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

Introduction

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

• Adequate exposure

• End of the bed inspection

CN I-XII

• CN I - Any change to sense of smell (vanilla essence is rarely used)

• CN II (Eyes)

  • Visual acuity- ask about glassses, offer- Snellen chart + one eye at a time; with glasses on ask to tell the time of the clock (colour- Ishihara plates)

  • Visual fields - both eyes, left & right eye - central & peripheral 

  • Pupillary response to light- direct & indirect, RAPD- pupil dilates with light (CN II, III)

  • Offer fundoscopy (shouldn't have to do it)

• CN III, IV, VI- eye movements

  • Draw H,

  • Finger-palm: vertical/ horizontal

  • Accommodation response (look into distance then finger close)

• CN V

  • Fine touch V1, V2, V3; (near midline to avoid cervical nerves)

  • Jaw open- don't let me close mouth

  • Jaw Reflex- abnormal to close, normal: no response

• CN VII

  • Eye brows to ceiling, close eyes (attempt to open)

  • Puff cheeks, show teeth, purse lips (don't let me open mouth)

• CN VIII

  • Hearing b/l- whisper number + rub fingers together & ask to repeat

• CN IX, X

  • Open mouth, say arh- palatal movements

  • Cough

• CN XI

  • Neck rotation + resistance

  • Shrug shoulders + resistance

• CN XII

  • Tongue in mouth + movements

Functions not assessed: 

• Corneal reflex (V, VII)

• Gag reflex (IX, X)

• Sensation to pain and temperature

• Speech

Conclusion

Thank patient, help to re-dress, wash hands.

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 

Signs

• RAPD- optic neuritis, glaucoma, macular degeneration, infection e.g. herpes

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 Ophthalmoplegia

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); check for pain- can stop if painful

• Adequate exposure

Inspection:

• End of the bed- muscle wasting (dorsum hand), fasciculations; hands

• Tremor, pronator drift (palms upwards)

• Posture- kypho-scoliosis

Motor

Tone

• Assess rigidity- global movements

• Spasticity- fast rotation of wrist

Power

• Shoulder: 

  • • Abduction C5 - deltoid muscles, auxiliary nerve

    • Adduction C6,7,8- lat dorsi muscles, 

• Elbow

  • • Flexion C5/6- musculocutaneous, biceps

    • Extension C7- radial, triceps

• Wrist 

  • • Flexion C7, C8- musculocutaneous, 

    • Extension C6, C7- radial 

• Finger 3rd

  • • Extension: C7- radial 

    • Flexion: C8, medial + ulnar

    • Finger abduction T1- median

    • Finger adduction

• Thumb 

  • Abduction

  • Adduction T1- ulnar 

• Squeeze fingers

Reflexes

• Biceps C5/6

• Supinator C5/6

• Triceps C7

  • Arm across chest, consider reinforcement maneuvers- grit teeth (distraction

Co-ordination- both proprioception, motor and cerebellar integration

• Finger nose - option to do with eyes closed, also can detect intention tremor

• Dysdiadochokinesia- cerebellar lesion

Sensory

Fine touch

• Check sensation on sternum, hands anatomical; 

  • Lateral arm C5- can feel it, then same?

  • Lateral forearm C6

  • Lateral 2nd finger- C6, median nerve

  • Middle finger tip - C7, 

  • Medial palm of hand, ulnar nerve

  • Medial forearm, C8

  • Medial arm T1

• Glove distribution- move up, any change 

• Dorsal column

Sharp touch

• Same as fine touch; spinothalamic pathway 

Vibration

• Feel on sternum- sensation of buzzing, rather than metal

• Start distally on 2nd finger- eyes close, when stops

• If not sensation, move up joints: 2nd PIPJ, MCPJ, wrist, elbow, shoulder

• Dorsal column

Proprioception

• 2nd distal phalanx: up or down with eyes shut

• Move proximally to phalanx, finger, wrist, elbow, shoulder

• Dorsal column

Conclusion

Thank patient [name] for time, hand gel. 

Signs

Tone

• Led pipe rigidity- Neuroleptic Malignant Syndrome (NMS) 

• Cogwheel rigidity- Parkinson's Disease 

Conditions

Parkinson's Disease 

• Cogwheel rigidity, resting tremor

• Bradykinesia

• Shuffling gait, stooping posture, poor arm swing

Lower Limb 

Examination

Introduction

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

• Consent- Hi __, would i able to able to examine your legs, looking at their motor functions, co-ordination sensation & gait; check pain

• Adequate exposure

Inspection: 

• End of the bed- muscle wasting, fasciculations, weakness, scars

Motor

Tone

• Roll legs

• Lift legs- slow & quick

• Clonus- > 5 beats

Power

• Hip 

  • • Flexion L2, femoral nerve

    • Extension, L5-S2, gluteal nerve

• Knee

  • • Flexion, S2, sciatic

    • Extension L3, femoral nerve, quadriceps

• Ankle

  • • Dorsi-flexion, L4 peroneal

    • Plantar flexion, S1 tibial

• Toe 1st 

  • • Flexion, L5 peroneal 

    • Extension S1, tibial

Reflexes

• Reinforcement & distraction, grip hands together

  • Knee L3/4 (lift knee + patellar tendon)

  • Achilles S1 (ankle extended, hit at MTP)

  • Plantar reflex S1 - warn feel ticklish, (scratch outside of foot up foot, first toe flexes)

Co-ordination- both proprioception, motor and cerebellar integration

• Heel shin

Sensory

Fine touch (cotton wool) 

• Touch onto sternum to know touch

  • Lateral mid thigh L2

  • Medial thigh above knee L3

  • Medial calf L4

  • Lateral calf L5

  • Anterior first toe L5

  • Anterior 5th toe S1, lateral 

• Ascending neuropathy- heel to thigh

 Sharp touch (pin prick)

• Same as fine touch

Vibration (tendon hammer)

• Buzzing not metal 

• Start on toe- tell when stopped buzzing

  • If can't tell, move up boney prominence landmarks- 1st to MTP, then, ankle, tibial prominence, patellar, ASIS 

Proprioception

• Toe up or down

• If nil sensation continue to ankle, knee, hip 

Gait

• Normal gait- walk & turn

• Heel-toe gait

• Romberg's test (balance) +- small push

Conclusion

Consider looking for a spinal scar. 

Thank the patient, help getting dressed and wash hands. 

Signs

Inspection

• Fasciculations

Tone

• Spasticity- increased tone with increased speed

• Rigidity- increased tone regardless of speed

• Clonus

Power

Localising the lesion

Reduced power

• UMN Lesion: central nervous system- brain & spinal cord

  • Reduced power, increased tone & reflexes

• LMN Lesion: peripheral nervous system

  • Reduced power, tone and reflexes, fasciculations; muscle wasting

• Causes

  • UMN: MS, stroke

  • LMN: peripheral neuropathy

  • Mixed: B12- subacute DGN of spinal cord, diabetes/ hypertensive neuropathy

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

Gait

Examination

Introduction

• Hand gel, introduction, consent, ask about pain/ mobility- fall risk

• Walking aid

• Fasciculation, wasting, scars; Parkinsoniasm rigidity + reduced facial expression; unilateral weakness 

Sit to stand

• Can add in standing with arms crossed to look for sarcopenia

Gait

• Simple walk: unaided- leg swing, arm swing & turn

• Heel-toe: ?ataxia

• Walk on tip-toes: S1 (plantar flexion)

• Walk on heels: L5- foot drop, bilateral could be CMT disease

Rhombergs

• Balance requires- sensory, vestibular and proprioception inputs

• Rhomberg's: eyes closed blocks sensory, if falls: issue with vestibular or proprioception

• Proprioception issues is called sensory ataxia

Signs

• Lesions are ipsilateral

• Nystagmus- fast beat towards lesion, slow beat away

• Rhomberg's positive causes

  • Sensory ataxia- B12 deficiency, syphillis

  • Peripheral neuropathy

  • Vestibular disorders- meniere's disease

  • Alcohol and drug consumption

Conditions

• Demyelination - younger (MS)

• Vascular- older (stroke)

• Alcohol Excess

Written in 2026