Cranial nerves: C1: Change in sense of smell? C2: Pupils? - Size? - Shape? - Isokor? - Direct pupillary reflex? - Consensual pupillary reflex? - Swinging light test? - Accommodation reflex? Visual fields? - 10 o'clock? - 2 o'clock? - 4 o'clock? - 8 o'clock? Visual accuracy? R 6/ , L 6/ Colour vision? Fundoscopy? Red reflex? C3/4/6: Ptosis? Eye movements (H shape)? Cover test? - No movement (normal)? - Eyes move temporarily (convergent squint (esotropia)? - Eyes move nasally (divergent squint (exotropia)? C5: Sensory (light touch and pinprick)? - Forehead (ophthalmic branch (V1))? - Cheek (maxillary branch (V2))? - Jaw (mandibular branch (V3))? Motor? - Teeth clenching (build of masseter and temporals)? - Mouth opening with resistance under the jaw, deviation? Jaw Jerk? - Slight closure of the jaw (normal)? - Brisk complete closure of the jaw (UMN lesion)? (Corneal reflex?) C7: Asymmetry? - Forehead wrinkles? - Nasolabial folds? - Angles of the mouth? Movements? - Raised eyebrows? Asymmetry? - Closed eyes? Power? - Blown out cheek? Power? - Smiling? Asymmetry? - Pursed lips? Asymmetry? - Closed lips? Power? Ear canal? Hearing changes (eg hyperacusis)? Taste changes (anterior 2/3 of tongue)? C8: Gross hearing test (whisper perceived at 15 and 60 cm)? Rinne's test? Weber's test? Unterberger/Turning test? - Patient remains in same position (normal)? - Patient will turn to the side of the lesion (vestibular lesion)? Head thrust test/vestibular-ocular reflex (VOR)? - Fixation maintained (normal)? - Eyes moving in the direction of the head before corrective refixation saccade to the nose (loss of vestibular function)? C9/10: Soft palate and uvula? - Asymmetry? - Deviation when patient says 'ahhh' away from side of lesion? (- Gag reflex?) Bovine cough? Coughing or delayed swallowing when drinking a glass of water? C11:

Shoulder shrugging against resistance (trapezius)? Head turning against resistance (sternocleidomastoid)? C12: Tongue wasting? Tongue fasciculations (minor can be normal)? Deviation when protruding tongue to side of lesion? Tongue pushes against finger on patient's cheek? Upper limb: Inspection? Scars? Wasting of muscles? Involuntary movements (dystonia, chorea, myoclonus)? Fasciculations? Tremor? Pronator drift? Tone? Smooth (normal)? Increased or decreased? - Wrist (all movements)? - Forearm (pronation/supination)? - Elbow (flexion/extension)? - Shoulder (flexion/extension/abduction/adduction)? Spasticity (velocity dependent, indicating UMN lesion)? Rigidity (velocity independent, indicating extrapyramidal lesion (Parkinsonismus)? Power? Shoulders? - Abduction (C5) (“Don’t let me push your shoulders down”)? - Adduction (C6/7) (“Don’t let me pull your arms away from your sides”)? Elbow? - Flexion (C5/6) (“Don’t let me pull your arm away from you”)? - Extension (C7) (“Don’t let me push your arm towards you”)? Wrist? - Extension (C6) (“Cock your wrists back and don’t let me pull them down”)? - Flexion (C6/7) (“Point your wrists downwards and don’t let me pull them up”)? Fingers? - Finger extension (C7) (“Put your fingers out straight and don’t let me push them down”)? - Finger ABduction (T1) (“Splay your fingers and don’t let me push them together”)? - First dorsal interosseous (FDI)? - Abductor digiti minimi (ADM)? Thumb Abduction (C8/T1) (“Point your thumbs to the ceiling and don’t let me push them down”)? Reflexes? - Biceps reflex (C5/6)? - Triceps reflex (C7)? - Supinator reflex (C6)? (- Hoffmann's reflex (finger flexor reflex)?) (- Palmar grasp reflex (frontal release sign if positive in adults and may signify frontal lobe damage or anterior cerebral artery syndrome)?) (- Masseter reflex (sign of UMN lesion above foramen frontal release sign if pronounced in adults)?) Sensation? Light touch sensation (wisp of cotton wool)? Pinprick sensation (sharp end of a neuro-tip)? Vibration sensation (interphalangeal joint of thumb → carpometacarpal joint of thumb → elbow → shoulder)? - C5 - On the lateral (radial) side of the antecubital fossa, just proximally to the elbow? - C6 - On the dorsal surface of the proximal phalanx of the thumb? - C7 - On the dorsal surface of the proximal phalanx of the middle finger? - C8 - On the dorsal surface of the proximal phalanx of the little finger? - T1 - On the medial (ulnar) side of the antecubital fossa, just proximally to the medial epicondyle of the humerus? Proprioception? - Thumb? - Wrist? - Elbow? - Shoulder? Coordination? - Finger-to-nose test? Dysdiadochokinesia? Lower limb: Inspection? Scars? Wasting of muscles? Involuntary movements (dystonia, chorea, myoclonus)? Fasciculations (LMND)? Tremor? Pronator drift? Gait? - Posture? - Arm swing? - Stride length? - Base? - Speed? - Symmetry? - Balance? - Abnormal movements? - Ataxie? - Parkinsonian? - High-stepping (unilateral or bilateral)? - Waddling gait (proximal lower limb weakness (e.g. myopathy))? - Hemiparetic? - Spastic paraparetic? - Tandem (heel-to-toe) gait? - Heel walking? Romberg's test (sensory ataxia (proprioceptive deficit)? Tone? - Leg roll? - Leg lift? - Ankle clonus? Power? Hip? - Flexion (L1/2) ('Raise your leg off the bed and stop me from pushing it down.")? - Extension (L5/S1) ('Stop me from lifting your leg off the bed.')? - Abduction (L4/5) ('Push your legs out')? - Adduction (L2/3) ('Squeeze your legs in')? Knee? - Flexion (S1) ('Bend your knee and stop me from straightening it.')? - Extension (L3/4) ('Kick out you leg'.)? Ankle? - Dorsiflexion (L4) ('Keep your legs flat on the bed ... cock your foot up towards your face ... don't let me push it down.')? - Plantarflexion (S1/2) ('Push down like on a pedal'.)? - Eversion (L5/S1) ('Push your foot out against my hand.')? Big toe? - Extension (L5) ('Don't leg me push your big toe down.')? Reflexes? - Patellar reflex (L3/4)? - Achilles reflex (L5/S1)? - Plantar reflex? Babinski sign (UMN lesion)? Sensation? Light touch sensation (wisp of cotton wool) (dorsal/posterior columns and spinothalamic tracts)? Pinprick sensation (sharp end of a neuro-tip) (spinothalamic tracts)? Vibration sensation (with 128 Hz tuning fork) (dorsal/posterior columns)? distal phalanx of great toe → proximal phalanx? - L1 - Midway between the key sensory points for T12 and L2 [clarification needed]? - L2 - On the anterior medial thigh, at the midpoint of a line connecting the midpoint of the inguinal ligament and the medial epicondyle of the femur? - L3 - At the medial epicondyle of the femur? - L4 - Over the medial malleolus? - L5 - On the dorsum of the foot at the third metatarsophalangeal joint? - S1 - On the lateral aspect of the calcaneus? - S2 - At the midpoint of the popliteal fossa? Proprioception? - Big toe? - Ankle? - Knee? - Hip? Coordination? - Heel to shin test? - Incoordination (dysmetria) suggestive of ipsilateral cerebellar pathology? Short neuro exam Reference(s): Geeky Medics: A collection of neurological examination OSCE guides