Neurological examination

Question 1

recite the process of a limb neurological examination.

Answer 1

1. Introduce self and wash hands
2. look at patient from end of bed, assess for muscle wasting and compare both sides. Look for fasciculations.
3. assess the tone of the arms by shaking their hand loosely and eliciting as much passive movement as possible. In the legs simply shake the thighs from side to side and lift the knees from the bed.
4. assess the power of the shoulders, elbows, wrists, fingers (grip and extend) abduction and adduction and thumb abduction/adduction- can also assess function such as hands behind head and picking up a coin.
5. finger-nose coordination test, heel shin test (slide heel up and down the contralateral shin)
6. reflexes: biceps, triceps, supinator, knee, ankle and plantar- reinforce by clenching teeth if needs be.
7. test sensation using cotton wool, neurotip and then proprioception of the thumb joint and big toe.

Question 2

Examine the second cranial nerve.

Answer 2

Optic. Snellen chart. Cover each eye and then do both eyes together.
Confrontation testing of visual fields. Face the patient and ask them to cover one eye and cover your corresponding eye. Wiggle your finger in each of the four quadrants and ask when the patient can see them. Test the direct and concentric visual reflexes by shining a penlight into both eyes and looking first for constriction of pupil in the eye being tested and then the other. Perform a fundoscopy by telling the patient to fix on a point over your shoulder and dim the lights, make sure half of your face does not overlap with the patients, get as close as possible. Also perform testing of accommodation reflex by asking the patient to focus on a distant point and the your finger.

Question 3

Examine the first cranial nerve.

Answer 3

Olfactory. Have you noticed any changes in your sense of smell?

Question 4

Examine the third, fourth and sixth cranial nerve.

Answer 4

Occulomotor, trochlear, adbucens. Asking the patient to keep their head perfectly still, draw double H shape with your index finger in front of the patient and ask them to follow it with their eyes. Ask if there is any blurred vision and watch for nystagmus.

Question 5

Examine the fifth cranial nerve.

Answer 5

Trigeminal. Ask the patient to clench their jaw and feel the masseter muscle bulk as well as the temporalis. Ask them to open their mouth against resistance (lateral pterygoid). Then ask them to close their eyes and stroke the ophthalmic, maxillary and mandibular portions of the trigeminal nerve comparing both sides for sensation testing.

Question 6

Examine the seventh cranial nerve.

Answer 6

Facial nerve. Ask the patient to perform a few facial expression. Ask them to crease up the forehead or frown, keep eyes closed against resistance, puff out cheeks and show their teeth.

Question 7

Examine the eighth cranial nerve.

Answer 7

Vestibulocochlear nerve. Perform a whisper test asking the patent to repeat what you have just uttered and then perform Rinne’s test by paling an active tuning form on the mastoid process, asking them when they can hear it and when it stops and then placing the form in front of their ear to see if they can hear that better. Webers test place tuning fork in middle of forehead and ask which side it is heard loudest.

Question 8

Examine the ninth cranial nerve.

Answer 8

Glossopharyngeal nerve. Ask patient to open their mouth and place a tongue depressor near the back of the throat- gag reflex.

Question 9

Examine the tenth cranial nerve.

Answer 9

Vagus nerve. Ask the patient to say ‘Aah’ and watch the uvula rise evenly.

Question 10

Examine the eleventh cranial nerve.

Answer 10

Accessory nerve. Ask the patient to shrug their shoulders against resistance, and turn their head against resistance.

Question 11

Examine the twelfth cranial nerve.

Answer 11

Hypoglossal nerve. Ask the patient to show their tongue and watch for deviation or fasciculations indicating a lesion ( tongue deviates in direction of lesion ).