Introduction. Basic steps and sequences involved in examining the nervous system in clinical medicine. Neurological history is of primary importance with the neurological examination being largely secondary, required mainly for ascertaining the anatomical site of a particular lesion. Types of problems that can occur with abnormalities of the nervous system discussed. Positioning of the patient for the examination is then mentioned, stressing the importance of making the patient comfortable and making any instructions simple and clear. Importance of explaining any procedures that may cause distress and maintaining the patient's confidence throughout the examination highlighted. Initial gait assessment is demonstrated. Evidence of ataxia tested by asking patient to walk along an imaginary line, one foot in front of the other.
Cranial Nerves assessment. Demonstration of the tests conducted with the patient. Facial symmetry is assessed and any scars or abnormalities noted. The patient's eyes are then assessed, followed by measurement of visual acuity (normally 6/6). Demonstration of the tests conducted with the patient with glasses on. Examination of visual field then assessed to see if there is a particular pattern of visual field deficit, suggesting a lesion in the nervous system at a particular location. Demonstration of the tests conducted with the patient, firstly using fingers and then using a red pin. Tests performed by comparing patient's field with the doctor's own visual field.
Examination of the pupillary responses. A bright torch is used to test the direct light reflex and the consensual reflex in each eye. Demonstration of the tests conducted with the patient. Accommodation reflex then tested. Ophthalmoscope then used to examine the back of the patient's eye.
Examination of eye movements supplied by cranial nerves III, IV and VI. Demonstration of the tests conducted with the patient. Examination of the lower cranial nerves, testing them in sequence (although they can be examined by function - motor and sensory). Trigeminal nerve tested by testing muscles of mastication innervated by it. Sensation in the face then tested using pinpricks in all three divisions of Trigeminal nerve. Demonstration of the tests conducted with the patient to assess any objective sensory loss.
Examination of the Corneal reflex, afferent through CNV and efferent through CNVII. Jaw Jerk then used to test stretch reflex of Trigeminal nerve. CNVII examined by asking patient to form various facial expressions. CNVII also provides taste sensation to anterior ? of tongue, and this can also be tested (although not demonstrated in this case). CNVIII then examined by testing for auditory acuity. CN IX and CNX then tested. CNXI assessed by asking patient to push their head against doctor's hand, elevating sternocleidomastoid. Shrugging shoulders tests Trapezius. Assessment of tongue position, wasting and movement then used to assess CNXII.
Examination of the motor system. Upper limbs checked first. How to examine is detailed including tests to carry out and what to look for. Demonstration of various tests on patient including examination of the hands. Involuntary movements also noted including tremor, jerky movements and chorea movements (examples shown). Tone examined by noting resistance to passive movement.
Muscle power in upper limbs then examined. Subtle degrees of weakness also tested for and methods for doing this explained. Muscles of the hand also examined in similar way.
Examination of the lower limbs then performed including explanation of what to look for, such as wasting etc. Tone and muscle power examined just as with upper limb. Examination of tone may be harder in lower limb, but detailed description of test given. Power then examined in lower limb. Muscles around the hip are tested first, moving down limb towards the toes.
Examination of deep tendon reflexes. Patient must be adequately positioned with arms comfortable. Reflex arc explained and appropriate use of hammer highlighted. Sequence of reflex tests explained and demonstrated in both upper and lower limbs.
Planter response tested using an orange stick. Tip of orange stick moved along planter surface while pressing with small degree of force (noxious stimulus). Positive Babinski sign explained, looking for the first movement of the big toe. Examination of co-ordination using finger-nose testing. Tremor or cerebella lesion would be revealed in this test. Rapid tapping of hand then compared. In the legs, the heal-shin test is used to test for coordination (demonstration of test shown including common abnormalities seen).
Examination of the sensory system. Objective evidence of sensory loss is the key thing to look for - vibration sense or a patch of numbness. Basic tests demonstrated. Vibration sense, light touch, temperature sensation and pin prick (pain sensation) tested. Joint position sense then tested and demonstrated. Importance of explaining to patient what they are doing stressed, as this if often the biggest source of error in this important test.
Examination of light touch. Wisp of cotton wool used to touch patient to map out an area of sensory loss. Pinprick test then used to assess pain sensation. Temperature sensitivity test then performed using cold tuning fork. Summary of examinations performed to test sensation.