Neurology

Question 1

Upper Limb

Answer 1

General inspection
Pillow under arms
Good exposure, ideally top off
- Facies
- Symmetry
- Obvious scars
- Back

Screening movements - legs, face (confirm just upper limb issue)

Inspection

• Wasting
• Fasciculations - motor neuron disease
• Split hand

Pronator drift
- Fatigue drift
- Cerebellar - upward drift
- Abnormal proprioception
Gentle push down ?return to normal
Play piano

Tone

• Shake hands ?myotonia
• Hypertonia (UMN)
• Rigidity

Power
Give yourself mechanical advantage - push furthest away from joint to give yourself leverage
Make sure to isolate the joint
- Shoulder flex C5/C6
- Shoulder extend C6/C7
- Shoulder abduct C5/6
- Elbow flex C5/6
- Elbow extend C7/8
- Wrist flex/extend C7/8
- Finger flexion/extension
- Finger abduction C8/T1

Reflexes

• Biceps
• Triceps - cross arms
• Hoffman reflex - flexion of thumb on light flicking of third digit

Finger nose coordination
Dysdiadochokinesis

Sensation 1. Spinothalamic (pain and T) 2. Dorsal (vibration, proprioception)
Dermatomal and cape area
- ?same on sternum versus hand
Ask “same?” - keep answers binary
If unclear, can check of forehead or nose
- Can skip cotton wool
- Proprioception small movements, should be able to feel 1-2 degrees
- Don’t tap tuning fork too strong, shouldn’t ring

Think as you go, formulate as you go
Consider whether other areas should be examined

Question 2

Lower limb

Answer 2

Stance - broad, narrow
Gait & general inspection
Inspect back
- Observe each joint
- ?Foot drop
- Heel to toe
- Walking on heels
Observe arm swing as well
Squat, lunge of each leg

Rhombergs
Consider retropulsion if obvious PD

Inspection

• Bulk
• Wasting
• Fasciculations

Tone

• Roll ?leadpipe
• Clonus - ankle (up to 5 beats is normal), patellar

Power

• Hip flex L2/3
• Hip extend L4/5/S1
• Hip abduct L2/3
• Hip adduct L4/5
• Knee flex L5/S1
• Knee extend L3/4
• Dorsiflexion L4/5
• Plantarflexion “step on my hand” L5/S1
• Inversion/Eversion turn foot it “keep it there”

Reflexes

• Knee - rest on your arm
• Externally rotate leg, mild knee flexion
• Ankle
• Plantar w/ thumb

Heel-shin
Toe tap

Sensation - Spinothalamic and Dorsal
Distal to prox ?stocking 
DON'T need to do dermatomes
- Sharp tip
- Proprioception - toes, knee
- Vibration - start and stop
- No cotton wool

Question 3

Cranial Nerves

Answer 3

General inspection

• Ptosis
• Myasthenia Gravis
• Horners

CN I - ?smell

CN II
- Can they see
- Glasses
- Visual acuity
- Pinhole
- Visual fields - small level of pt, knee to knee, tell me when you see the 'red'
Cover your own eye
- DW about blind spot
- Red colour desaturation

CN III, IV, VI

• Eye movements
• Pain, diplopia
• Nystagmus - direcitonal, vertical (central), horizontal (peripheral), bidirectional, gaze evoked (cerebellar)
• Accommodation
• RAPD, afferent pupilary defect
• Cover/uncover test (not essential)

Fundoscopy

• Arm on shoulder
• Find red reflex
• Move in close
• “can’t see”

CN V

• Sensation
• Corneal reflex - ask
• Masseter - jaw or clench

CN VII
?Horner's
Sweat, ptosis
- Forehead
- Shut eyes
- Puff cheeks/smile
- Ant 2/3 tongue taste

CN VIII

• Fingers to distract one ear, whisper number in other
• Rinne - 256Hz
• Weber - 256Hz
• Audioscope

CN IX/X

• Uvula deviation (points away from defect)
• Fasciculations
• Proud tongue (points towards defect)
• Gag reflex

CN XI
- Shoulder, SCM
CN XII

Jaw jerk

Test others
- Fatigueability - chicken wings

Question 4

Most common neuro cases

Answer 4

1. CN VII palsy
2. CN VI palsy
3. CN III palsy v. Horner