Lesson 5.5: Neurological Examination
Neurological stations assess your ability to perform a systematic examination and interpret patterns of findings. The pattern, not the individual sign in isolation, is what points to the diagnosis.
Upper Limb Neurological Checklist
- Inspection — wasting, fasciculation, asymmetry, posture
- Tone — normal / spastic (clasp-knife) / rigid / flaccid
- Power — shoulder abduction, elbow flexion/extension, wrist flexion/extension, grip and finger abduction
- MRC grading: 0=none, 1=flicker, 2=gravity eliminated, 3=against gravity, 4=against resistance, 5=normal
- Reflexes — biceps (C5/6), supinator (C5/6), triceps (C7)
- Coordination — finger-nose test; dysdiadochokinesis
- Sensation — light touch, pinprick, vibration (128Hz tuning fork), proprioception
- Offer lower limb examination, cranial nerves, cerebellar assessment, gait
Lower Limb Neurological Checklist
- Inspection — wasting, fasciculation, foot drop, abnormal posture
- Gait — ask patient to walk: observe pattern (see table below)
- Tone — clasp-knife (UMN) / lead-pipe or cogwheel (Parkinson) / flaccid (LMN)
- Power — hip flexion/extension, knee flexion/extension, ankle dorsiflexion/plantarflexion
- Reflexes — knee (L3/4), ankle (S1/2), plantar response (Babinski sign)
- Coordination — heel-shin test
- Sensation — dermatomal and peripheral nerve distributions, compare sides
- Romberg test — eyes open vs closed
UMN vs LMN — Interpreting the Pattern
When neurological findings are handed to you, this table tells you what they indicate:
| Feature | UMN (Upper Motor Neurone) | LMN (Lower Motor Neurone) |
|---|---|---|
| Tone | Increased — spasticity (clasp-knife) | Reduced — flaccidity |
| Power | Weakness in UMN pattern | Weakness in nerve/muscle distribution |
| Reflexes | Brisk / hyperreflexia | Reduced or absent |
| Plantar response | Upgoing — Babinski positive | Downgoing or absent |
| Wasting | Absent or mild and late | Present, often early |
| Fasciculations | Absent | Present |
| Examples | Stroke, MS, spinal cord compression | Peripheral neuropathy, disc prolapse, Guillain-Barré |
Gait Patterns
| Pattern | What It Looks Like | Likely Cause |
|---|---|---|
| Hemiplegic | Circumduction of one leg; arm held flexed | Contralateral stroke (UMN) |
| Cerebellar ataxia | Broad-based, unsteady, veers to one side | Cerebellar disease, alcohol |
| Parkinsonian | Shuffling, small steps, stooped, reduced arm swing | Parkinson's disease |
| Steppage | High step, foot slap on landing | Foot drop — common peroneal nerve (L4/5) |
| Sensory ataxia | Wide-based, markedly worse with eyes closed — Romberg positive | Posterior column disease, B12 deficiency |
| Antalgic | Short stance phase on affected side | Pain (hip/knee OA, fracture) |
Cranial Nerve Quick Reference
| Nerve | What to Test | Key Finding to Report |
|---|---|---|
| II — Optic | Visual acuity, fields (confrontation), pupil light reflex | RAPD, field defects, papilloedema |
| III, IV, VI | Eye movements (H pattern), ptosis, pupil size | Diplopia, ptosis, blown pupil |
| V — Trigeminal | Sensation in V1/V2/V3; jaw motor (clench) | Facial sensory loss, jaw deviation |
| VII — Facial | Raise eyebrows, close eyes, show teeth, puff cheeks | UMN: spares forehead. LMN: whole face. |
| VIII — Vestibulocochlear | Whisper test; Rinne and Weber (512Hz) | Conductive vs sensorineural deafness |
| IX/X — Vagus | Palate elevation, uvula position, speech | Uvula deviates away from lesion |
| XI — Accessory | Shoulder shrug; head turn against resistance | Weakness in shoulder shrug or neck rotation |
| XII — Hypoglossal | Tongue protrusion | Deviates toward lesion (LMN); wasting suggests MND |