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

• If unconscious, See Unconscious Examination.

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

• Ask to shake hand, ask if R or L-handed.
• Ask name, present location, how long in hospital. See Mental Status Reference.
• If detect abnormality while pt. talks, See Speech Disorders Reference.

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

• See Cranial Nerves Examination.

Upper limbs

The upper/lower limb exams checklist is a SCRIPT:

• Sensation
• Coordination
• Inspection
• Power
• Tone

But just reassemble them back into a logical order: inspection always goes first; sensation goes last since takes so long.

Upper limbs: inspect

• Pt sits over side of bed facing Dr.
• 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 [who is this Paper From?]:
  • 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

• Supinator/Brachioradialis (C5-6).
• Biceps (C5-6).
• Triceps (C7-8).
• Fingers (C7-T1).
• See Deep Tendon Reflexes Reference.

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.
  • Repeat the moving up or down, then leave it either up or down.
  • Ask pt is 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 knee 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

• Auscultate for bruits (atherosclerotic dz).
• See Carotid Examination for details.

Aspiration

• Paralyzed pt may have aspirated fluid. See Pulmonary Examination.
• Feeding assistance devices, such as PEG (dysphagia, usu. 2º to neurological damage, like stroke).