Nervous system Examinations

Introduction

In the neurology PACES examination, you will likely be expected to perform a cranial nerve, upper or lower limb examination. Often their is only a single sign which you're expected to give a differential for. 

Core Presentations

• Isolated undiffereniated sign

• Stroke

• Multiple Sclerosis

• Parkinson's Disease

• Peripheral neuropathy

• Charcot-Marie-Tooth Disease

• Myotonic dystrophy

• Myasthenia Gravis

• Polio

• Acromegaly

• Normal Examination

Cranial Nerves

Examination

Intoduction

• Introduction, correct patient, consent, wash hands (WINDEC)

• Adequate exposure

• End of the bed inspection

Examination

• Any change to sense of smell

• Eyes

  • Visual fields - both eyes, left eye, right eye

  • Offer Visual Acuity

  • Pupillary response to light- direct & indirect, RAPD

  • Eye movements: draw H

• Facial Sensation

• Motor- movement of:

  • Facial muscles

  • Head and shoulder 

  • Tongue

• Special Tests: 

  • Cough 

  • Swallow water

  • Speech

Functions not assessed: 

• Corneal reflex

• Gag reflex

• Sensation to pain and temperature. 

Cranial Nerve Functions

• CN 1- Olfactory: sensory- smell

• CN 2- Optic: Visual acuity (visual fields), pupillary sensory response

• CN 3- Oculomotor: motor eyelids, pupil constriction, eye muscles- inferior oblique; medial, superior and inferior rectus

• CN 4- Trochlear: motor- superior oblique

• CN 5- Trigeminal: sensation of face; motor- mastication

• CN 6- Abducens: motor- lateral rectus

• CN 7- facial: motor movements of face V1, V2, V3, anterior 2/3rd of tongue

• CN 8- vestibulo-cochlear: hearing & balance

• CN 9- glossopharngeal: posterior 1/3rd tongue, swallowing

• CN 10- Vagus: parasympathetic autonomic control of heart, lungs, 

• CN 11- accessory: motor- head and shoulder

• CN 12- hypoglossal: motor- tongue 

Conditions

• Oculomotor Nerve Palsy (Cranial Nerve III)- unilateral affected eye, fixed in down and out; ptosis +- mihydrosis

• Trochlear Cranial Nerve IV Palsy- inability to move affected eye inferior at ADDuction, head tilted

• Abducens Cranial Nerve VI Palsy- inability to ABDuct affected eye

• Bell's palsy: unilateral paralysis of all 3 segments of face

Complex ophthamloplegia

Multiple eye signs not fitting into one cranial nerve:

• Vasculitis, Lyme disease, Meningitis, Sarcoidosis

• Thyroid eye disease

• Myasthenia Gravis

• Myotonic Dystrophy

• Miller Fisher Syndrome

• Ophthalmoplegic Migraine- painful mononeuropathy that self resolves

Upper Limb 

Examination

Introduction

• Introduction, correct patient, consent, wash hands (WINDEC)

• Adequate exposure

• Inspection: end of the bed

Motor

Tone

Power

• Shoulder: 

  • • Abduction C5 - auxiliary

    • Adduction C6,7,8

• Elbow

  • • Flexion C5/6- musculocutaneous

    • Extension C7- radial

• Wrist 

  • • Flexion C5- musculocutaneous

    • Extension C6- radial 

• Finger 3rd

  • • Extension: C7- radial 

    • Flexion: C8, medial + ulnar

    • Finger abduction T1- median

• Thumb adduction T1- ulnar 

Reflexes

• Biceps C5/6

• Triceps C7

• Supinator C5/6

Sensory

Fine touch

• Shoulder tip C4

• Regimental badge C5

• Tip of thumb C6

• Tip of middle finger C7

• Tip of little finger C8

• Medial mid forearm T1

Proprioception

Co-ordination- both proprioception, motor and cerebellar integration

• Finger nose

• Dysdiadochokinesia

Conclusion

I have not assessed the sensory temperature or pain (spinothalamic) or vibration (dorsal column- medial leminiscus tract) modalities. 

Lower Limb 

Examination

Introduction

• Introduction, correct patient, consent, wash hands (WINDEC)

• Adequate exposure

• Inspection: end of the bed

Motor

Tone

Power

• Hip 

  • • Flexion L1/2, femoral

    • Extension, L5/S1, gluteal

• Knee

  • • Flexion, L5/S1, sciatic

    • Extension L3/4, femoral

• Ankle

  • • Dorsi-flexion, L4 peroneal

    • Plantar flexion, S1 tibial

• Toe 3rd 

  • • Flexion, L5 peroneal 

    • Extension L5, tibial

Reflexes

• Knee L3/4

• Ankle S1

• Plantar reflex S1

Sensory

Fine touch

• Antero-medial mid thigh L2

• Medial thigh above knee L3

• Medial Malleolus L4

• Dorsal 1st webspace L5

• Lateral heel S1

Proprioception

Co-ordination- both proprioception, motor and cerebellar integration

• Heel shin

Gait

• Normal gait

• Heel-toe gait

• Rhomberg's test +- accenuated

• Consider quadriceps test of strenght

Conclusion

I have not assessed the sensory temperature or pain (spinothalamic) or vibration (dorsal column- medial leminiscus tract) modalities. 

Written in 2026