CLINICAL NEUROLOGICAL EXAMINATION

INTRODUCTION
DEAR MEDICAL SUDENTS:
• THIS BOOKLET IS WRITTEN TO AID YOU IN CLINICAL NEUROLOGICAL
EXAMINATION.
• THE SKELETON OF THE CURRICULUM IS OSCE BASED (OBJECTIVE
STRUCTURED CLINICAL EXAMINATION.
• THE COURSE IS DIVIDED INTO FOUR WEEKS & FIFTH FOR REVISION
IF TIME TABLE ALLOWS.
• THE STUDENT SHOULD PREPARE & STUDY THE WEEK”S PROGRAME
ON ATTENDING THE DAY OF THE CLINICAL SESSION.
• THE TEACHER”S DUTY IS TO IMROVE, DISCUSS, SUPERVISE THE
CLINICAL SKILLS & ILUUSTRATING VAGUE POINTS.
• THE PROGRAMM NEEDS TEAM WORK & PREAPARTION OF THE
WEEK”S PROGRAM WHILE ATTENDING THE SESSION.
• WEEK BY WEEK THE SCHEDULE SHOULD GO ON, WHO EVER IS THE
TEACHER SUPERVISING THE SESSION.
• ANYTIME DON’T HESITATE TO CONDUCT THE TEACHER FOR NOTES.

GOOD LUCK

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 CLINICAL NEUROLOGICAL EXAMINATION

FIRST WEEK
KEYNOTES IN CLINICAL EXAMINATIN:
• By each station in clinical examination, you should be able to answer the two
questions:
• WHERE is the lesion?
• WHAT is the lesion?
• Understanding the principle of UMNS & LMNS and the differentiation between
them & anatomical localization of the lesion in the pyramidal pathway.
• Keeping in mind the dermatomal distribution.
• Realization the concept of contralateral cerebral control versus the ipsilateral
cerebellar control of the body.
• Retrivation of basic neuroanatomical background.

PARADIGMS OF NEUROLOGICAL EXAMINATION

• GENERAL NEUROLOGICAL EXAMINATION

GAIT.
CONSCIOUS
MENTAL STATE
SPEECH
MENINGEAL SIGNS

• EXAMINATION OF THE CRANIAL NERVES

(12 PAIRS)

• EXAMINATION OF THE UPPER & LOWER LIMBS

MOTOR
SENSORY
CEREBELLAR

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 CLINICAL NEUROLOGICAL EXAMINATION
GENERAL NEUROLOGICAL EXAMINATION
GAIT:

Inspecting patients walk for 10 meters & while turning through 180* & return, to
notice abnormality in stance, arm swings, steps, stride & stability ….etc
EX:

• Hemiplegic gait (circumduction gait): the patient walks with affected leg
extended difficult to flex hence making out semicircle.
Where? Contralateral pyramidal tract.
• Shuffling gait (parkinsonism): narrow stance, flexed legs as if glued to the
ground (shuffling). Where ? contralateral basal ganglia.
• Scissoring gait: bilateral hyperextended difficult to flex legs causing scissor like
walk. Where? Bilateral pyramidal tract lesion.
• Waddling gait: weakness of hip flexors thence using trunk aid to flex more the
legs. Where ? proximal myopathy.
• Ataxic gait: tendency to (VEER or SWAY) to the side of the lesion despite
accepted power. Where ? ipsilateral cerebellum.
• High steppage gait: weakness of foot dorsiflexion, hence hyperelevating the
legs to avoid stumbling. Where? Peroneal or sciatic injury (dorsiflexors).
• Stamping gait: loss of foot sensation that is touching ground, hence depending
on the sound of feet slapping (stamping) the ground. Where? Sensory
neuropathy.

CONSCIOUSNESS:
• Sleep & consciousness is complex subject that is switched on & off by the the
ASCENDING RETICULAR ACTIVATING SYSTEM in the pontomedullary junction &
modulated by contribution from the sensory inputs, cerebral cortex,
hypothalamic hormonal influences & external factors.

• HOW TO EXAMINE COSCIOUSNESS:

1-CALLING THE PATIENTS NAME (in accepted volume & distance).

2-Rubbing the chest while calling his name.

3-Appling pain for further stimulation,
the pain areas are (should be examined bilaterally):

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a- Glabellar area by thumb
b- Nipples
c- Nail bed of the fingers & d- toes.

• DISTURBANCES IN THE LEVEL OF CONSCIOUSNESS:

1-COMA: is sleep like state, with maintained cardiorespiratory drive, BUT anaware
of his INTERNAL ENVIRONMENT (eating, drinking, urination, defecation & sexual
drive) all lost & not reactive to his EXTERNAL ENVIRONMENT (climate, people…
etc).

2-STUPOR: THE patient is sleepy, but rouse able by stimulation.

3-LETHARGY (drowsy): Mildest form patient is only drowsy.

DISTURBANCES IN THE CONTENT OF THE CONSCIOUSNESS:

1-CONFUSIONAL: the patient is wake but disoriented to the time (day vs night,
hour, day, date ,,,,etc, to place (home vs hospital, city, state … etc) & to person
(relative vs DR …..etc).

2-DELIRIUM: = (confusion + mental & physical hyperactivity)

Ie patient is confused & overactive in speech and motor.

III- MENTAL STATE EXAMINATION: (3*3)

1-ORIENTATION: to the time (day vs night, hour, day, date ,,,,etc, to place (home vs
hospital, city, state … etc) & to person (relative vs DR …..etc).
2-MEMORY:

A-immediate memory (registration): the ability to repeat sentence after examiner.

B-Recent memory (recall): by giving the paient sentence & asked to repeat 5
minutes later.
C-Remote memory: asking the patient far life events.

3-JUDGEMENT:

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A-SIMILARITY & DIFFERENCES: EX between dwarf & child.

B-UNDERSTANDING PROVERB: should be from the culture of the patient, e.g. bird
in the hand better than ten on tree. …..etc
C-SERIAL SEVENS: 100-7=93-7=86-7=79 ……ETC 3

IV- MENINGEAL IRRITATIVE SIGNS

The CNS is protected by skull bones, multi layers of meninges, CSF cushion. The
meningeal signs warning to protect n take care of CNS.
HOW TO EXAMINE FOR MENINGISMUS??
1-NECK STIFFNESS

• In SUPINE position, without pillows

• while holding head with both hands,
• RESISTANCE RATHER THAN PAIN, when trying to passively flex the neck in
ANTEROPOSTERIOR direction. NB the presence of lateral (Rt TO Lt) resistence
should alert towards local neck pathology rather than CNS insult.
2- KERNIG TEST:

1-SUPINE Position, without pillows

2- HOLDING the flexed (HIP, KNEE) JOINTS AT 900 from the knee & ankle joints
3-trying to passively extend the knee joints
4-the presence of INITIAL RESISTENCE rather than PAIN signifies meningeal
irritation
NB MENINGEAL IRRITATION CAUSES BILATERAL KERNIG TEST, UNILATERALAITY
SHOULD RISE THE POSSIBILITY OF LOCAL PATHOLOGY.
3-BRUDZINSKI TEST:

• -supine patient.

1-ACTIVE METHOD (IN CONSCIOUS ADULT)

Patient try flex his neck against resistance put by examiners palm against his
forehead, RESULT: there will be bilateral assymetrical hip flexion.
2-PASSIVE METHOD ( INFANCY OR UNCONSCIOUS ADULT)

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Here like neck stiffness, the examiner flexes the patients head passively, & looks at
pt legs for the asymmetrical hip flexion.

DDx OF POSITIVE MENINGISMUS:

1-CNS INFECTIONS: (MENINGITIS RATHER THAN ENCEPHLAITIS)

2-INTRACRANIAL BLEEDING: (CLASSICALY SAH)
3-POSTERIOR FOSSA SOL.
4-RARELY HYPERTENSIVE ENCEPHALOPATHY

V- SPEECH EXAMINATION (LANGAUAGE)

• Speech centers is located in the dominant hemisphere, there is the
MOTOR CENTER IN THE BROCA AREA ( ANTERIOINFERIOR FRONTAL) for speech
production (fluency), & the SENSORY RECEPTIVE CENTER (POSTERIOR
SUPERIOR TEMPORAL GYRUS) for understanding received speech
(comprehension); disorders of which causes MOTOR & SENSORY DYSPHASIA
RESPECTIVELY.
• DYSARTHRIA is problem of articulation, listen to spontaneous speech (volume,
rhythm & clarity) could be of various causes:
• Cerebellum causing SCANNING ATAXIC DYSARTHRIA
• BASAL GANGLIA causing MONOTONUS DYSARTHRIA

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• SUBCORTICAL LESION causing SLURRED DYSARTHRIA
• BRAIN STEM LESION causing BULBAR DYSRTHRIA which is nasal with difficulty
swallowing.

• PREREQUISITES FOR LANGUAGE EXAMINATION:

1- Pt’s mother accent.
2- Handedness of the patient.
3- Literateness of the patient.
4- Special senses of the patient (vision & hearing).

• STEPS OF LANGUAGE EXAMINATION:

1-COMPREHENSION IS the most important first step, examining the WERNICKE AREA,
BY giving 5 NON SYMBOLIC ORDERS, I.E without pointing to the patient.
If comprehension is lost all next steps pt cannot do.
2-Expression

• for examining the broca dysphasia i.e. non fluency &

• Examining for dysarthrias i.e. listen to the PATTERN OF THE VOICE)

HERE, examination is done by asking patient question and make him have long
answer till you RECOGNIZE THE FLUENCY & PATTERN of his speech.

3-READING: IS examined by making the patient read a clear writing.

4-WRITING:by asking the patient write down a sentence.
5-NAMING: try patient name 20 but familial objects.
6-REPETITION: here you try make the patient repeat a sentence thrice without
interruption

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WEEK TWO
CRANIAL NERVES EXAMINATION
KEYNOTES:
• Cranial nerves posses significant importance because of their localizing value.
• Hence, understanding basic anatomy of cranial nerves is of great value.
• Remember that we have 12 pairs of cranial nerves .
• First two cranial nerves don’t have nuclei, 3rd & 4th nuclei is in the midbrain, 5th, 6th, 7th
& 8th nuclei in the pons, 9th, 10th, 11th & 12th cranial nerves with nuclei in medulla
oblongata.
• 4th cranial nerve is the only one undergo decussation.

OPTIC NERVE EXAMINATION:

1-VISUAL ACUITY.
2-VISUAL FIELDS.

3-COLOR VISION.
4-FUNDOSCOPY.
1-VISUAL ACUITY:

• each eye must be examined separately by covering the other eye.

• SNELLEN CHART used in ophthalmology is more precise.
• CLINICALLY: we use paper with number or if illiterate write letter C & ask for
the direction of the opening, NB in distance of 6M.

2-COLOR VISION:
• MOSTLY of ophthalmological importance, here ISHIHARA CHART is used.

3-VISUAL FIELDS:
• OPHTHALMOLOGICALLY: more precise by PERIMETRY MACHINES.
• NEUROLOGICALLY CLINICALLY: CONFRONTATION TEST:

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1-both examiner & patient should be infront each other (sitting or standing), 1m apart, in
same axis (X & Y), RIGHT EYE of examiner meets lefts of the patient & vice versa.

2-PERIPHERAL VISUAL FIELD: (each eye separately)

- By dividing the visual field of each eye into 4 compartments

- Using the (WHITE HATPIN) or index & middle finger of both hand on the opposite
compartments
- Moving them alternately & or simultaneously
- Asking the patient which is moving
- Another way of examining:
- By bringing the (white hatpin) or moving index from the outermost angle of the each
of the 4 compartments into the center of the field
- And asking whether he see it or not

- then examine the other eye.

3- THE CENTRAL VISUAL FIELD:

-USE the red hatpin to test one eye qualitatively at a time

-ask the patient to cover one eye and look at you directly

-shut your eye opposite to the patient covered eye

-hold the red hat pin in the centre of the vf as close to fixation point

-ask for the color of the hatpin if it is pale or pink implicate the optic nerve affection

-compare the four quadrants centrally.

(the visual field for red is smaller than than for white)

4- BLIND SPOT: use red hat pin with diameter of 11mm, look for the blind spot in the mid
temporal visual field, which is only one diameter.

5- Using the ophthalmoscope examining the optic discs, retina & the blood vessels.

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OLFACTORY NERVES EXAMINATION

1. Each nostril should be examined separately by closing the other with piece of cotton.
(check that the nasal passages are clear)
2. Four test tubes covered by plaster for blocking vision, should be two third filled with,
COFFEE, TOBBACCO, SOAP & PEPPERMINT (pure olfactory & non irritant).
3. Each in turn placed in front of nostril to smell.
4. Examine the other nose later.

NB

• note that loss of smell is the most important & especially unilateral is
neurological; while bilateral is usually of other causes
• ANOSMIA: loss of smell.

OCULAR MOTILITY EXAMINATION (CN III, IV & VI)

CN III OCULOMOTOR: SUPPLY: MEDIAL RECTUS, INFERIOR RECTUS, SUPERIOR RECTUS &
INFERIOR OBLIQUE.

CN IV TROCHLEAR NERVE: SUPPLY THE SUPERIOR OBLIQUE MUSCLE.

CN VI ABDUCENS: SUPPLY THE LATERAL RECTUS MUSCLE.

NB EACH MUSCLE ACTS LIKE ITS NAME WITH SOME EXTORSION, EXCEPT THE OBLIQUE
MUSCLES AGAINST ITS NAME WITH SOME INTORSION.

STEP 1: (PRIMARY POSITION) EYES LOOKING AT FAR SUBJECT: LOOK FOR 4

1-STRABISMUS (SQUINT): HORIZONTAL MISALLIGNMENT (CONVERGENT OR

DIVERGENT).
2-EYELIDS : (PTOSIS):DROOPING of the eyelids (unilateral vs bilateral), (partial vs
complete). LID LAG, MARGINS, EDEMA

3-PROPTOSIS (EXOPHTHALMOS): out bulging of the eye vs ENOPHTHALMOS.

4-PUPILLARY SIZE & SYMMETRY.

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STEP 2 (MAKE THE EYES MOVE IN H SHAPE slow movement (PURSUITS)) &
(BINOCULAR EXAMINATION) two eyes altogether. 4
1-WEAKNESS: LOOK FOR any muscle weakness.

2-DIPLOPIA: ask for any double vision. (in each arm of the H)
3-NYSTAGMUS: look for the rhythmic oscillatory involuntary eye movement during
the pursuits of H.
4-SACCADES: check for the saccadic eye movements jumps fast without head
movement in the same H shape.
STEP3: REFLEXES

1-LIGHT REFLEX: AFFERENT limb: optic nerve, EFFERENT LIMB: OCULOMOTOR NERVE.
Shin torch focused light on the cornea from lateral side, normally should cause bilateral
meiosis.

2-ACCOMODATION REFLEX: Same limbs.

Focusing on far subject, then getting closer and closer there will be: convergence,
partial ptosis & meiosis.

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CN V TRIGEMINAL NERVES
1-MOTOR: MUSCLES OF MASTICATION
A-INSPECTION: -Temporalis wasting

-jaw deviation & masseter wasting

B-POWER: Palpating the temporalis & ASK CLINCH the teeth
Palate masseters & ask clinch the teeth.
Put your finger under chin resisting & ask open the mouth (lat. Pterygoids)
NB in case of weakness trigeminal muscles deviates to the weak side

C-REFLEXES:
1-JAW GERK:
-ASK the pt to let the mouth hang loosely open
-put your forefinger in the midline between the lower lip & chin

- make the hammer slip down your index while tapping.

(look for any reflex shutting of the jaw; normal response is absent or just present)
2-CORNEAL REFLEX: AFFERENT LIMB: V1, EFFERENT LIMB: FACIAIL NERVES;
-ask pt to look upward & gently depress lower eyelid.

-on touching the most lateral border of the cornea with damp cotton wool, causes bilateral
eye closure for protection.

2-SENSORY EXAMINATION:
V1: from mid vertex to angle of the eyelids.

V2: from the angle of the eyelids till the angle of the mouth.

V3: from the angle of the mouth till angle of the mandible

The three divisions to be compared on both sides for:

1- Touch: use cotton

2- Pain: use pinprick
3- Temperature:use tubes filled with cold n hot water.

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CN VII FACIAL NERVES

(MUSCLES OF FACIAL EXPRESSION)
1-INSPECTION:
-Frontal wrinkles
-Palpebral fissure symmery

-nasolabial folds depth symmetry

-angle of mouth (DROOPING: to the side of lesion & DEVIATION: to the normal side).
(MINOR ASYMETRY OF THE FACE IS COMMON & RARELY PATHOLOGICAL)

2-MUSCLES IN ACTION:

-FRONTALIS: frowning or look upward. (loss of wrinkles)

-orbicularis oculi: forceful eye closure till burring eyelashes or against resistance.
(inability to close eyes weel)
-orbicularis oris: whistling or blow the cheeks.

(loss of whistling or tightly closing mouth)

-buccinators: show his teeth: angle of mouth deviates to the normal
NB:

• UMNL CN VII spares upper part of face due to bicortical rpresentation

• LMNL CN VII affect whole muscles of that side

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CN VIII VESTIBULOCOCHLEAR NERVES:

COCHLEAR NERVES: RENNIE & WEBER TESTS IN ENT EXAMINATION
VESTIBULAR NERVES: CALORIC TEST (OCULOVESTIBULAR R)
DOLL’S EYE TEST (OCULOCEPHALIC TEST)

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CN IX & X: GLOSSOPHARYNGEAL & VAGUS NERVES

• Taste to the posterior two thirds of the tongue & somatic sensation to oropharynx.
• Aid in swallowing.

1-Speech: bulbar vs psuedobulbar

2-AAAH TEST: the uvula for centrality, it deviates to the normal side, ASK pt to say AAAAH .
3-CHECH POSTERIOR PHARYNGEAL SENSATION on either sides.. 11CM pin.

4- GAG REFLEX: becomes evident with checking the post pharyngeal sensastion.

5-SWALLOWING TEST: ask for swallowing if accepted, try the 3oz test; drink 3 ounces of water
as one sip.

CN XI ACCESSORY NERVES
1-TRAPEZIUS MUSCLES:

-FACING THE PATIENT.

-PALPATE THE RIGHT AND LEFT TRAPEZIUS MUSCLES WITH FOUR FINGERS.

-ASK THE PATIENT TO ELEVATE THE SHOULDERS.

-FEEL: THE BULK OF MUSCLE & THEIR POWER.

2-STERNOMASTOIDS:
-PALPATE THE MUSCLE WITH FINGERS.

-PUT THE OTHER HAND ON THE PT OTHER SIDE OF MANDIBLE

-ASK THE PATIENT TO PUSH YOUR HAND TO THE OPPOSITE SIDE

-FEEL: THE POWER OF PUSH & BULK OF THE MUSCLE.

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CN XII HYPOGLOSSAL NERVES

1-INSPECTION: WHILE the tongue is in situ inspect for: wasting & fasciculation.

2-ACTION: ASK TO

-PROTRUDE THE TONGUE NB in case of weakness it deviates to the weak side

-ASK THE PATIENT TO PRESS THE CHEECK FROM INSIDE BY TINGUE, WHILE YOU PRESS FROM
OUTSIDE BY YOUR FINGER

-ASK THE PATIENT SAY (YELLOW LORYY) (SPEECH DYSARTHRIA)

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WEEK THREE
MOTOR SYSTEM EXAMINATION
NB CLINICAL EXAMINATION OF THE MOTOR SYSTEM NEUROLOGICALLY is concerned
with four cardinal steps:
1- INSPECTION
2- TONE
3- POWER
4- REFLEXEX

1-INSPECTION: neurologically, after exposure till nipples in upper limbs then till
groin in lower limbs, inspection is for four:
a- Abnormal posture.
b- Abnormal movements:
c- Bulk of muscles
d- Fasciculations

2-TONE: MUSCLE TONE: is defined as the state of resting muscle contraction, which is
felt as resistance to passive movement around a joint.

• Normal Tone is judged as appropriate for the subjects gender, age, physique &
built.
• HYPOTONIA: a decreased tone that is felt as (floppy) or (doughy) or (flaccid) is
a sign of LMNS in the pyramidal tract.
• HYPERTONIA: increased tone (resistance) around the joint is classified into two
forms:
• SPASTIC HYPERTONIA: felt as initial resistance to the passive movement then
give up of the resistance, hence named (CLASP KNIFE SPACTICITY) IS a sign of
UMNL in the pyramidal tract.
• RIGIDITY: here resistance is felt continuously of same degree hence called
(LEAD PIPE RIGIDITY) WHICH is sign of basal ganglial disease in the
extrapyramidal system.
• COG WHEEL RIGIDITY: SOMETIMES cogwheel rigidity is interrupted by tremor
in basal ganglial disease hence giving the character of cogwheel like pattern.
• NB THE WAY TONE EXAMINATION IS RAPID, DECEPTIVE PASSIVE MOVEMENT
IN THE PROXIMAL JOINTS & SLOW PASSIVE MOVEMENTS IN THE DISTAL JOINT.
(THE PATIENT FULLY RLAXED)

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UPPER LIMB TONE EXAMINATION:

• Patient is lying supine or sitting comfortable
1- ELBOW JOINT: relaxed patient, rapid, deceptive flexions & extensions.
2- Wrist joints: slow, passive flexion extensions & circumductive movements.
• Always compare joint with twin on other side.
• Flow in proximal to distal direction.

LOWER LIMBS TONE EXAMINATION:

• SUPINE, relaxed patient:
1- Hold the lower limb from the knee joint by both hands & move it inward & out
ward &:
- Feel the resistance in the hip hoint.
- Look at the feet how they lag (hypotonia) or move as one piece
(hypertonia).
2- Hold the lower limb from the knee by both hands &: elevate it & suddenly
release it to drop. (look: drop as one piece of floppy)
3- Hold lower limb from the knee by left hand & from ankle with right hand: & try
to passively extend & flex it from the knee joints (feel the resistance).
4- Hold the limb from the shin with left hand & by the right hand do passive
flexion extensions & circumductive movements for the feet.
• NB in each the past four steps compare the right to left.

3-POWER EXAMINATION:
• THE MRC ( MEDICAL RESEARCH COUNCIL) has graded the power into:
0 no contraction at all
1 FLICKERY muscle contraction that don’t move the joint
2 Contraction that moves the limb horizontally within gravity limits
3 Contraction that moves the limb vertically against gravity but not
resisting the examiner.
4 Contraction that works against gravity & resisting examiner but not
appropriate for the patient.
5 Contraction against resistance that is normal expected to the
patient

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UPPER LIMB POWER EXAMINATION:
• PT SITTING OR LYING
• PUT THE JOINT NEUTRAL POSITION.
• PATIENT IS PUTTING POWER & EXAMINER IS ONLY RESISTING.
• COMPARE MUSCLE WITH OTHER SIDE TWIN muscle.
1- ASKED TO RAISE BOTH ARMS.
2- SHOULDER: FLEXION vs extension
Abduction vs adduction
3- ELBOW: FLEXION – EXTENSION
4- WRIST: FLEXION – EXTENSION
5- FINGERS: FLEXION – EXTENSION

TION

LOWER LIMB POWER EXAMINATION: (SUPINE)

1-HIP: -FLEXION – EXTENSION
-ABDUCTION-ADDUCTION
2-KNEE JOINT: FLEXION-EXTENSION
3-FEET: DORSIFLEXION-PLANTER FLEXION
EVERSION- INVERSION

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4-REFLEXES (DEEP TENDON REFLEXES) (STRETCH REFLEXEXES)

NB
1-EXPOSURE: EXPOSE THE MUSCLE BEING EXAMINED
2-NEUTRAL POSITION: THE JOINT SHOULD BE IN NEUTRAL POSITION.
3-PALAPATE: THE TENDON FOR ACCURATE LOCALISATION
4-HAMMER:FROM THE MOST DISTAL END TO BE CAUGHT & ELAVATED &
ALLOWED TO DROP BY GRAVITY.
5-COMPARE THE WITH OTHERSIDE TWIN REFLEX

NB RESULTS: grades of the reflexes

- ABSENT: EVEN AFTER REINFORCEMENT
+ WEAK (HYPOREFLEXIA) ONLY MUSCLE CONTRACTION (NO MOVEMENT
ACROSS THE JOINT)
(-+) ONLY PRESENT WITH REINFORCEMENT
++ NORMAL REFLEX MUSCLE CONTRACTION WITH MOVEMT ACROSS THE
JOINT
+++ HYPERREFLEXIA BRISK CONTRACTON & JOINT MOVEMANT
++++ CLONUS TAPPING WITH HUMMER ELICIT REPITIVE MUSCLE
CONTRACTIONS.

NB
REINFORCEMENT (JENDRASSIC MANEAUVER) IN anxious patient for better
reflex demonstration we distract his attention. Upper limbs: by clinching

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teeth. Lower limb: by can be tried by having the patient cup their fingers on
each hand and try to pull the hands apart.

UPPER LIMB REFLEXES:

1-BICEPS JERK C5,6:
2-SUPINATOR JERK C5,6
3-TRICEPS JERK C6,7

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4-HOFFMAN SIGN C8T1 (UMNS & physiologically anxiety): The Hoffmann's

reflex test itself involves loosely holding the middle finger and flicking the
fingernail downward BY YOUR THUMB, allowing the middle finger to flick
upward reflexively. A positive response is seen when there is flexion and
adduction of the thumb on the same hand.

5-FINGER JERK C8,T1 : The finger jerk reflex observed during a neurological exam by
striking the fingers directly with a hammer when the patient's arm is relaxing. In this
activity user can observe the finger movements by striking on doctor’s fingers with a
hammer.

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LOWER LIMBS REFLEXES:

1-KNEE JERK L3,4

2-ANKLE JERK S1,2

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3-PLANTAR RESPONSE S1,S2 :

• The lateral side of the sole of the foot is rubbed with a blunt
instrument or device so as not to cause pain, discomfort, or injury to
the skin; the instrument is run from the heel along a curve to the toes
(metatarsal pads).
• Many reflex hammers taper at the end of the handle to a point which
was used for testing the plantar response in the past, however, due to
the tightening of infection control regulation this is no longer
recommended. Either a single use device or the thumb nail should be
used.

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• There are three responses possible:

• Flexor: the toes curve down and inwards, and the foot inverts; this is
the response seen in healthy adults.
• Indifferent: there is no response.
• Extensor: the hallux dorsiflexes, and the other toes fan out; this is
Babinski's sign, which indicates UMNS.
• The Babinski response is also normal while asleep and after a long
period of walking.

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WEEK FOUR
SENSORY SYSTEM EXAMINATION
NB THE SENSORY ASCENDING SYSTEM IS DIVIDED INTO:
DORSAL TRACT (JOINT POSITION SENSE, VIBRATION & PRESSURE)
VENTROLATERAL TRACT (PAIN, TOUCH & TEMPERATURE)

NB knowledge THE DERMEATOMAL SENSORY DISTRIBUTION IS OF GREAT VALUE IN

LOCALISING THE LESION.

NB

• EXAMINATION IN ASCENDING PATTERN OF DERMATOMAL DISTRIBUTION OR

ACCORDING CASE SCENARIOS’ CLINICAL SUSPICION, comparing to twin limb.
• i.e. lower limb then upper limbs

ANTERIOLATERAL COLUMN SYSTEM EXAMINATION:

TOUCH: USING a wisp of cotton to:
1-test the feeling of touch 2-notice asymmetry of feeling.

PAIN: using single use, pin, again for:

1-feeling the pain or discomfort 2-report asymmetry of the feeling

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TEMPERATURE: using covered test tube with hot water & second with cold water,
and assessing the sensation.

DORSAL COLUMN SYSTEM EXAMINATION:

JOINT POSITION SENSATION: 1-with eyes closed,
2-hold the joint from both sides,
3-move the part distal to joint up and down and ask the
patient the direction of the movement.
4-in ascending fashion a- interphalangeal joint
b-ankle joint
c-knee joint

so does for the upper limbs.

VIBRATION EXAMINATION:
1- TUNNING FORK 128Hz
2- On bony prominences:
-TIP OF BIG TOE
-malleolus
-tibial tuberosity
-anterior superior iliac spine
-DISTAL IP OF FOREFINGER
-styloid process of radius
-olecranon
-acromion
3- Compare right to left for: decreased feelin, absent.

CEREBELLAR EXAMINATION
NB CEREBELLAR FIBERS UNDERGO DOUBLE DECCUSSATION, HENCE IT COORDINATE &
BALANCES IPSILATERAL SIDE OF THE BODY.
NB CEREBELLAR SIGNS ARE DIVIDED INTO SPECIFIC & NON SPECIFIC CEREBELLAR SIGN.

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NON SPECIFIC CEREBELLAR SIGNS:
Are of secondary importance as they occur in other conditions, ex:
1-hypotonia.
2-ataxia.
3-nystagmus.

4-dysrthria.
NB FOR examining cerebellum patient should have normal power.

SPECIFIC CEREBELLAR SIGNS:

Are of great localising value as they are more specific for cerebellar disease:
1-DYSDIADOKINESIA: difficulty in performing rapid alternating movements.
2- REBOUND PHENOMENON: impaired balance between agonist & antagonist
muscles, The Holmes rebound phenomenon is a reflex that occurs when one attempts
to move a limb against resistance that is suddenly removed. When the resistance is
removed, the limb will usually move a short distance in the original direction, at which
point the antagonist muscles will contract, causing the muscle to yank back in the
opposite direction.

3-INTENTION TREMOR: also known as cerebellar tremor, is a dyskinetic disorder

characterized by a broad, coarse, and low frequency (below 5 Hz) tremor.
4-DYSSENERGIA: disturbance of muscular coordination, resulting in uncoordinated and
abrupt movements.
5-DYSMETRIA: refers to a lack of coordination of movement typified by the
undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is
described as an inability to judge distance or scale.

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CLINICAL TESTS FOR THE CEREBELLUM:
1- REBOUND PHENOMENON: illustrated above.
2- RAPID ALTERNATING TEST: is demonstrated clinically by asking the patient to tap
the palm of one hand with the fingers of the other, then rapidly turn over the
fingers and tap the palm with the back of them, repeatedly.

3- FINGER NOSE TEST: which the patient is asked to alternately touch their nose and
the examiner's finger as quickly as possible, and the examiner's finger is
occasionally moved suddenly to a different location. LOOK FOR:
IINIIALLY: INTENTION TREMOR, THEN DYSSENERGIA, FINALLY: DYSMETRIA

4- HEEL SHIN TEST: Test procedure:

1. With patient lying supine. Instruct the patient to raise one leg and with their
heel touch their opposite knee, dragging the heel along the skin, along the shin
toward the ankle and then slowly back up to the knee. Both legs are tested in
similar fashion.
2. Assess for accuracy of heel placement. Note if the heel is not pushed down the
shin without deviating or jerking.

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Test findings (Positive & Negative results):

1. Assess for accuracy of heel placement. Note if the heel is not pushed down the
shin without smoothly and accurately.
2. Any Inability to perform this test properly may indicate possible cerebellar
trauma.

5- HEEL TOE TEST: TANDEM GAIT

1-Ask the patient to walk in a straight line with one foot immediately in front of
the other (heel to toe), arms down by their side.
2-Stay close enough to patient to catch them if they fall.

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