Nervous system Examinations

Examination Components

Motor

Tone

Assessed by:

• UL- shaking hand and flexing elbow suddenly

• LL- rolling leg & flexing knee suddenly

Findings:

• Increased

  • Spasticity- velocity dependent, UMN

  • Rigidity- velocity independent, dopamine related

• Reduced

  • LMN sign

Spasticity is a non speciific UMN sign. 

Rigidity is associated with dopamine status

• Low dopamine- Parkinsonism (cogwheel rigidity)

• High dopamine- Neuroleptic malignant status (lead pipe rigidity)

Power

Assessment:

• UL- globally with handshake, pronator drift- then each muscle group

• LL- gait, then each muscle group

Findings: 

• Can only be reduced or normal. 

Reduced Power

1. Localise the lesions (!) see below

2. Distribution- proximal, distal or generalised

Upper Motor Neuron Lesion

• Reduced Power

• Increased tone (spasticity)

• Increased reflexes- hyper-reflexia & presence of extra reflexes, e.g. jaw jerk

• Upwards plantar reflex, 

• Clonus presence, Hoffman's sign 

Lower Motor Neuron Lesion

• Reduced power

• Reduced tone

• Reduced or absent reflexes 

• Fasciculations, muscle wasting

• Downward plantar reflex

• Radiculopathies are often painful

Myopathy

• Muscle weakness- usually proximal & painful

• Normal tone, reflexes

• Severe can have reduced tone and muscle wasting

Neuromuscular Junction

• Evidence of fatigue-ability

• Cranial Nerves: eye movement looking vertically up

• Upper Limbs: maintain upward chicken wings

• Lower Limbs: maintain hip flexion lifting leg

Reflexes

Assessment:

• Ensure tendon is stretched & relaxed

Findings:

• Increased

  • Brisk response

  • Can be elicites by touching tendon

  • Abnormal presence of certain reflexes- like jaw jerk - that shouldn't be present

• Normal

  • Reduced- elicited wit reinforcement

• Absent

  • Not present with reinforcement

A brave candidate would describe reflexes as brisk. A more ordinary candidate would be happy with present, reduced and absent.

Co-ordination

Often limited by lack of power. 

Classification of ataxia

• Cerebellar (DANISH)- DDK (Dysdiadochokinesia) etc

• Sensory ataxis (loss of proprioception input)- Rhomberg's test

• Vestibular- inner ear dysequilibrium

Sensory

Notoriously unreliable examination, due to subjective nature

Categorise

• Distribution: proximal, distal or generalised

• Dermatonal pattern

• By modality & its spinal pathway

  • Dorsal column- proprioception & vibration

  • Lateral spinothalamic- pain & temperature

  • Anterior spinothalamic- crude touch and pressure

Examinations

90% of stations will be

• Cranial Nerve Examination, 

• Upper Limb Examination

• Lower Limb & Gait Examination

10%

• Disease specific examinations

• Cerebellar Exam

Disease Specific

Respiratory compromise:

• Concerns in MND, GBS, CIDP, MG, 

• Breath count- concern if < 12

• Respiratory effort with cough, sneeze, deep inspiration

• Bulbar involvement concerning- speech, swallow

• Absent bowel sounds (in GBS)

Parkinsonism:

• Idiopathic Parkinsons, Drug induced, Vascular Parkinsons

• Bradykinesia- bilateral quickly tap fingers together or bounce heel on leg

• Rigidity- increase tone, stiffness; cogwheel rigidity

• Gait- shuffling, stooped with reduced arm swing

• Micrographia- write name on paper

Fatiguability:

• NMJ disease: Myasthenia Gravis (MG), Lamberton Eaton Syndrome (LES) 

• Cranial Nerves: eye movement looking vertically up

• Upper Limbs: maintain upward chicken wings

• Lower Limbs: maintain hip flexion lifting leg

Myotonia

• Specific for Myotonic Dystrophy

• Handshake can show myotonia

• Unable to flick hands open

Motor Neuron Disease

• Fasiculations

• UMN + LMN lesions painless

Cerebellar 

Examination

DANISH

• Dysdiadokokinesis

• Ataxic Gait

  • Walk + heel toe walk- may require chaperone

  • Can be performed last

  • Heel-toe co-ordination last

• Nystagmus- draw H

• Intention Tremor- touch nose and examiner's finger, tremor upon touching examiner's finger

• Staccato Speech- baby hippopotamus, british constitution

• Hypotonia & Hyporeflexia

  • Examine all UL + LL reflexes as time allows

  • UL + LL tone

Would be reasonable to examine the gait last. 

Signs

• Lesions are ipsilateral

• Nystagmus- fast beat towards lesion, slow beat away

Conditions

• Demyelination - younger (MS)

• Vascular- older (stroke)

• Alcohol Excess

Signs

Localising the lesion (!)

A. Isolated signs:

1. Motor Weakness

   1. UMN 

   2. LMN

   3. UMN + LMN

   4. Muscle

   5. NMJ

2. Sensory

3. Co-ordination

B. Mixed signs:

1. Motor & Sensory

2. Motor & Co-ordination

3. Sensory & Co-ordination

4. Motor, Sensory & Co-ordination

Isolated Signs

1.0 Motor

1.1 Isolated UMN

• Space occupying lesion- e.g. malignancy or abscess

• Multiple sclerosis- younger female

• Stroke - older- dense unilateral weakness + speech/ visual changes

Spine (Myelopathy)

• LMN at level of lesion

• UMN in all levels below

• Normal examination cranial nerve examination

• Usually bilateral

Brain

• Typically unliteral 

• Abnormal cranial nerves- speech, swallow, vision

1.2 Isolated LMN

• Peripheral Neuropathy (DANG THERAPIST)

  • Diabetes

  • Alcohol

  • Nutritional: B12, folate, thiamine,

  • GBS

  • Toxin: amiodarone, chemotherapy

  • Hereditary- Charcot Marie Tooth, Multifocal Motor Neuropathy (MMN) 

  • Environmental: lead

  • Relapsing- CIDP, 

  • Amyloidosis

  • Paraproteinemia- myeloma

  • Infective: Lyme Disease, Syphilis, HIV, Leprosy

  • Systemic: hypothyroidism, renal failure, SLE

  • Tumours: nerve sheath tumour, paraneoplastic

• Isolated - distinctive distribution

  • Radiculopathy - painful

  • Mononeuropathy

    • UL: radial, ulnar, median nerve palsies

    • LL: peroneal palsy

1.3 Isolated UMN + LMN

• MND- nil sensory changes

• Subacute degeneration of spinal cord- typically has sensory changes

• Syphillis- wide presentation, as does SLE & HIV

1.4 Isolated to Muscle 

• Myopathies

  • Proximal

    • Acquired:

      • Immune- polymyositis, dermatomyositis

      • Hypothyroidism; 

      • Statin, steroid or alcohol related

    • Inherited: 

      • Myotonic dystrophy- type 1

      • Muscular Dystrophy- Duchenne's, Beckers

  • Distal

    • Inclusion body myositis

    • Myotonic dystrophy type 2

1.5 Isolated to the NMJ 

• Myasthenia Gravis

• Lamberton Eaton Syndrome

2.0 Sensory (only)

• Glove/ stocking distribution: peripheral neuropathy

• Dermatonal pattern: mononeuropathy

3.0 Co-ordination (only)

• Ataxia

  • Cerebellar- DANISH signs

    • Lesion- Stroke, Malignancy, MS

    • Inherited- Friedreich's Ataxia

    • Alcohol

  • Sensory Ataxia -   loss of vibration & proprioception, worse with closing eye 

    • Peripheral & Central- B12 deficiency

    • Central - accompanying UMN weakness

    • Peripheral - accompanying LMN weakness

  • Vestibular- BPPV, Labyrinthitis, Vestibular Schwannoma

Mixed Signs

B, 1.0 Mixed Motor and Sensory

1.1 UMN + sensory

• Multiple sclerosis

• Stroke - if hemiplegic

1.2 LMN + sensory

• Many of the peripheral neuropathies are predominantly sensory: alcohol, diabetes, B12 deficiency

• Lead is a rare cause of a predominantly motor 

1.3 UMN + LMN + sensory

• Subacute DGM spinal cord

• Non specific: syphillis, SLE & HIV (rescue examples !)

B, 2.0 Mixed Motor & Co-ordination

• Usually co-ordination is unable to assess with a lack of power. 

• Otherwise same list as co-ordination causes

B 3.0 Mixed Sensory & Co-ordination

• Ataxia

  • Cerebellar

    • Lesion- Stroke, Malignancy, MS

    • Inherited- Friedreich's Ataxia

    • Alcohol

  • Sensory (proprioception)- B12 deficiency

B 4.0 Motor, sensory & Co-ordination

Same as motor + sensory as as unlikely  able to assess co-ordination with weakness. 

Written in 2026