Neurological Examination

■ IPTRCS

■ GENERAL INSPECTION
■ Remember to look for asymmetry.
1. Stand back and look at the patient for an abnormal posture—for example,
one due to hemiplegia caused by a stroke. In this case, the upper limb is
flexed and there is adduction and pronation of the arm, while the lower limb
is extended.
2. Look for muscle wasting, which indicates a denervated muscle, a primary
muscle disease or disuse atrophy. Compare one side with the other for
wasting and try to work out which muscle groups are involved (proximal,
distal or generalized, symmetrical or asymmetrical).
3. Inspect for abnormal movements, such as tremor of the wrist or arm.
■ P: Power is graded from 05
– 0 = nil, 1 = flicker, 2 = unable to sustain posture against gravity, 3 = able to
sustain posture against gravity, 4 = subnormal power (against resistance), 5 =
normal power.
■ Tone
■ R: if reflexes are absent, do the reflex re-inforcement. In UL, ask the patient to
clench their teeth. In LL, ask the patient to ‘Grip your fingers and pull your hands
apart’
■ Muscle Stretch reflexes (deep tendon reflexes):
– Biceps: C5,6
– Brachioradialis: C5,6
– Triceps: C6,7
– Quadriceps (knee-jerk): L2,3,4
– Gastrocnemius and soleus (ankle jerk): L5; S1,2
■ Sensation: Fine touch (cotton wool wisp, don’t stroke the skin – hair movement!), Temperature,
Vibration (128 Hz)– acromion / elbow / wrist / ASIS / knee / malleolus, Proprioception – upper and
lower limb digits (joint position sense).
■ Quick test of lower limb power
– stand up on his or her toes (S1)
– stand up on the heels (L4, L5)
– squat and stand again (L3, L4)

■ Coordination (cerebellum):
– Finger nose: Look for the following abnormalities: (1) intention tremor, which is tremor increasing
as the target is approached (there is no tremor at rest); and (2) past-pointing, where the patient’s
finger overshoots the target towards the side of cerebellar abnormality. These abnormalities occur
with cerebellar disease.
– Dysdiadochokinesis: This movement is slow and clumsy in cerebellar disease and is called
dysdiadochokinesis
■ Heel–shin test:
■ Toe–finger test
■ Type of cases that involve neurological exam:
– CN exam
– TIA
– Conversion disorder
– Bells palsy case
– Parotid enlargement case
– Cholesteatoma