This document summarizes guidelines and techniques for examining the upper and lower limbs and cranial nerves during a neurology teaching session. For the upper limb, it describes how to observe patients, inspect for signs, and test tone, power, and reflexes at major joints. It distinguishes between central and peripheral signs. For the lower limb, it outlines how to observe gait and test for upper and lower motor neuron signs. It also describes mixed signs. For cerebellar examination, it details tests for the upper limbs and distinguishes intention tremors from other tremors. For tremor and Parkinson's disease, it describes how to observe and test for tremors, bradykinesia, and rigidity. Finally,

1. Summary of Practical sessions
GP Neurology teaching
25th Feb 2016

2. Guidelines for GP upper limb motor
examination - Tim Williams
1. Examination will never “trump” a good history
2. Observation is the first rule of medicine – watch patients walk into the
consultation room and undress for examination. Formal “inspection thereafter,
actively looking for wasting, fasciculation etc.
3. Remember “hard” (wasting, tone changes, reflexes) vrs “soft” (power,
incoordination/clumsiness) signs.
4. After inspection think tone, power and reflexes – remember two movements or
flexion/extension at each of the major upper limb joints (shoulder, elbow, wrist
and fingers).
5. Remember cardinal differences between central (UMN) signs: preserved bulk,
increased tone, pyramidal pattern weakness and brisk reflexes), and
peripheral (LMN) signs: reduced bulk and tone, weakness and flat/absent
reflexes.
6. Think patterns of localisation – single or multiple sites, or even a “system”
disorder

3. Lower Limb Examination
Gina Kennedy + Kirstie Anderson
• Gait – if they can walk narrow based and quick (?normal arm swing both sides/turn on
one smooth movement/walk heel to toe well/stand on heels and stand on toes and can
hop either leg and squat – then little chance of major surprises when examining on the
bed – so if you only have time for one thing – look carefully at gait in the corridor
• UMN signs:
– hyperreflexia, increased tone, upgoing plantars
– Causes: any inflammation or SOL above L1, use sensory level to determine where
to image
• LMN signs:
– Fasiculations, reduced/absent reflexes, reduced tone
– Causes: anything below L1 such as cauda equina compression, peripheral nerve
problem (GBS)
• Mixed signs:
– Fasiculations and spasticity (MND), absent reflexes and extensor plantars (B12
deficiency)

4. Cerebellar ataxia – Adam Cassidy
• In the upper limbs look for
– Past pointing
– Intention tremor
– Dysdiadochokinesia
• When doing finger-nose testing, ensure the patient stretches fully
to reach your finger
• In an intention tremor the amplitude increases as the target is
approached
• If a patient has a postural tremor, this will not disappear on doing
the finger-nose test. In such patients the amplitude does not
increase as the target is reached and this is a kinetic tremor
• Most doctors who think they are seeing an intention tremor are
actually seeing a postural and kinetic tremor in somebody with a
diagnosis of essential tremor

5. Cerebellar ataxia – Adam Cassidy
• Very rare to see in general practice
• Lots of older people wobble a bit on finger-nose
testing and don’t have cerebellar ataxia
• Supporting features include gait ataxia,
nystagmus and dysarthria
• More common causes:
– Chronic: Alcoholic cerebellar
degeneration
– Subacute: Drugs – phenytoin,
carbamazepine
– Acute: Cerebellar stroke

6. Tremor/PD – Naomi Warren
• Tremor examination
– Observation – at rest, posture, action and with gait
– Benign tremors – more symmetrical and
postural/action
• Parkinson’s Disease
– Tremor – asymmetric, rest
– Bradykinesia – decrement in “quacking duck” (core
feature)
– Rigidity
– Gait – reduced arm swing

7. Cranial Nerves - Joe Guadagno
Eye movement disorder (Diplopia)
CN III, IV & VI: extraocular muscles
1. are the eyes looking in the same direction?
2. is there nystagmus?
3. is there double vision?
• primary position: 4 questions
-is there ptosis?
• don’t move on until you have answered all 3
questions!
Clinical examination
3 questions to ask at each of the 5 stations
• cover each eye
• uniocular diplopia
– ocular/retinal pathology (v rare)
– non-organic
• more than two images
– usually mad
• non-neuromuscular causes (eg thyroid)
• muscular disorders
• neuromuscular junction (myasthenia)
• individual cranial nerve palsies (III, IV, VI)
• central eye movement problems
– gaze palsies
– INO
– nystagmus
Abnormalities
• III, IV or VI?
• feasible combination?
• not simple III/IV/VI + no nystagmus
– muscle (CPEO)
– NMJ (fatigue)
• not simple III/IV/VI + nystagmus
– brainstem
Very basic rules of thumb!
Think -
“look straight”
“look left”
“look right”
“look at the tip of
your nose”
• lesion in medial
longitudinal
fasciculus
• aBducting eye
has nystagmus
• aDducting eye
fails to aDduct
• lesion is on the
side of failed
aDduction
Remember INO’s - think MS