1. Consciousness
2. Environmentgeneral appearance
3. Handednessspeech
4. Headneckneck stiffness
5. Cranial nerves
6. Upper limbs: inspecttonepowerreflexescoordsensory
7. Lower limbs: inspecttonepowerreflexescoordgaitsensory
8. Systems: spinecarotid bruitaspiration

Consciousness

• If unconsciousSee Unconscious Examination.

Environment

• Bed: one siderail raised (hemiplegia).
• Bed: pt.'s bad eye side placedagainst wall so they can't be surprised (stroke).
• Bed: soft mattress to avoid pressure sores (mobility difficulty).
• Bed: V-shaped posture pillows since pt. unable to support self.
• Tables: all medsetc. within reach of non-siderailed arm (hemiplegia).
• Room: hoistwheelchairwalker (paralysis).
• Room: NG tube (palsy of throat CN's).
• Room: ventilatorlife support machines.

General appearance

• Age of pt. (Parkinson's usu. 45+etc).
• Chorea (Huntington'srheumatic feverdrugsetc).
• Ethnicity (scandinavian: multiple sclerosis).
• Ballismadystonia (usu. drugs)noticeable tremor.
• Posture: leaning to one side (hemiplegia).
• Posture: stooped forward (Parkinson's).
• Only using one hand on tray (hemiplegia).

Handednessspeech

• Ask to shake handask if R or L-handed.
• Ask namepresent locationhow long in hospital. See Mental Status Reference.
• If detect abnormality while pt. talksSee SpeechDisorders Reference.

Head

• Asymmetryunilateral facial drooping (stroke).
• Ptosis.
• Serpentine stare (Parkinson's).
• Licking of lips.
• Scars of previous operations.
• Traumainjuryabnormalities. 
• Mental retardation syndrome facies: Down'sFASetc.
• Eyes: exophthalamos (thyroxicosis)Kayser-Fleisher rings (Wilson's).

Neckneck stiffness

• Neck: thymectomy scar (MG).
• Neck: thyroidectomy scar (thyrotoxicosis).
• Beware of performing manipulation on a cervical spine injury pt.
• Hand under occiputflex neck to chin and see if resistance.
  • Resistance causes: raised ICPcervical fusion or spondylosisParkinson'smeningitis.
• If suspect meningitis (feverphotophobia) do Kernig's sign.

Cranial nerves

• See Cranial Nerves Examination.

Upper limbs: inspect

• Patient sits over side of bed facing you.
• For rest of examinationcomparing L side to R side.
• Asymmetry.
• Deformities: wrist dropwaiter's tipclaw hand.
• Muscle wastingfasciculations. Include shoulder girdle.
• Tremor:
  • Intention (cerebellar).
  • Resting with pill-rolling (Parkinson's).
  • Action tremor (BAT:  Benign essential tremor syndromeAnxietyThyrotoxicosis).
• Feel hand for heat (thryrotoxicosis)grip.
• Pronator drift: pt's eyes closedarms extendedwith palms up. Tap pt'sarms briskly downward (arm drifting into pronation: UMNLcerebellarpost. column loss).
• Pseudoathetosis from proprioceptive loss.
• Muscle bulktenderness.

Upper limbs: tone

• Ask pt. if any tenderness in any jointsso won't hurt them whenmanipulating them for tone.
• Grasp under elbow and wristand rotate the 2 joints to assessresistance.
  • If Parkinson'scogwheel rigidity in wrist [combination of tremor andincreased tone].
  • If Parkinson'slead pipe resistance when flexing forearm.
• If ulnar nerve indicatedFroment's sign:
  • Give pt a piece of paper for each hand.
  • Ask pt to grasp papers by moving straightened thumb to radial side ofindex finger.
  • Affected thumb is forced to flex at interphalangeal joint to grip paper.
• If median nerve indicatedpen touching test:
  • Pt's hand supine.
  • Dr. hold's pen above thumb
  • Ask pt. to lift thumb to touch it.
  • Affected thumb can't touch pen. 

Upper limbs: power

• Assess shoulderelbowwristfingers.
  • Assess by ability to push against Dr's hand.
  • Assess across a single joint at a time [eg: Dr's hand on bicepnotforearmto assess shoulder power]. 
• If MG suspected:
  • Pt. holds arms above head.
  • MG pt. will lose powerafter contractions.
• See Power Scale Reference.

Upper limbs: reflexes

• Supinator/Brachioradialis (C5-6).
• Biceps (C5-6).
• Triceps (C7-8).
• Fingers (C7-T1).
• See DeepTendon Reflexes Reference.

Upper limbs: coordination

• Pt. finger touches Dr's fingersthen to pt's nose testing for dysdiadochokinesiarebound.
• Dysdiadochokinesia:
  • Pt's palm on dorsum of their opposite hand.
  • Pt flips their hand quickly so the two hand dorsums touch.
  • Repeat quickly.

Upper limbs: sensory

• Dorsal columns (vibration):
  • Place on sternum [the last area lost] so pt. knows how the buzzingfeels.
  • Pt's eyes shut and 128 Hz fork on distal interphalangeal joint: ask iffelt.
  • If can feelask pt. to say when it stopsthen later stop it.
  • If deficient: assess dermatomes at wristelbowshoulderboth anteriorand posterior.
  • See Dermatomes Reference.
• Dorsal columns (proprioception):
  • Grasp pt's distal phalynxmove up and down to show what to do.
  • Tell pt. to close eyes and repeat thissaying whether it's up or down.
• Spinothalamic (painforget temperature):
  • Sterile toolpick or broken wood tongue depressor on forehead or anteriorchest.
  • Pt. closes eyestells if sharp or dull.
  • Stick each dermatome looking for corddermatomeperipheral nervestocking glove.
• Light touch: cotton wool. Dab skin lightlydon't stroke.
• If lesionfeel for thickened nerves:
  • Ulnar at elbow
  • Median at wrist
  • Radial at wrist
  • Axilla.

Lower limbs: inspect

• Asymmetry.
• Muscle wastingfasciculationstremor.
• Muscle bulk: quadsanterior tibials.
• Foot bruisinginfections from peripheral neuropathy.

Lower limbs: tone

• Orthopods may roll legs for a quick preliminary inspection of tone.
• Tone of kneesankles.
• Test clonus by pushing lower end of quads sharply down towards knee (sustained contractions:UMNL).

Lower limbs: power

• Power: hipskneesankles. "Lift legdon't let me push itdown". "Push leg downdon't let me push it up".
• See Power Scale Reference.

Lower limbs: reflexes

• Knee (L3-4).
• Ankles (S1-2).
• Plantar (L5S1-2).
• Ankle clonus test:
  • Place pt's knee bentthigh externally rotated.
  • Dr lifts pt's heel in Dr's cupped hand.
  • Dr quickly dorsiflexes pt's ankle and holds it flexed for 3 seconds.
  • Clonus if sustained movement afterwards.
• See DeepTendon Reflexes Reference.

Lower limbs: coordination

• Heel-shin test:
  • Pt kicks a heel outthen touches that heel to other shin.
  • Repeat in a smooth motion loop.
  • Alternatively: heel sliding up and down on opposite shin.
• Toe-touching test.
• Tapping of feet.

Lower limbs: gait

• Walk few feet then walk back.
• Notice signature gaits:
  • Trendelenberg gait (proximal myopathy).
  • Shuffling gait (Parkinson's).
  • High-stepping gait (foot drop).
  • Hemiplegic gait [swinging one leg in lateral arc] (usu. stroke).
• Walk heel to toe (hard: midline cerebellar).
• Walk on heels (hard: L4-5 footdrop).
• Squat or sit then stand up (proximal myotrophy).
• Romberg sign positive if unsteadiness is worse when eyes closed.

Lower limbs: sensory

• Sensory pin prickvibrationproprioceptionlight touch. Same as was forUpper Limbs.
• If peripheral sensory losstry to establish sensory level. See DermatomesReference.
• Examine sensation in saddle region.
• Test anal reflex (S2-4).

Spine

• Back: deformityscarsneurofibromas.
• Palpate for tenderness over vertebral bodies.
• Straight leg raising test:
  • Pt tries to lift straight leg.
  • Full lifting will be prevented if slipped disc.
• For moreSee Rheumatoid Examination.

Carotid bruit

• Auscultate for bruits (atherosclerotic dz).
• See Carotid Examination for details.

Aspiration

• Paralyzed pt may have aspirated fluid. See PulmonaryExamination.
• Feeding assistance devicessuch as PEG (dysphagiausu. 2º toneurological damagelike stroke).

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