Nervous System Examination Routine

NERVOUS SYSTEM EXAMINATION

Mr K is a 58 years old gentleman who has been having difficulty in walking.

Please examine the Neurological system and lower limbs of this patient.

How to approach the case

Greet the patient and introduce yourself.

Steps in Examination :

Aim to shake his hand.Once a candidate had a patient with Myotonic dystrophy in one of the exams.
When he shook his hand , he wouldn’t let go. He had myotonic dystrophy which the candidate failed to pick due to examination anxiety.

Tell him I am Dr S and I want to examine your legs.

If you are comfortable ,is it OK if I proceed with the examination?

Look at the face of the patient . Any particular facies ? ( e g mask like face )

Any Ptosis ?/ Droping of eyelid?

Any obvious cranial nerve palsy eg eye deviated out and down etc ?

Look at the back for Scoliosis , Scar marks , Winging of scapula etc ?

Look at the legs of the patient for any wasting , fasciculations , abnormal movements etc.

Gait :

Now ask the patient to get up and take a few steps forward to the wall and have a look at his gait.

At this point it would be great idea to walk close to the patient , supporting him in the event if he falls at all.

Now tell the patient to walk back aiming to test Tandem walking .

(Tandem gait is a gait where the toes of the back foot touch the heel of the front foot at each step. Neurologists sometimes ask patients to walk in a straight line using tandem gait as a test to help diagnose ataxia, especially truncal ataxia, because sufferers of these disorders will have an unsteady gait.)

Tell patient to stand up straight and close his eyes and support him. ( Romberg”s Test)

The Romberg test is used to investigate the cause of loss of motor coordination (ataxia). A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception. If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature, that is, depending on localized cerebellar dysfunction instead.

Tell the patient to walk back into the bed,supporting him

Tone

Now examine tone of the legs

Check for ankle clonus and plantars as well.

Power / Motor Examination

Examine the power of lower legs.

Sensory Examination

Now do a quick sensory examination and reflexes of the lower limbs including ankle and knee jerk.

Reflexes:

Plantars

Co-ordination

Examine co-ordination of the legs including heel knee shin test.

Cerebellar signs

Look for cerebellar signs including intention tremor and Disdiadochokinesis.

In sensory system examination,look for Pin prick,temperature ,joint position and two point discrimination.

If possible,do a fundoscopy / atleast mention it.

Aim to see if patient has a drug chart and taking any medications.

Diagnosis of the patient :

The patient had Ataxic gait .This is seen in patient having lesions of the central part of the cerebellum
Positive Romberg.

Romberg's test is positive in conditions causing sensory ataxia such as:

Vitamin deficiencies such as Vitamin B12

Conditions affecting the dorsal columns of the spinal cord, such as tabes dorsalis (neurosyphilis), in which it was first described.

Conditions affecting the sensory nerves (sensory peripheral neuropathies), such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).

Friedreich's ataxia

Ménière's disease