Nervous System Examination

Question 1

What steps should be taking when doing observation of upper limbs in a neurological examination?

Answer 1

Look for:
Scars 
Wasting 
Involuntary movements 
Fasciculations
Tremors
Skeletal deformities

Question 2

What steps should be taking when assessing tone of upper limbs in a neurological examination?

Answer 2

Ask patient to relax and text tone by performing:
Passive movement of elbow flexion and extension
Forearm pronation and supination
Wrist flexion and extension

Question 3

What steps should be taking when assessing power of upper limbs in a neurological examination?

Answer 3

Test:
Shoulder abduction(elbows in air, push up hard against you)
Elbow flexion and extension(pull me towards you, push away with elbows flexed)
Wrist flexion and extension (make a fist and cock it back while examiner resits, push fist down against resistance)
Finger flexion and extension (hold fingers out straight as examiner tries to flex them at the knuckles)
Intrinsic muscles of hand (spread fingers and resist examiner pushing them shut)
Pronator drift (patients arms out in front with palms up and eyes closed- watch for any drifting)

Question 4

What steps should be taking when assessing co-ordination of upper limbs in a neurological examination?

Answer 4

Finger-nose test
Outstretched arms to test for postural tremor or dystonia
Dysdiachokinesis (rapidly moving hand movements)

Question 5

What steps should be taking when assessing reflexes of upper limbs in a neurological examination?

Answer 5

Biceps- place thumb or index finger over biceps tendon and strike own finger
Supinator- place index finger over a point 3-4cm above the distal end of the radius with the patients arm semi-pro ages and then strike own finger
Triceps- strike the tendon directly about 2cm above the olecranon

Question 6

What steps should be taking when assessing sensation of upper limbs in a neurological examination?

Answer 6

Light touch (cotton wool thumb, middle and little fingers then medial and lateral aspects of forearm and arm)
Pinprick- neurotip on same areas as light touch 
Vibration- place 128Hz tuning fork on distal landmark such as most distal joint of finger, if can't be felt move proximally 
Joint position sense- patient close eyes and test proprioception of one finger

Question 7

What steps should be taken when observation lower limbs in a neurological examination?

Answer 7

Look for:
Scars
Wasting 
Involuntary movements 
Fasciculations 
Tremors
Skeletal deformities

Question 8

What steps should be taken when assessing tone of lower limbs in a neurological examination?

Answer 8

Check if patient has any pain 
Passive movement of:
-hip rotation
-hip flexion
-knee flexion
Assess for clonus- rotate ankle then sudden dorsiflexion

Question 9

What steps should be taken when assessing power of lower limbs in a neurological examination?

Answer 9

Test the following movements against resistance:
Hip flexion and extension (push thigh up and down against resistance)
Knee flexion and extension (bend knee and pull towards/push away)
Ankle dorsiflexion and plantarflexion (pull foot towards/push away them keeping knee straight)
Big toe extension (pull big toe towards them)

Question 10

What steps should be taken when assessing co-ordination of lower limbs in a neurological examination?

Answer 10

Heel shin test

Question 11

What steps should be taken when assessing reflexes of lower limbs in a neurological examination?

Answer 11

Knee reflex- place your left forearm under the knee and lift it so the heel is still laying on the bed, strike the patellar tendon (Assesses L3 and L4)
Ankle reflex- stretch foot while patient flexes knee and rotates hip and strike Achilles’ tendon (assesses S1)
Use reinforcement if not initially present- ask patient to interlock fingers and pull apart when you say
Plantar response

Question 12

What steps should be taken when assessing sensation of lower limbs in a neurological examination?

Answer 12

Light touch- medial and lateral aspect of each foot, medial and lateral shin, medial, mid and lateral thigh
Pinprick- same as light touch
Vibration
Joint position test- hold toe laterally
Romberg’s test- stand up with eyes closed and see if they come off balance

Question 13

What steps should be taken when assessing gait in a neurological examination?

Answer 13

Assess rising from sitting 
Observe patient: 
Walking and turning
Walking heel-to-toe
Walking on tiptoes and on heels

Question 14

How is the first cranial nerve tested in clinical examination?

Answer 14

Ask about any change in smell- unilateral or bilateral

Question 15

How is the second cranial nerve tested in clinical examination?

Answer 15

Visual acuity- ask if patient can see equally with each eye, snellen chart more accurate- testing one eye at a time
Pupillary responses- afferent reflex CNII, efferent CNIII
Visual fields- compare patients visual field with your own by sitting opposite them at the same level and test visual field with your hand equi-distant between the patient and yourself
Visual inattention- sit facing patient and ask patient to look at your face then point to the hand with the moving finger
Accommodation- ask patient to focus on your finger as you move it closer
Fundoscopy

Question 16

How is the third cranial nerve tested in clinical examination?

Answer 16

Eye movements- follow H and ask patient to tell you if they have any double vision

Question 17

How is the fourth cranial nerve tested in clinical examination?

Answer 17

Follow the H

Question 18

How is the fifth cranial nerve tested in clinical examination?

Answer 18

Sensation- touch ophthalmic, maxillary and mandibular divisions using cotton wool and neurotip
Motor- palpate bulk of masseter muscle and ask patient to clench teeth, ask patient to open jaw against resistance to test pterygoids
Corneal reflex- afferent V1 and efferent CNVII
Jaw jerk reflex- afferent and efferent V3

Question 19

How is the sixth cranial nerve tested in clinical examination?

Answer 19

Follow the H with eyes

Question 20

How is the seventh cranial nerve tested in clinical examination?

Answer 20

Inspection of face for any asymmetry
Motor- look at facial movement- have patient wrinkle forehead, screw up eyes and smile/show their teeth. Ask patient to fill cheeks with air then press gently on their cheeks to try and expel air

Question 21

How is the eighth cranial nerve tested in clinical examination?

Answer 21

Vestibular- check for nystagmus(usually done when testing eye movements)
Check balance (done when testing gait)
Hearing- whisper tests, tuning fork tests

Question 22

How is the ninth and tenth cranial nerve tested in clinical examination?

Answer 22

Inspection- ask patient to open mouth and say ah, look to see if palate moves symmetrically and uvula stays central
Ask patient to cough and head if it sounds normal
Gag reflex- only when clinically indicated

Question 23

How is the eleventh cranial nerve tested in clinical examination?

Answer 23

Trapezius function- place hands on patients shoulders and ask them to shrug their shoulders
SCM function- get patient to turn head so you can see SCM then push against the side of your fist with their face

Question 24

How is the twelfth cranial nerve tested in clinical examination?

Answer 24

Inspection- ask patient to open mouth and look at the tongue at rest for fasciculation, wasting or deviation
Motor- ask patient to Stick out tongue and move it from side to side
Speech- ask them to say the days of the week

Question 25

What questions need to be asked in an abbreviated mental test?

Answer 25

Age 
Time 
Address 
Year
Name of this place
Identify 2 persons 
DOB
Date of First World War 
Name of present monarch
Count backwards from 20 to 1

Question 26

What questions need to be asked in a mental status questionnaire?

Answer 26

Name of this town 
Their address 
Current year 
Current month
Current date 
Age
Month of birth 
Year of birth 
Name of the current prime minister
Name of the previous prime minister