Sensory system of the upper limbs examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Position him so that he is comfortably seated and ask him to expose his arms and to position
them so that the palms are facing towards you.
• Ask if he is currently experiencing any pain.
To examine the sensory system, test light touch, pain, vibration sense, and proprioception.
Do not forget to inspect the arms before you start. In particular, look for muscle wasting,
fasciculation, scars and other obvious signs.
is touched with a wisp of cotton wool. Apply the cotton wool to his sternum as a test. Then apply
it to each of the dermatomes of the arm, moving from the hand and up along the arm. Remember
to compare both sides against each other, asking, “Does it feel the same on both sides?”.
• Pain. Ask the patient to close his eyes and apply a sharp object – ideally a neurological pin – to
the sternum and then to each of the dermatomes of the arm, as above. Compare both sides
against each other. If there is any loss of or difference in sensation, map out the area affected.
Figure 25. Dermatomes of the arm.
90 Station 34 Sensory system of the upper limbs examination
• Vibration. Ask the patient to close his eyes and apply a vibrating 128 Hz tuning fork (not the
wrist and then the elbow (only if not felt more distally). Compare both sides against each other,
asking the patient to tell you when he feels the vibration stop (you can hasten this by touching
finger between the thumb and index finger of one hand. With the other hand, move the distal
phalanx up and down at the joint, asking him to identify the direction of each movement. Hold
the joint and phalanx from the sides, i.e. from their lateral and medial aspects. Tell the patient
something like, “I’m going to move your finger up and down. Is this up or down?” “What about this?
And that?” Again, compare both sides.
• Ensure that he is comfortable.
• Ask to carry out a full neurological examination.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a sensory system of the upper limbs examination station
• lesion affecting a single nerve, e.g. ulnar, median, or radial nerve (see Station 33).
• lesion affecting multiple nerves in a glove and stocking distribution, such as in diabetic
• lesion affecting a single root nerve, e.g. C6.
• numbness to touch and vibration and loss of proprioception (and weakness) on same side of
the lesion, and loss of pain and temperature sensation on the opposite side.
• caused by lateral hemisection or injury of the spinal cord.
• loss of pain and temperature sensation but not of other sensory modalities.
Motor system of the lower limbs examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Position him and ask him to expose his legs.
• Ask if he is currently experiencing any pain.
• Look for deformities of the foot.
• Look for abnormal posturing.
• Ensure that the patient is not in any pain.
• Ask the patient to relax the muscles in his legs.
• Test the tone in the legs by rolling the leg on the bed, by flexing and extending the knee, and/
or by abruptly lifting the leg at the knee.
the forefoot. Compare muscle strength on both sides, and grade it on the MRC scale for muscle
2 Movement, but not against gravity.
3 Movement against gravity, but not against resistance.
4 Movement against resistance, but not to full strength.
Table 15. Important root values in the lower limb – muscle strength
• Hip flexion (femoral nerve and iliopsoas muscle) L1, L2
• Hip extension (inferior gluteal nerve and gluteus maximus muscle) S1
• Hip adduction (obturator nerve and adductor muscles) L2
• Knee flexion (sciatic nerve and hamstrings) L5, S1
• Knee extension (femoral nerve and quadriceps) L3, L4
• Foot dorsiflexion (deep peroneal nerve and tibialis anterior muscle) L4, L5
• Foot plantar flexion (tibial nerve and gastrocnemius muscle) S1
• Big toe dorsiflexion (deep peroneal nerve and extensor hallucis longus) L5
92 Station 35 Motor system of the lower limbs examination
• Test the knee jerk and ankle jerk with a tendon hammer (see Figure 26). Test the knee jerk by
raising and supporting the knee with one arm and striking the patellar tendon with the other.
To test the ankle jerk, abduct and externally rotate the hip and flex the knee and ankle. Then
strike at the Achilles’ tendon. Compare both sides. If a lower limb reflex cannot be elicited, ask
the patient to hook flexed fingers and pull apart while you re-test.
Figure 26. Testing the knee (A) and
• Test for clonus by holding up the ankle and rapidly dorsiflexing the foot (2–3 beats is normal).
• Test for the Babinsky sign (extensor plantar reflex) by scraping the side of the foot with your
thumbnail or, ideally, with an orange stick. The sign is positive if there is extension of the big
toe at the MTP joint, so-called ‘upgoing plantars’.
Table 16. Important root values
Station 35 Motor system of the lower limbs examination 93
• Carry out the heel-to-shin test.
– lie the patient on a couch. Ask him to run the heel of one leg down the shin of the other,
and then to bring the heel back up to the knee and to start again. Ask him to repeat the test
• If he can, ask the patient to walk to the end of the room and to turn around and walk back. (See
Station 37: Gait, co-ordination, and cerebellar function examination.)
• Ensure that he is comfortable.
• Ask to carry out a full neurological examination.
• Summarise your findings and offer a differential diagnosis.
power, reduced reflexes, down-going plantars, normal co-ordination, wasting, and fasciculations.
Figure 27. Testing for the Babinsky or extensor plantar sign.
94 Station 35 Motor system of the lower limbs examination
Conditions most likely to come up in a motor system of the lower limbs examination station
• lesion affecting a single nerve, most commonly the
common peroneal nerve (resulting in foot drop).
• lesion affecting multiple nerves in a glove and
stocking distribution as in diabetic neuropathy.
• lesion affecting a single root nerve (see Table 16).
• paralysis or weakness on one side of the body
accompanied by decreased movement control,
spasticity, and hyperreflexia (upper motor neurone
• signs include unilateral or bilateral lower
limb motor and/or sensory deficits.
• the ankle jerks are usually absent on both
• upper motor neurone signs such as
Babinsky sign and clonus are absent.
• symmetrical weakness predominantly
affecting proximal muscle groups.
• in contrast to neuropathy, in myopathy
muscle atrophy and hyporeflexia occur
Sensory system of the lower limbs examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and ask for his permission to carry it out.
• Position him on a couch and ask him to expose his legs.
• Ask if he is currently experiencing any pain.
To examine the sensory system, test light touch, pain, vibration sense, and proprioception.
• Light touch (not light rub). Ask the patient to close his eyes and to say ‘yes’ each time he is
touched with a wisp of cotton wool. Apply the cotton wool to his sternum as a test. Then apply
it to each of the dermatomes of the leg, moving from the foot and up along the leg. Remember
to compare both sides against each other, asking, “Does it feel the same on both sides?”.
• Pain. Ask the patient to close his eyes and apply a sharp object – ideally a neurological pin – to
the sternum and then to each of the dermatomes of the leg, as above. Compare both sides
against each other. If there is any loss of or difference in sensation, map out the area affected.
• Vibration. Ask the patient to close his eyes and apply a vibrating 128 Hz tuning fork (not the
only if not felt distally). Compare both sides against each other, asking the patient to tell you
when he feels the vibration stop (you can hasten this by touching the tuning fork).
Figure 28. Dermatomes of the leg.
96 Station 36 Sensory system of the lower limbs examination
between the thumb and index finger of one hand. With the other hand, move the distal phalanx
up and down at the joint, asking him to identify the direction of each movement. Hold the joint
and phalanx from the sides i.e. from their lateral and medial aspects. Tell the patient something
like, “I’m going to move your toe up and down. Is this up or down?” “What about this? And that?”
Again, compare both sides. If the patient is able to stand, you can also perform Romberg’s test
(see Station 37: Gait, co-ordination, and cerebellar function examination).
• Ensure that he is comfortable.
• Ask to carry out a full neurological examination.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a sensory system of the lower limbs examination station
• lesion affecting a single nerve.
• lesion affecting multiple nerves as in alcoholic or diabetic neuropathy.
• lesion affecting a single root nerve (see Figure 28).
• signs include unilateral or bilateral lower limb motor and/or sensory deficits, including ‘saddle
anaesthesia’ (loss of sensation in the area of the buttocks and perineum).
• loss of sensation including light, pain, temperature, vibration, and proprioception on one side
• numbness to touch and vibration and loss of proprioception (and weakness) on same side of
the lesion, and loss of pain and temperature sensation on the opposite side.
• caused by lateral hemisection or injury of the spinal cord.
• loss of proprioception and vibration but not of other sensory modaliti
Gait, co-ordination, and cerebellar function
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask if he is currently experiencing any pain.
• Inspection. Inspect the patient in the sitting position, noting any abnormalities of posture. Ask
• Gait and arm swing. Ask him to walk to the end of the room and to turn around and walk back.
If he normally uses a stick or frame, he should not be prevented from doing so. Note the gait
and also the arm swing and any difficulty in standing or turning.
• Heel-to-toe test/tandem gait. Ask him to walk heel-to-toe, ‘as if on a tightrope’. Ataxia on a
narrow-based gait suggests a cerebellar or vestibular lesion.
• Romberg’s test. Ask him to stand unaided with his feet together and his arms by his sides.
Assess with his eyes open and then with his eyes closed. If he sways and threatens to lose his
balance when his eyes are closed, the test is said to be positive, indicating posterior column
You must be in a position to steady the patient should he threaten to fall.
• Resting tremor. Ask the patient to sit down, to rest his hands in his lap, and to close his eyes.
Resting tremor is a sign of Parkinson’s disease.
• Intention tremor. Ask the patient to do something, e.g. remove his watch or write a sentence.
• Muscle tone in the arms. Examine muscle tone in the elbow (flexion and extension) and wrist
(flexion and extension, abduction and adduction) joints. Compare both sides.
• Dysdiadochokinesis. Ask the patient to clap and then show him how to clap by alternating the
palmar and dorsal surfaces of one hand. Once he is able to do this, ask him to do it as fast as he
can. Ask him to repeat the test with his other hand.
• Finger-to-nose test. Place your index finger at about 2 feet from the patient’s face. Ask him to
touch the tip of his nose and then the tip of your finger with the tip of his index finger. Once he
is able to do this, ask him to do it as fast as he can. And remember that he has two hands! Look
for intention tremor and dysmetria (past-pointing), both signs of cerebellar disease.
• Fine finger movements. Ask the patient to oppose his thumb with each of his other fingers in
turn. Once he is able to do this, ask him to do it as fast as he can. Again, remember that he has
• Muscle tone in the legs. Ask the patient to lie down on a couch and, if possible, to relax the
• Heel-to-shin test. Ask the patient to run the heel of one leg down the shin of the other, and
then to bring the heel back up to the knee and to start again. Ask him to repeat the test with
98 Station 37 Gait, co-ordination, and cerebellar function examination
Assessment of cerebellar function
• If you are specifically asked to assess cerebellar function, carry out the above plus test
eye movements (nystagmus) and ask the patient to say ‘baby hippopotamus’ (slurred/
staccato speech). If you are then asked to list cerebellar signs, remember the mnemonic
– Dysdiadochokinesis and dysmetria (finger overshoot)
– Nystagmus – test eye movements
– Slurred/staccato speech – ask the patient to say ‘baby hippopotamus’ or ‘British constitution’
• Ask the patient if he has any questions or concerns.
• Ensure that he is comfortable.
• Ask to carry out a full neurological examination.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a gait, co-ordination, and cerebellar function examination
• the pelvis tilts upwards, the hip is abducted, and the leg is swung forwards in a semi-circular
• the leg is stiff and extended but the arm may be held in flexion and adduction with minimal
• a spastic gait seen in cerebral palsy and resulting from muscle contractures.
• the hips, knees, and ankles are flexed, producing a crouching and tiptoeing appearance.
• in addition, the hips are adducted and internally rotated, such that the knees cross or hit each
other in a scissor-like movement.
• seen in Parkinson’s disease.
• short shuffling steps with stiff arms and legs and stooped posture; difficulty starting and
• seen in spinal and cerebellar lesions and in alcohol intoxication.
• unsteady, broad-based gait with a lurching quality.
• seen in peripheral neuropathies.
• weak foot dorsiflexors result in a high-stepping gait with foot-slapping; the high-stepping is
an attempt to prevent the foot from dragging and being injured; also called ‘high-stepping
gait’ or ‘foot-slapping gait’.
Station 37 Gait, co-ordination, and cerebellar function examination 99
• seen in weakness of the hip abductors or in an inability or reluctance to abduct the hip, e.g.
due to a fractured neck of femur or to arthritic pain.
• the pelvis tilts to the unaffected side in the stance phase; as a result, the trunk lurches to the
affected side in an attempt to maintain a level pelvis.
• bilateral Trendelenburg results in a typical waddling gait.
• seen in arthritis and trauma.
• avoidance of motions that trigger pain.
• often quick, short, and light footsteps.
• not to be confused with a Trendelenburg gait.
• in muscular diseases the proximal pelvic girdle muscles are most affected, such that the
patient is unable to stabilise the pelvis in the stance phase.
• the pelvis drops to the side of the leg being raised, and this results in a broad-based, waddling
The patient is likely to find the assessment difficult and distressing, so remember to be especially
empathetic. In particular, do not rush the examination or keep on interrupting the patient, but move
at a pace that feels comfortable for him.
Dysphonia Motor impairment of ability to vocalise speech
Dysarthria Motor impairment of ability to articulate speech
Dysphasia Cognitive impairment of ability to comprehend or express language
Aphasia Complete inability to comprehend or express language
Note: Expressive dysphasia (Broca’s area, in the inferolateral dominant frontal lobe) and receptive
dysphasia (Wernicke’s area, in the posterior superior dominant temporal lobe) often co-exist.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the assessment and obtain his consent.
• Check that he speaks English and that he can hear you.
• Ask him to try to describe his current problems.
Name: (year) (season) (month) (date) (day)
Name: (country) (county/region) (town) (hospital) (floor)
Nominal dysphasia is a common form of expressive dysphasia. Ask the patient to name some common
objects such as a watch, pen, or badge; then to name the components of some of these objects, e.g.
answer can help to distinguish nominal from receptive dysphasia.
Station 38 Speech assessment 101
Assess whether the patient has difficulty understanding you by asking him to carry out some simple
a more complex three-stage command, for example, “Using your left hand, touch your nose and then
Conductive aphasia is the inability to repeat words or phrases despite intact understanding. Ask the
patient to repeat, “No ifs, ands or buts.”
hippopotamus’, ‘Biblical criticism’, ‘Artillery’.
Assess the structures involved in phonation and articulation by asking the patient to repeat:
• ‘Ah’ Palate, larynx, and expiratory muscles.
• Make a note of the patient’s volume of speech, which may be low if there is weakness of the
vocal cords or respiratory muscles. Ask him to cough, and look out for ‘bovine’ cough, which
would suggest a lesion of cranial nerve X impairing the closure of the vocal cords.
• Ask the patient to carry out simple sums and subtractions.
• Ask the patient to write a sentence.
• Ask the patient if he has any questions or concerns.
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