Nervous: Examination
- Consciousness
- Environment, general appearance
- Handedness, speech
- Head, neck, neck stiffness
- Cranial nerves
- Upper limbs: inspect,
tone, power,
reflexes, coord,
sensory
- Lower limbs: inspect,
tone, power,
reflexes, coord,
gait, sensory
- Systems: spine, carotid bruit, aspiration
- Bed: one siderail raised (hemiplegia).
- Bed: pt.'s bad eye side placed
against wall so they can't be surprised (stroke).
- Bed: soft mattress to avoid pressure sores (mobility difficulty).
- Bed: V-shaped posture pillows since pt. unable to support self.
- Tables: all meds, etc. within reach of non-siderailed arm (hemiplegia).
- Room: hoist, wheelchair, walker (paralysis).
- Room: NG tube (palsy of throat CN's).
- Room: ventilator, life support machines.
- Age of pt. (Parkinson's usu. 45+, etc).
- Chorea (Huntington's, rheumatic fever, drugs, etc).
- Ethnicity (scandinavian: multiple sclerosis).
- Ballisma, dystonia (usu. drugs), noticeable tremor.
- Posture: leaning to one side (hemiplegia).
- Posture: stooped forward (Parkinson's).
- Only using one hand on tray (hemiplegia).
- Asymmetry, unilateral facial drooping (stroke).
- Ptosis.
- Serpentine stare (Parkinson's).
- Licking of lips.
- Scars of previous operations.
- Trauma, injury, abnormalities.
- Mental retardation syndrome facies: Down's, FAS, etc.
- Eyes: exophthalamos (thyroxicosis), Kayser-Fleisher rings (Wilson's).
- Neck: thymectomy scar (MG).
- Neck: thyroidectomy scar (thyrotoxicosis).
- Beware of performing manipulation on a cervical spine injury pt.
- Hand under occiput, flex neck to chin and see if resistance.
• Resistance causes: raised ICP, cervical fusion or spondylosis, Parkinson's
meningitis.
- If suspect meningitis (fever, photophobia) do Kernig's sign.
Cranial nerves
- Patient sits over side of bed facing you.
- For rest of examination, comparing L side to R side.
- Asymmetry.
- Deformities: wrist drop, waiter's tip, claw hand.
- Muscle wasting, fasciculations. Include shoulder girdle.
- Tremor:
• Intention (cerebellar).
• Resting with pill-rolling (Parkinson's).
• Action tremor (BAT: Benign essential tremor syndrome, Anxiety,
Thyrotoxicosis).
- Feel hand for heat (thryrotoxicosis), grip.
- Pronator drift: pt's eyes closed, arms extended, with palms up. Tap pt's
arms briskly downward (arm drifting into pronation: UMNL, cerebellar,
post. column loss).
- Pseudoathetosis from proprioceptive loss.
- Muscle bulk, tenderness.
- Ask pt. if any tenderness in any joints, so won't hurt them when
manipulating them for tone.
- Grasp under elbow and wrist, and rotate the 2 joints to assess
resistance.
• If Parkinson's, cogwheel rigidity in wrist [combination of tremor and
increased tone].
• If Parkinson's, lead pipe resistance when flexing forearm.
- If ulnar nerve indicated, Froment's sign:
• Give pt a piece of paper for each hand.
• Ask pt to grasp papers by moving straightened thumb to radial side of
index finger.
• Affected thumb is forced to flex at interphalangeal joint to grip paper.
- If median nerve indicated, pen touching test:
• Pt's hand supine.
• Dr. hold's pen above thumb
• Ask pt. to lift thumb to touch it.
• Affected thumb can't touch pen.
- Assess shoulder, elbow, wrist, fingers.
• Assess by ability to push against Dr's hand.
• Assess across a single joint at a time [eg: Dr's hand on bicep, not
forearm, to assess shoulder power].
- If MG suspected:
• Pt. holds arms above head.
• MG pt. will lose power
after contractions.
- See Power Scale Reference.
- Pt. finger touches Dr's fingers, then to pt's nose testing for dysdiadochokinesia, rebound.
- Dysdiadochokinesia:
• Pt's palm on dorsum of their opposite hand.
• Pt flips their hand quickly so the two hand dorsums touch.
• Repeat quickly.
- Dorsal columns (vibration):
• Place on sternum [the last area lost] so pt. knows how the buzzing
feels.
• Pt's eyes shut and 128 Hz fork on distal interphalangeal joint: ask if
felt.
• If can feel, ask pt. to say when it stops, then later stop it.
• If deficient: assess dermatomes at wrist, elbow, shoulder, both anterior
and posterior.
• See Dermatomes Reference.
- Dorsal columns (proprioception):
• Grasp pt's distal phalynx, move up and down to show what to do.
• Tell pt. to close eyes and repeat this, saying whether it's up or down.
- Spinothalamic (pain, forget temperature):
• Sterile toolpick or broken wood tongue depressor on forehead or anterior
chest.
• Pt. closes eyes, tells if sharp or dull.
• Stick each dermatome looking for cord, dermatome, peripheral nerve,
stocking glove.
- Light touch: cotton wool. Dab skin lightly, don't stroke.
- If lesion, feel for thickened nerves:
• Ulnar at elbow
• Median at wrist
• Radial at wrist
• Axilla.
- Asymmetry.
- Muscle wasting, fasciculations, tremor.
- Muscle bulk: quads, anterior tibials.
- Foot bruising, infections from peripheral neuropathy.
- Orthopods may roll legs for a quick preliminary inspection of tone.
- Tone of knees, ankles.
- Test clonus by pushing lower end of quads sharply down towards knee (sustained contractions:
UMNL).
- Power: hips, knees, ankles. "Lift leg, don't let me push it
down". "Push leg down, don't let me push it up".
- See Power Scale Reference.
- Knee (L3-4).
- Ankles (S1-2).
- Plantar (L5, S1-2).
- Ankle clonus test:
• Place pt's knee bent, thigh externally rotated.
• Dr lifts pt's heel in Dr's cupped hand.
• Dr quickly dorsiflexes pt's ankle and holds it flexed for 3 seconds.
• Clonus if sustained movement afterwards.
- See Deep
Tendon Reflexes Reference.
- Heel-shin test:
• Pt kicks a heel out, then touches that heel to other shin.
• Repeat in a smooth motion loop.
• Alternatively: heel sliding up and down on opposite shin.
- Toe-touching test.
- Tapping of feet.
- Walk few feet then walk back.
- Notice signature gaits:
• Trendelenberg gait (proximal myopathy).
• Shuffling gait (Parkinson's).
• High-stepping gait (foot drop).
• Hemiplegic gait [swinging one leg in lateral arc] (usu. stroke).
- Walk heel to toe (hard: midline cerebellar).
- Walk on heels (hard: L4-5 footdrop).
- Squat or sit then stand up (proximal myotrophy).
- Romberg sign positive if unsteadiness is worse when eyes closed.
- Sensory pin prick, vibration, proprioception, light touch. Same as was for
Upper Limbs.
- If peripheral sensory loss, try to establish sensory level. See Dermatomes
Reference.
- Examine sensation in saddle region.
- Test anal reflex (S2-4).
- Back: deformity, scars, neurofibromas.
- Palpate for tenderness over vertebral bodies.
- Straight leg raising test:
• Pt tries to lift straight leg.
• Full lifting will be prevented if slipped disc.
- For more, See Rheumatoid Examination.
- Paralyzed pt may have aspirated fluid. See Pulmonary
Examination.
- Feeding assistance devices, such as PEG (dysphagia, usu. 2º to
neurological damage, like stroke).