GKT CLINICAL SKILLS: PHYSICAL EXAMINATION PATIENT EDUCATOR PROGRAMME.
NEUROLOGY EXAMINATION.
Systems Check List.
Order Of Examination
General appearance
Higher Function
Cranial Nerves
Motor System
Sensory System
Stance and Gait

Appropriate introduction to patient giving your own name and checking the name of the patient

Explain the purpose and main steps of the examination

Gain verbal consent to proceed with the examination

Invite the patient to ask questions at any point during the examination

Wash hands before the beginning of the examination

General Appearance
In individual cases it may be better to focus the examination on the affected part. It may well
be more convenient to examine stance and gait before examining the patient in the couch.
HIGHER FUNCTIONS
1. The student should check whether you are left or right handed.
2. The student should establish that you are alert and able to give a clear history. If
relevant they should be able to perform the Mini Mental State Examination.
CRANIAL NERVES (CN 1-12)
3. CN1.The student should ask if you can appreciate taste and smell. They should
be able to know how to test these by firstly asking you to close your eyes then
sniff the room air and say whether you can smell at all then ask you to sniff a
couple of basic smells such as coffee or peppermint. These can be presented in
small containers for you to smell in each nostril in turn.
4. CN2.The student should ask you if you have reduced vision in either eye. They
should use a Snellen chart to test your sight and if you wear distance glasses
they can be worn. They must test each eye seperatley. The student should know
to have the 3 meter chart 3 meters away and the 6 meter chart 6 meters away.
They may also want to use a pinhole …………………
5. The student should ask you if you have any reduced vision in either eye. They
should test this by asking you to look directly into their eyes. They must sit
directly in front of you for this. They should stretch both arms out and waggle one
or both forefingers asking you to say which one they are moving. You must be
asked to look straight ahead into their eyes for accuracy during this test. Then
they should ask you to cover one eye and look into their opposite eye. Then the
student should extend out their arms and waggle their fingers from and extended
arm to a narrowed position and ask you to tell them when their fingers come into
your path of vision. This should be tested on one side then the other in smooth
movements both high and low and with full extension of their arm and then with
their arm moving in towards your point of central vision.
6. Using an opthalmoscope. The student is looking at your fundus (the inner most
point of your eye). They should ask you to remove your glasses and they too
should remove theirs. The student should ask you to fix your eye on a distant
point or object. It is sometimes helpful if they suggest something what you are to
loom at and is
7. Observe for pstosis, pupil size, squint, proptosis
8. Test for pupillary response to light
9. Test for pupil near response
10. Ask if the patient has double vision
11. Examine the range of horizontal and vertical eye movements
12. Check for nystagmus
13. Check for any numbness and altered sensation to the face
14. Test corneal reflex (this must not tested on the patient educator)
15. Test jaw jerk with hammer
16. Inspect face at rest for symmetry
17. Ask patient to close both eyes tightly and check for burying of the eyelashes
18. Ask patient to show their teeth and whistle
19. Assess hearing bilaterally
20. Examine external ear using auroscope
21. Test for gag reflex (this must not be performed on the patient educator)
22. Ask patient to say “ah” to observe the soft palate movement
23. Ask patient to shrug both shoulders against resistance
24. Ask patient to turn head bilaterally against resistance
25. Protrude tongue and move from side to side
MOTOR SYSTEM
27.The student should make sure that you are comfortable, the back of the couch
should be raised and your upper body exposed. The student should observe your
torso and will be looking for any obvious abnormalities, skin changes, deformity,
wasting and involuntary movements. (If the student is just doing the “Limb” section of
the neuro examination then they should also check whether you are right or left
handed). The student should ask you to lean forward so that they can observe your
back, especially around the shoulder. The student should look at your hands,
especially observing your thumb. The student should also observe your legs and
look over your thigh muscles for quadracep wasting and then at your feet. The
student may also ask you to flex your foot to help them look for the oyster muscle.
This can be seen on the outside edge of the foot just under the ankle bone when the
foot is slightly flexed.
The student should ask you to close your eyes and extend your arms out in front of
you with your palms down and then palms up. The student will be looking for any
irregular movements of your hands and fingers.
UPPER LIMB
Tone
28. The student should hold your arm and support it at the elbow then take your
hand in theirs and turn it repetitively. They must make sure you are relaxed and
not moving your hand yourself. They will be looking for any “catches” in your
wrist movement and may want to increase the speed at which they turn your
hand to find this. The student may ask you to raise your opposite arm to help
bring out any signs of rigidity in the hand being tested.
Power
Test the following muscle groups in order and compare each side as you progress
29. Shoulder abduction. The student should ask you to extend your arm out with
you’re elbow slightly bent and then ask you to resist their attempt to push your
arm down. They need to put pressure on your upper not lower arm.
30. Elbow flexion. The student should ask you to bend your elbow making a “punch
fist”. They will ask you to resist their attempt to straighten it out by putting
pressure on your lower arm.
31. Elbow extension. The student should ask you to bend your elbow and make a
“punch fist”. They will ask you to resist their attempt to bend it by putting pressure
under your lower arm.
32. Wrist extension. The student should ask you to extend your wrist and then ask
you to resist their attempt to try to bend it.
33. Finger extension. The student should ask you to spread your fingers out straight
and then resist their pressure over your knuckles to push them down. The
student should use the outside edge of their hands.
34. Grip. The student should ask you to curl your fingers around their own and ask
you resist their attempt to open your grip.
35.First dorsal interosseous. The student should ask you to extend out your fingers
and then ask you to resist their pressure to push them together. The student should
test each finger in isolation from the other.
34. Abductor pollicis brevis. The student is looking at your thumb movement. The
student should ask you to open your hand flat out with the palm upwards and
then ask you lift your thumb vertically and resist their pressure to try to push it
back to the horizontal.
Power is graded on a scale of 1-6 with 1 being complete paralysis and 6 being normal
power. The student should be able to test your muscle power against gravity and also
where gravity is excluded. An exercise to demonstrate this is to ask you to bend your
elbow and raise your lower arm up to 45%. You should have your wrist palm side up and
make a fist and then be asked to see if you can move your wrist up against gravity. Then
you should turn your wrist over and see if you can move your wrist down with the aid of
gravity.
35. Biceps reflex. Your arm should be relaxed and bent by the side of your body. The
student should feel for your bicep tendon with their forefinger first then tap lightly
with the reflex hammer over the tendon. The student should make sure he/she
has a light grip of the hammer and uses it in a relaxed way making sure they get
the “wobble” effect with the hammer before hitting the tendon.
36. Triceps reflex. Your arm should be relaxed and bent by your side, a little further
across your body than when testing for your bicep reflex. The student should
support your elbow with one hand and tap over the triceps tendon with the
hammer. There is no need for the student to feel for the tendon first but they
should make sure they hit the tendon and not the muscle immediately above. (If
a response cannot be found then the student may ask you to clench your teeth
just as they strike the tendon with the reflex hammer. The timing for this needs to
be precise)
37. Wrist (brachioradialis) reflex. Your arm should be in the same position as for
biceps and the student should feel for the tendon first just above your wrist then
strike with the hammer.
38. Knee reflex. Your knee should be bent at 90% and the tendon felt just beneath
the kneecap before the student strikes with the hammer. The student should
support the underneath of your knee. (If a response cannot be found then the
student may ask you to clasp your hands and try to pull apart as they strike with
the reflex hammer)
39. Ankle reflex. Your foot should be in the mid position at the ankle with your knee
bent and the thigh externally rotated on the couch. The student should stretch
your foot up, keeping check that you are relaxed, and then hit the Achilles tendon
with the hammer.
40. Plantar response. The student should use an orange stick or pencil for this. Your
foot should be flexed up and a line drawn with the stick starting from the outside
edge of the sole of the foot at the heel and continuing round to the big toe. The
student should use moderate to firm pressure. Only if the toe extends up is this
considered a positive response, known as a Babinski response. Curling down is
normal.
LOWER LIMB
41. The student should ask you to expose your lower limbs and lie back on the
couch, supported by a pillow. They should look for any obvious abnormality, skin
changes, deformity, wasting and involuntary movements. The student should
check to see if you have any pain in your lower limbs. The student should check
you are relaxed and comfortable throughout. Both legs should be tested in
sequence throughout examination.
Tone
42. Roll leg on the couch and test for quadriceps catch. The student should roll your
leg gently on the couch and then with their hand placed directly under your knee
lift it up quickly so that it flexes.
Power
Test the following muscle groups in order and compare each side as you progress43. Hip flexion. The student should ask you to raise your straight leg up above 45%
and you should be asked to resist their pressure to lower it. The student should
put pressure on your thigh and not your shin.
44. Hip extension. The student should ask you to keep your leg flat on the couch and
not let them push it up from underneath the calf or thigh.
45. Knee flexion. The student should ask you to bend your knee and resist them
trying to straighten your leg out against their pressure on your thigh.
46. Knee extension. The student should ask you straighten out your leg with your
knee relaxed and resist their pressure under your thigh to bend it.
47. Ankle dorsiflexion. The student should ask you to flex your foot and resist their
pressure on the front of your foot to push it down.
48. Ankle planter flexion. The student should ask you to push your foot down (like
putting your foot hard down on the accelerator pedal) and resist their pressure to
push it up.
49. Ankle eversion. The student should ask you to move your foot out from the ankle
against resistance on the outside of your foot.
50. Ankle inversion. The student should ask you to move your foot from the ankle
inwards against pressure on the inside of your foot.
51. Extensor hallucis longus. The student should ask you to raise your big toe up
away from the other toe digits.
Co-ordination
The student should raise the back of the couch and make sure you are sitting up
comfortably with your lower body covered with a blanket if needed.
52. Finger-nose-finger exercise. The student should ask you to extend out one arm
and with your forefinger touch their extended finger then touch your nose. This
needs to be repeated at pace and with the student moving the position of their
finger in multiple directions. Your arm should be extended some way away from
your body.
53. Rapid alternating hand tapping movement. The student should ask you to rapidly
tap one of your hands onto the other with a twisting (flapping) movement. The
supporting hand should be still. This can be done either with your hand resting on
your body or raised just in front of you.
54. Heal to shin test. The student should get you to raise one leg up so that your
heel is against the knee of the opposite leg. You should then trace a line with
your heel down the shin of your leg to your foot then raise the leg up and start
back at the knee. Constant contact with the leg should be maintained.
Sensory system
55.Note if the patient has noticed any altered sensation in any part of the body using
a) light touch, b) vibration, c) joint position, d) pinprick bilaterally.
Light Touch. The student should use a cotton wool ball and demonstrate to you how
it feels by lightly touching you with it just above the shoulder blade or on your
forehead (their touch should not be so light as to tickle, remembering that one touch
is better then a wispy movement). They should check on the sensation you feel when
touched by the cotton wool. The student should then use the cotton wool to touch
you in multiple places from your foot working their way up to your chest. You should
be asked to indicate if you have any areas of a lack of sensation. It is not enough to
test on only a couple of areas.
Vibration. The student should again demonstrate the sensation of the tuning fork
against your collarbone or forehead. The student should strike the tuning fork on the
side of the bed only if they explain to you first what they are doing. Otherwise they
should use their fingers to set the vibrations going. They should ask you to tell them
whether you can feel the vibration when the fork is placed on your toe. They may ask
you to tell them both when you feel the vibrations and when they cease. The tuning
fork should be tested on your wrist, elbow then shoulder blade.
Joint position. The student needs to isolate the end of your finger (the one nearest
the thumb) and hold it either side of the end joint with their fingers. Then you should
be asked to tell them with your eyes closed when they are moving your joint up or
down. They should establish you know what the movements are before they ask you
to close your eyes. The same movement should be done with the big toe. They must
hold the toes on the outside edge and not on the top and bottom.
Pinprick. The student should use a neuro tip and follow the same pattern as for the
light touch with the cotton wool. They should make sure that you are comfortable
with the sensation of the pinprick before they start the test. They should ask you if
you feel a dull or sharp sensation throughout. The student should dispose of the
neuro tip in the sharps bin as soon as this part of the examination is complete.
STANCE AND GATE
55. Ask patient to rise from their chair without using their hands and stand still with
their feet together.
56. Ask patient to walk across the room turn round and walk back
57. Ask the patient to walk across the room with one foot directly in front of the other
in a heel to toe movement.
58. Ask the patient to walk across the room on their toes.
59. Ask the patient to walk across the room on their heels.
60. Ask the patient to stand with their feet together with eyes open and then with
them closed. The student should be ready to catch you when you close your
eyes in case you fall.