Nervous: Examination
  1. Consciousness
  2. Environment, general appearance
  3. Handedness, speech
  4. Head, neck, neck stiffness
  5. Cranial nerves
  6. Upper limbs: inspect, tone, power, reflexes, coord, sensory
  7. Lower limbs: inspect, tone, power, reflexes, coord, gait, sensory
  8. Systems: spine, carotid bruit, aspiration
Consciousness
Environment
  • Bed: one siderail raised (hemiplegia).
  • Bed: pt.'s bad eye side placed against wall so they can't be surprised (stroke).
  • Bed: soft mattress to avoid pressure sores (mobility difficulty).
  • Bed: V-shaped posture pillows since pt. unable to support self.
  • Tables: all meds, etc. within reach of non-siderailed arm (hemiplegia).
  • Room: hoist, wheelchair, walker (paralysis).
  • Room: NG tube (palsy of throat CN's).
  • Room: ventilator, life support machines.
General appearance
  • Age of pt. (Parkinson's usu. 45+, etc).
  • Chorea (Huntington's, rheumatic fever, drugs, etc).
  • Ethnicity (scandinavian: multiple sclerosis).
  • Ballisma, dystonia (usu. drugs), noticeable tremor.
  • Posture: leaning to one side (hemiplegia).
  • Posture: stooped forward (Parkinson's).
  • Only using one hand on tray (hemiplegia).
Handedness, speech
Head
  • Asymmetry, unilateral facial drooping (stroke).
  • Ptosis.
  • Serpentine stare (Parkinson's).
  • Licking of lips.
  • Scars of previous operations.
  • Trauma, injury, abnormalities. 
  • Mental retardation syndrome facies: Down's, FAS, etc.
  • Eyes: exophthalamos (thyroxicosis), Kayser-Fleisher rings (Wilson's).
Neck, neck stiffness
  • Neck: thymectomy scar (MG).
  • Neck: thyroidectomy scar (thyrotoxicosis).
  • Beware of performing manipulation on a cervical spine injury pt.
  • Hand under occiput, flex neck to chin and see if resistance.
    Resistance causes: raised ICP, cervical fusion or spondylosis, Parkinson's meningitis.
  • If suspect meningitis (fever, photophobia) do Kernig's sign.
Cranial nerves
Upper limbs: inspect
  • Patient sits over side of bed facing you.
  • For rest of examination, comparing L side to R side.
  • Asymmetry.
  • Deformities: wrist drop, waiter's tip, claw hand.
  • Muscle wasting, fasciculations. Include shoulder girdle.
  • Tremor:
    Intention (cerebellar).
    Resting with pill-rolling (Parkinson's).
    Action tremor (BAT:  Benign essential tremor syndrome, Anxiety, Thyrotoxicosis).
  • Feel hand for heat (thryrotoxicosis), grip.
  • Pronator drift: pt's eyes closed, arms extended, with palms up. Tap pt's arms briskly downward (arm drifting into pronation: UMNL, cerebellar, post. column loss).
  • Pseudoathetosis from proprioceptive loss.
  • Muscle bulk, tenderness.
Upper limbs: tone
  • Ask pt. if any tenderness in any joints, so won't hurt them when manipulating them for tone.
  • Grasp under elbow and wrist, and rotate the 2 joints to assess resistance.
    If Parkinson's, cogwheel rigidity in wrist [combination of tremor and increased tone].
    If Parkinson's, lead pipe resistance when flexing forearm.
  • If ulnar nerve indicated, Froment's sign:
    Give pt a piece of paper for each hand.
    Ask pt to grasp papers by moving straightened thumb to radial side of index finger.
    Affected thumb is forced to flex at interphalangeal joint to grip paper.
  • If median nerve indicated, pen touching test:
    Pt's hand supine.
    Dr. hold's pen above thumb
    Ask pt. to lift thumb to touch it.
    Affected thumb can't touch pen. 
Upper limbs: power
  • Assess shoulder, elbow, wrist, fingers.
    Assess by ability to push against Dr's hand.
    Assess across a single joint at a time [eg: Dr's hand on bicep, not forearm, to assess shoulder power]. 
  • If MG suspected:
    Pt. holds arms above head.
    MG pt. will lose power after contractions.
  • See Power Scale Reference.
Upper limbs: reflexes
Upper limbs: coordination
  • Pt. finger touches Dr's fingers, then to pt's nose testing for dysdiadochokinesia, rebound.
  • Dysdiadochokinesia:
    Pt's palm on dorsum of their opposite hand.
    Pt flips their hand quickly so the two hand dorsums touch.
    Repeat quickly.
Upper limbs: sensory
  • Dorsal columns (vibration):
    Place on sternum [the last area lost] so pt. knows how the buzzing feels.
    Pt's eyes shut and 128 Hz fork on distal interphalangeal joint: ask if felt.
    If can feel, ask pt. to say when it stops, then later stop it.
    If deficient: assess dermatomes at wrist, elbow, shoulder, both anterior and posterior.
    See Dermatomes Reference.
  • Dorsal columns (proprioception):
    Grasp pt's distal phalynx, move up and down to show what to do.
    Tell pt. to close eyes and repeat this, saying whether it's up or down.
  • Spinothalamic (pain, forget temperature):
    Sterile toolpick or broken wood tongue depressor on forehead or anterior chest.
    Pt. closes eyes, tells if sharp or dull.
    Stick each dermatome looking for cord, dermatome, peripheral nerve, stocking glove.
  • Light touch: cotton wool. Dab skin lightly, don't stroke.
  • If lesion, feel for thickened nerves:
    Ulnar at elbow
    Median at wrist
    Radial at wrist
    Axilla.
Lower limbs: inspect
  • Asymmetry.
  • Muscle wasting, fasciculations, tremor.
  • Muscle bulk: quads, anterior tibials.
  • Foot bruising, infections from peripheral neuropathy.
Lower limbs: tone
  • Orthopods may roll legs for a quick preliminary inspection of tone.
  • Tone of knees, ankles.
  • Test clonus by pushing lower end of quads sharply down towards knee (sustained contractions: UMNL).
Lower limbs: power
  • Power: hips, knees, ankles. "Lift leg, don't let me push it down". "Push leg down, don't let me push it up".
  • See Power Scale Reference.
Lower limbs: reflexes
  • Knee (L3-4).
  • Ankles (S1-2).
  • Plantar (L5, S1-2).
  • Ankle clonus test:
    Place pt's knee bent, thigh externally rotated.
    Dr lifts pt's heel in Dr's cupped hand.
    Dr quickly dorsiflexes pt's ankle and holds it flexed for 3 seconds.
    Clonus if sustained movement afterwards.
  • See Deep Tendon Reflexes Reference.
Lower limbs: coordination
  • Heel-shin test:
    Pt kicks a heel out, then touches that heel to other shin.
    Repeat in a smooth motion loop.
    Alternatively: heel sliding up and down on opposite shin.
  • Toe-touching test.
  • Tapping of feet.
Lower limbs: gait
  • Walk few feet then walk back.
  • Notice signature gaits:
    Trendelenberg gait (proximal myopathy).
    Shuffling gait (Parkinson's).
    High-stepping gait (foot drop).
    Hemiplegic gait [swinging one leg in lateral arc] (usu. stroke).
  • Walk heel to toe (hard: midline cerebellar).
  • Walk on heels (hard: L4-5 footdrop).
  • Squat or sit then stand up (proximal myotrophy).
  • Romberg sign positive if unsteadiness is worse when eyes closed.
Lower limbs: sensory
  • Sensory pin prick, vibration, proprioception, light touch. Same as was for Upper Limbs.
  • If peripheral sensory loss, try to establish sensory level. See Dermatomes Reference.
  • Examine sensation in saddle region.
  • Test anal reflex (S2-4).
Spine
  • Back: deformity, scars, neurofibromas.
  • Palpate for tenderness over vertebral bodies.
  • Straight leg raising test:
    Pt tries to lift straight leg.
    Full lifting will be prevented if slipped disc.
  • For more, See Rheumatoid Examination.
Carotid bruit
Aspiration
  • Paralyzed pt may have aspirated fluid. See Pulmonary Examination.
  • Feeding assistance devices, such as PEG (dysphagia, usu. 2 to neurological damage, like stroke).