
  • Lift lower leg, then jolt up and see if foot drags along bed (normal) or jerks up (spasticity).

  Power

  Rate on the MRC scale, where 0 is no contraction, then:

  1. Flicker of contraction
  2. Some active movement but not against gravity e.g. horizontal across a surface.
  3. Active movement vs. gravity.
  4. Active movement vs. resistance but less than normal.
  5. Normal power.

  Key points:

  • In general, try and test joints in a resistant to gravity position, to check if they are at least 3/5.
  • Stabilise joint with one hand, and test with the other.
  • If power seems reduced, make sure it really is by asking them to resist you as best as possible.
  • As well as the MRC scale, power can be described as 'collapsing weakness' if it is strong then gives way.

  Upper limb:

  • Do one side at a time, except the shoulders, done simultaneously.
  • Shoulders: they do chicken wings, and you push up (tests adduction) and down (tests abduction).
  • Elbows: they put fists up and you pull (tests flexion) and push (tests extension).
  • Wrist: they cock their wrists back with palm facing forwards, and you push down (tests extension). Then they point their hands down, and you push up (tests flexion).
  • Fingers: they straighten out (extend) their fingers and you push down (tests radial nerve), they spread out their fingers (abduct) and you push in (tests ulnar nerve), and they place palms face up and point thumb up (abduct) which you try and push down (tests median nerve).

  Lower limb:

  • Hip: they lift leg up, then you try and push down with one arm at upper leg (not below knee). Then ask patient to pin leg down to bed, and you try and lift around the level of the patella.
  • Knee: they flex knee with foot off bed, then try to push and pull against your hand. Note that if they can stand, likely knee extensors are 5/5.
  • Ankle: they cock their feet back, with you demonstrating with your hands, then you push down on their feet (tests dorsiflexion, aka extension). Then they push their feet down like on a pedal, with you pushing up (tests plantarflexion, aka flexion). If they have foot drop, you have to passively dorsiflex the foot before asking them to plantarflex down.
  • Toes: optional, but if doing it, make sure to do both dorsi- and plantarflexion.

  Summarizing:

  • Sample description of weakness: "The patient has a {global/proximal/distal}, {unilateral/bilateral/symmetrical/asymmetrical}, {mild/moderate/severe} weakness of the {upper/lower} limbs". This is probably more useful and comprehensible than listing the MRC score for each joint.

  Reflexes

  Key points:

  • Hyperreflexia ('brisk' reflexes) suggest established UMN lesions.
  • Hyporeflexia suggests LMN lesions. If you can't elicit, distract them and watch muscle closely for twitches. Then report "reflexes absent, even with distraction"; don't chicken out and say "couldn't elicit the reflexes".

  Upper limb:

  • Biceps reflex: tap thumb held over biceps tendon, and look for flexion at elbow.
  • Supinator reflex (aka brachioradialis reflex): tap fingers places over posterior radial area, looking for finger grab.
  • Triceps reflex: have patient bring hand to anterior mid-line, then tap your fingers placed over the triceps, looking for a muscle twitch.
  • Distraction: ask them to clench their teeth together.
  • If brisk reflexes are found, also check the finger reflex – place your fingers across their upturned fingers, tap and look for flexion – and Hoffman reflex – flick distal phalanx of middle finger, and look for thumb flexion.

  Lower limb:

  • Knee: sling your arm under their leg and place it on their other knee, then tap just below patella. Alternatively, they can hang legs over side of bed.
  • Ankle: they splay legs, you dorsiflex the ankle, you tap the achilles. Alternatively, they can hang legs over the side of the bed, or kneel on a chair with the ankle unsupported and the achilles facing up.
  • Distraction: grab hands together, and pull on 3 (when you tap for the reflex).
  • Babinski reflex (aka plantar reflex): firmly stroke plantar foot with an orange stick, neurotip, or finger nail, moving lateral then across to medial. A +ve sign is extension of the big toe (extensor plantar response), suggesting an UMN lesion. Flexion of the big toe (plantar flexor response) is normal.
  • Clonus: with the knee flexed, have them relax their foot, then you firmly jerk it upwards. Unsustained clonus (1-2 beats) is normal, but sustained clonus suggests an UMN lesion.

  Function

  • Upper limb: do a button.
  • Lower limb: walk, then walk on tiptoes and heels, then walk on line ('tightrope'). If obviously unsteady with normal walking, no need to do the latter two.

  Co-ordination

  Impairment of co-ordination, known as ataxia, suggests a cerebellar lesion. If it involves over- or under-shooting a movement, it is known as dysmetria.

  Upper limb:

  • Finger-nose coordination: patient moves fingertip from their nose to your fingertip, which is held at their full stretch arm length. Move your finger while they're withdrawing it back to their nose, not as they're reaching for it. If there is difficulty, there is "finger-nose ataxia".
  • Dysdiadochokinesia: clap their hands together, rapidly alternating the side of one.
  • Finger-thumb coordination: patient touches each finger to the thumb in turn.
  • Now a good time to check for bradykinesia: ask them to repeatedly and rapidly pinch their thumb to their index finger, and "keep the movement nice and big". In Parkinsonism, the movement will become slower and smaller.

  Lower limb:

  • Heel-shin test: drag heel of one foot down the shin of the other.

• Limb sensory examination

  Pain and touch

  • Check the spinothalamic tract (pain) with a neurotip, and dorsolateral tract (soft touch) with twisted cotton wool, touching their skin with their eyes closed.
  • Clearly test either side of axial lines (e.g. T1/2 on medial arm, C5-7 on lateral), as these divisions are clear.
  • Alternate left/right sides at each dermatome to check they are equal.

  Vibration

  • 128 Hz tuning fork on bony prominence. Demonstrate on sternum first so they know what it feels like.
  • Have the patient look away and say when it stops (when you grip the fork firmly).
  • Start distal then, if sensation absent, move proximal. Knuckles, wrist, then elbow for the upper limb, and big toe, medial malleolus, then tibial tuberosity for the lower limb.

  Proprioception

  • Hold distal interphalangeal joint on both sides, then move up and down, asking patient where it is.
  • Ask them to say "up, down, or not sure" – the latter to presents lucky guesses – and check 3 times.
  • Demonstrate up/down movement with eyes open first to explain.

  Diabetic foot exam

  Look:

  • Lower leg and foot.
  • Make sure to check between toes and on back of feet.

  Feel:

  • Temperature
  • Pulses: DP and PT. Use doppler US if available.
  • Cap refill.

  Check foot sensation with 10 g neurofilament, pushing until it bends:

  • 5-10 points on the sole e.g. 1st, 3rd, and 5th toes, 1st, 3rd, and 5th MTPs, then 2 in the middle and 1 at the back.
  • No point testing callused areas as they will be insensate.

  Further sensory testing:

  • Modalities: fine touch (cotton wool), vibration, proprioception.
  • Go from proximal to distal, as we're looking for peripheral neuropathy and not central or root lesions. Start at distal feet and move up leg until sensation felt.

  And finally:

  • Ankle jerk reflex.
  • Gait
  • Inspect shoes.

• Cranial nerve 1 and nasal examination

  CN1 exam

  Ask: "any change in your sense of smell lately?"

  ENT nasal exam

  Inspect:

  • External surface of nose: skin disease or deformity?
  • Stand behind patient and ask them to look up. Look down the nose from above to detect any deviation.
  • Press on the tip of the nose to elevate it and inspect the anterior nares.

  Nasal speculum (thudicums), large-bore speculum, or an auriscope for internal inspection:

  • Note if the septum is in the midline, any bleeding points, clots where bleeding has recently stopped, or perforations.
  • On the lateral wall, inspect the anterior end of the inferior turbinate. In children, the middle turbinate may also be visible. Turbinates appear red and vascularised, and are tender to touch, while polyps are white/grey and non-tender.
  • Specialists can see the postnasal space by using a small mirror inserted through the mouth and passed beyond the soft palate, or by passing a nasal endoscope to the back of the nose.

  Palpation:

  • Feel the nasal bones gently to distinguish bony from cartilaginous deformity.
  • Feel any facial swelling for tenderness.
  • Block each nostril in turn and ask the patient to breathe in so that you can assess nasal obstruction.

• Cranial nerve 2, 3, 4, and 6 examination and fundoscopy

  Examines vision (CN2) and movement of extraocular muscles (CN3, 4, 6)

  Observe

  Inspect in primary position (patient looking ahead), looking at/for:

  • Are the pupils equal, central, and circular?
  • Eyelids. If ptosis is present, note fraction of pupil covered.
  • Conjugate gaze: are both eyes looking in the same direction?
  • Nystagmus
  • Double vision: hold up one finger and ask how many they see. If diplopia present, check with each eye covered in turn, which usually resolves it (unless monocular diplopia).

  Reflexes

  The following check CN2-3 function:

  • Pupillary response/light reflex: bring in torch light from side, first watching ipsilateral pupil for direct response, then watching contralateral pupil for consensual response. Do the other eye. Don't be too close or too straight on.
  • Swinging light test: focus torch on one pupil for 3 seconds, then quickly move to other. Initial constriction then slight dilation is normal. Affected side would dilate notably in relative afferent pupillary defect (RAPD).
  • Accommodation (pupillary constriction, convergence, accommodation): ask patient to focus on pen (held far) or distant point, then finger (near). Eyes should rotate medially and pupils constrict.

  Acuity

  Ask if they normally wear glasses:

  • If yes, keep them on for vision testing. If they don't have them with them, use pinholes.
  • Make them use distance glasses (driving, TV), not reading glasses.
  • This is important, as we are testing best corrected vision.

  Snellen chart with patient 6 meters away:

  • Patient covers each eye in turn (ideally with paddle) and establishes lowest line they can read.
  • Mark them as the furthest line down they scored no more than 2 errors on. Alternatively whatever line their closest to, then +1,2.. or -1,2…
  • 6/6 is normal i.e. the patient can see at 6 m what most people can see at 6 m. 6/60 is really bad i.e. the patient can see at 6 m what most people can see at 60 m.
  • The chart distance should be written on it. For a 3 m chart the numbers written on will have been calibrated for the equivalence on a 3 m chart, so still report as e.g. 6/6.

  If unable to read Snellen chart from 6 m, try the following in turn until they see something:

  • Move the chart to 3 m (3/60), and if still unable, 1 m (1/60).
  • Count fingers.
  • Wave hands. Would record as e.g. "hand movement at 0.5 m".
  • Shine light on each sides.

  Alternatives to Snellen:

  • Check reading vision with anything available. Again, cover each eye in turn.
  • Jaeger chart: have them read, one eye at a time, with them holding it at a normal reading distance (i.e. not right up in their face). Rate them as whatever the notation is next to last read para e.g. N1.
  • Tumbling E: hold at 6 m, and have the patient point with their fingers which way the E's fingers are pointing. Useful as tests acuity without requiring literacy.

  Colour vision testing:

  • Ishihara charts.

  Movement

  • Have them keep their head still while they follow your finger making a H and then going up and down in the centre.
  • Ask them to report any pain or double vision.
  • You may need to gently hold their head still.
  • Look for nystagmus, diplopia, and comment on degree of movement impairment (% or °).
  • If multiple and/or bilateral deficits, check for fatigability (myasthenia gravis) by asking them to hold upward gaze.
  • Patient may have an abnormal head posture to make up for lesion e.g. looking towards side of CN6 palsy, or head turned and chin depressed in CN4 palsy.

  Inattention and fields

  Inattention:

  • Hold both hands up, wiggle fingers, ask them to point at which ones. Do this in superior field and inferior field.
  • If there is loss, can usually still see it if one side done alone, but when wiggling both they only see one.

  Fields:

  • Position yourself in front of patient, knees almost touching (arm-length from their shoulder).
  • Central vision: each eye covered in turn, "does my face look normal with all features present?".
  • Gross test first (optional): have patient cover each eye in turn. Raise your hand either side of midline of open eye, with one holding 1 finger, and the other 2, and ask how many. Do it superior then inferior, thus covering all quadrants.
  • Both you and patient cover opposite eyes (e.g. your right their left) – using palm not fingers to prevent peeking – then you wiggle a finger in each quadrant in turn, starting at the periphery and bringing it in. Switch hands but not eyes as you cross. Then do other eye. A white pin can be used instead of a wiggling finger.

  Colour desaturation:

  • Hold red pin in centre of visual field, and ask what colour it is: if they say pale or pink, suggests desaturation (indicating optic nerve damage).
  • Have them compare between eyes.
  • If they already reported a problem in one eye, do the good eye first.
  • Compare the 4 fields centrally, checking for desaturation in each.

  Blind spot:

  • Move pin horizontally across vision until it disappears.
  • Move back and forward until it disappears for patient.
  • If patient's blind spot is bigger than yours, it may indicated papilloedema.

  Fundoscopy

  Aka ophthalmoscopy.

  Method

  Basics:

  • Patient focuses on fixed point behind you, with their glasses off, sitting while you stand.
  • Hold scope vertically and to your eye.
  • Use your right hand and right eye to examine their right eye, and then switch for the left.
  • Use a smaller aperture light setting if the pupil is small.
  • Ideally dilate pupils with 1% tropicamide, allowing 15 minutes to take effect.
  • Take a systematic approach with ROAM: Red reflex, Optic disc, Arcades, and Macula.

  Red reflex:

  • Best seen from 15 cm away, 15° from midline.
  • Absent (black) in cataracts (and opaque lens).

  Visualise the optic disc, with brighter optic cup in its centre:

  • Move in, rest your thumb on their brow.
  • Find vessels, focus, and follow to a bifurcation, which will point to the disc. Should be midway down and medial, and you usually have to move downwards and inwards to get there.
  • Should be pale, clearly defined, with no cupping or swelling.
  • A swollen optic disc – with unclear edges – can be a sign of papilloedema, optic neuritis, or deposits (e.g. drusen). Papilloedema is a swollen disc due to ↑ICP, suggesting a space-occupying lesion, cerebral oedema, or hypertension. Only say what you see i.e. a swollen disc, and suggest papilloedema as a possible cause, but don't say that you can 'see papilloedema'.
  • Cupping: cup:disc ratio ≥0.5. Sign of glaucoma.
  • Blood in disc: sub-arachnoid haemorrhage (SAH).

  Arcades and macula:

  • Follow vascular arcades (vessels), looking up, down, left, and right.
  • Can also look at other parts of the retina by having them look in the direction of the part you want to see.
  • Visualise the macula: move laterally or ask them to quickly look into the ophthalmoscope light.

  Findings

  White stuff:

  • Hard exudates: yellow flecks of phospholipids, due to ↑cholesterol.
  • Cotton wool spots: nerve fibre ischaemia from diabetes, HTN, HIV, or anaemia.

  Red stuff:

  • Pre-retinal (aka vitreous) haemorrhages are big blobs, seen in diabetes (DM), SAH, and HTN.
  • Flame haemorrhages have feathery edges, seen in HTN.
  • Blots are medium-sized (Both DM or HTN).
  • Dots are small microaneurysms (DM).

  Diabetic retinopathy:

  • Non-proliferative retinopathy: hard exudates (shiny vs. dull drusen), cotton-wool spots, blot and dot haemorrhages.
  • Proliferative retinopathy: fragile new vessels, pre-retinal haemorrhages.

  Hypertensive retinopathy:

  • Chronic hypertension: AV nicking (as stiff arteriole crosses larger vein, indents and deviates vein), silver wiring (lining of arterioles).
  • Hypertensive crisis: cotton wool spots, papilloedema, blot and flame haemorrhages, macular star.

  The sensitivity of fundoscopy by non-specialists for many of these findings is poor, and retinal photography is often needed for reliable diagnosis.

• Cranial nerve 5 examination

  Examines facial sensation and masticator function.

  Sensation:

  • Use twisted cotton wool piece for soft touch (chief sensory nucleus) and a neurotip for pain (spinal trigeminal nucleus). First demonstrate on sternum.
  • Ask patient to close eyes and say when you touch and if it feels the same on both sides.
  • Do left then right for each division (CN51-3), all with wool then all with the neurotip.

  Motor (CN53) examination of the muscles of mastication:

  • Patient clenches jaw then you feel bulk of temporalis and masseter.
  • Patient opens mouth and protrudes jaw. Move left and right against your resistance.

  Reflexes:

  • Jaw jerk (CN53 for both afferent and efferent): place your thumb under patient's mouth and tap. Should not close or perhaps just move slightly. Marked closure suggests UMN lesion.
  • Corneal reflex (CN51 afferent and CN7 efferent): as the patient looks up and away, you gently touch a wisp of cotton to the iris (i.e. cornea) near the junction with the sclera. Both eyes should blink. Do it away from the pupil, as that would trigger a blink reflex (CN2).

• Cranial nerve 7 examination

  Examines facial expression.

  Inspect for asymmetry of:

  • Wrinkles
  • Nasolabial folds.
  • Mouth

  Ask patient to make movements:

  • Raise eyebrows: temporalis muscle, CN7 temporal branch. Remember if it's an UMN lesion, the upper face is spared as its supply is bilateral, while the contralateral lower half is affected.
  • Close eyes tightly, and you try to open them: orbicularis oculi muscle, CN7 zygomatic branch.
  • Purse lips tightly, and you try to open each side: orbicularis oris muscle, CN7 buccal branch. Blowing out cheeks also tests this.
  • Bear teeth in cheesy smile: lower lip depressors, CN7 marginal mandibular branch.
  • Grimace: platysma, CN7 cervical branch.

  Ask about:

  • Taste on the anterior tongue.
  • Increases in loud noises, which may suggest a weak stapedius failing to dampen noise.

  If CN7 palsy found, do otoscopy to check for cholesteatoma.

• Cranial nerve 8 examination and otoscopy

  Examines hearing and balance.

  Inspection and palpation

  • Look for scars (including behind ear), redness, swelling, or discharge.
  • Palpate for tenderness over mastoid and tragus. Latter suggests otitis externa.

  Crude hearing

  • Stand behind ear to examine, and ask them to cover opposite ear, or you press on tragus.
  • Whisper number from 2 feet away (20-25 dB). If they can't hear, try talking (30-35 dB), or loud speech.
  • Test other ear.

  Tuning fork tests

  Use 512 Hz tuning fork.

  Rinne's test compares bone and air conduction of sound:

  • Ding fork and place base against mastoid process.
  • Ask patient when they stop hearing the noise. When they say yes, place the other end of the fork to the ear and ask if they can hear it.
  • +ve response is normal i.e. airway has better conduction.
  • -ve response is abnormal i.e. bone conduction is better. Suggests ipsilateral conductive loss.

  Weber's test:

  • Ding fork and place base on forehead.
  • Ask if equal, or stronger on one side.
  • Lateralises towards conductive loss and away from sensorineural loss.

  Summary of findings:

  • Sensorineural loss: Rinne's +ve (as bone and airway have equal loss) and Weber's away.
  • Conductive loss: Rinne's -ve and Weber's towards. The latter occurs because bone conduction is better on the affected side since there is no interference from airway sound. Suggests external or middle ear disease.

  Otoscopy

  Basics:

  • Use biggest speculum possible.
  • Hold scope horizontally and to your eye, with index finger running along like pencil, resting little finger on their cheek.
  • Your right hand and right eye for their right ear, then switch for the left.

  Process:

  • Tilt patient's head away, pull pinna up and back (or just back for kids), and go in shallow.
  • Don't push too deep, just rotate in place. Move around to observe the full tympanic membrane.

  Normal tympanic membrane:

  • Grey (not red from inflammation).
  • Semi-transparent (not opaque).
  • Cone of light clear and towards feet (not dispersed as if bulging).
  • Flat (not bulging).
  • Intact (not perforated).

  Romberg's test

  Romberg's test for balance mainly tests leg and trunk proprioception, so actually not a good test of vestibular balance.

• Cranial nerves 9-12 and mouth examination

  CN9-10 – Palate, swallow, and phonation

  Note if speech is normal:

  • Hoarseness would suggest recurrent laryngeal nerve (CN10) damage.
  • Laryngeal function also checked with swallow or cough.

  Shine torch in mouth as patient says 'ah':

  • Palate should elevate symmetrically and uvula should remain central.
  • CN10 lesion would lead to uvula deviating away and palate not rising on affected side.

  Gag reflex (CN9 afferent and CN10 efferent):

  • Touch palatine tonsils.
  • Not really done!

  ENT mouth exam

  • Open mouth, look at buccal mucosa, teeth, and gums with torch. Note dental hygiene and any gingivitis. Inspect hard palate for cleft palate, high arched palate, or telangiectasia.
  • Use tongue depressor stick to move apart teeth from gums, looking in creases, on the top then bottom. Any discoloration, inflammation, or ulcers? Make sure to look in the retromolar area (beyond the end of the teeth), as it is a common site for squamous cell carcinoma.
  • Look for the sublingual caruncle at the base of the lingual frenulum, where Wharton's duct (submandibular) and the sublingual duct drain. Then look for Stensen's duct (parotid) adjacent to the second upper molar.
  • Get them to say aah, and hold down tongue with tongue depressor. Look at soft palate (cleft, telangiectasia?), uvula (symmetrical?), tonsils (size, colour, discharge, symmetry).
  • Get them to lift tongue and look underneath.
  • Get them to stick tongue out and look on side for lumps.
  • If you see any lesion, palpate with gloves.

  CN11 – Spinal muscles

  • Patient shrugs shoulders, and resists you pushing down.
  • Patient turn head to left and tight, and resists you pushing.

  CN12 – Tongue intrinsic muscles

  • Inspect for any fasciculations.
  • Patient protrudes tongue and move left and right. Deviates towards CN12 lesion.
  • Patient pushes tongue against inner cheek, and resists your hand pressing on outer cheek.