Neurological examination

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Five-part short neurological examination

Part I neurological examination
• General demeanour
• Speech
• Gait
• Arm swinging
  
  Part II neurological examination
• Fundi
• Pupils
• Eye movements
• Facial movements
  Tongue
  
  Part III neurological examination
• Posture of outstretched arms
• Wasting, fasciculation
• Power, tone
• Coordination
• Reflexes
  
  Part IV neurological examination
• Power (hip flexion, ankle dorsiflexion)
• Tone
• Reflexes
• Plantar responses
  
  Part V neurological examination
• Ask the patient
  

1. Look at the patient
2. Examine the head
3. Examine the upper limbs
4. Examine the lower limbs
5. Assess sensation

The relevant findings are drawn together in a brief written diagnostic summary. This will form the basis for investigations, transfer of information, and management.

Ten-part neurological examination

• Orientation in time and place, recall of recent and distant events (memory, level of intellect, language and speech/cerebral dominance, other disorders of skilled function, e.g. apraxia)
  
  Upper limbs:
• Wasting and fasciculation
• Posture of arms: drift, rebound, tremor
• Tone: spasticity or extrapyramidal rigidity
• Power: 0-5 scale
• Tendon reflexes: + or ++ normal; +++ increased:
• 0 absent with reinforcement
  
  Thorax and abdomen:
• Respiration
• Thoracic and abdominal muscles
• Abdominal reflexes
• Cremasteric reflexes
  
  Lower limbs:
• Wasting and fasciculation
• Tone, power and tendon reflexes
• Plantar responses

First, ask whether feeling in the limbs, face and trunk is entirely normal

Posterior columns:
• Vibration (using a 128 Hz tuning fork)
• Joint position
• Light touch
• 2-point discrimination (normal: 0.5 cm fingertips, 2 cm soles)
  
  Spinothalamic tracts:
• Pain: use a split orange-stick or a sterile pin
• Temperature: hot or cold tubes

If sensation is abnormal, chart areas involved

1. State of consciousness, arousal, appearance (e.g. coma)
2. Mental state, attitude, insight
3. Cognitive function
4. Gait and Romberg's test
5. Skull shape- circumference, bruits
6. Neck- stiffness, palpation and auscultation of carotid arteries
7. Cranial nerves
8. Motor system
9. Coordination and fine movements
10. Sensory system