NERVE EXAMS

CNS
PNS – LL
PNS – UL
Clinical Examination Template: Cranial Nerves

Introduction
● Greet your patient, introduce yourself and your role
Hello, my name is, I am a medical student, can I confirm name and DOB
● Explain what you are going to do and why, and gain consent to proceed with
the examination
Today I shall be doing nerves exam on you to test the nerves in your face,
have you had one before… This will involve me having a look and feel of your
face as well as asking you to do some facial movements and asking you
some questions about your smell, taste, vision and hearing… Does that sound
ok with you, are you ok with me doing this examination on you?
● Ask the patient about pain and chaperone

● Clean your hands + PPE

● Ongoing communication to patient

General observation
I will first start by observing the patient and the bedside
Go around the bed and patient
Patient
- Colour, in pain
- Conscious level
- Speech slurring
- Facial asymmetry
- Problems with eyelids and pupils, strabismus (eyes point in different
directions)
- Limb weakness
Bedside
- Walking aids
- Hearing aids
- Visual aids
- Medication, surgical equipment, fluid thickener

Olfactory nerve – CN 1

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 - Screening question – “Have you ever had any problems with your smell or
noticed any changes”
- Testing – use strong-smelling food, ask patient to close eyes, block one nostril
and smell, try again with other nostril
Optic nerve – CN 2 (AFRO)
- Screening question – “Have you ever had any problems with your vision or
noticed any changes”
- “Do you wear glasses”
- 4 aspects to test

o Pupil reflex – light and accommodation

o Visual acuity
o Visual fields
o Fundoscopy

Observation of eyes
- Pupil size and shape
- Pupil symmetry – strabismus

Pupillary light reflexes

- Direct and consensual pupillary reflexes - shine light into pupil – ipsilateral
pupil should constrict to light (direct reflex), contralateral pupil should constrict
to light (consensual light reflex)
- Check the opposite side
- Issues with direct reflex – CN 2 lesion
- Issues with consensual reflex – CN 3 lesion

Accommodation
- Hold pen/finger approximately 1 metre away from the patient
- Gradually move towards nose
- Normal exam – both pupils should constrict as the eyes converge and
accommodate to focus on finger

Can also do swinging light reflex – relevant afferent pupillary defect such as optic
neuritis, MS

Visual acuity
- Snellen chart – test each eye separately, cover the other
- Patient can wear glasses during this

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 - Can also do near vision (testing near sight using small script like magazine
and Ishihara (colour blindness)

Visual fields
- Testing the 4 quadrants – move fingers from periphery to centre
- Confrontation test – sit in front of patient at around arms-length, finger should
be equal distance away from both of you, patient and you should be at eye
level
- Ask patient to tell you when they can see fingers – see if this is same for you
- Can also do visual inattention (which finger am I wiggling) and blind spot (the
red pin test)

Fundoscopy
- Offer to do
- Direct visualisation of the retina
- Place head on the forehead
- First find fundal reflex – then use your right eye to examine patient’s right eye
- Find the 4 vessels
- Visualise the macula
- Repeat in left eye – using your left eye

Oculomotor/trochlear/Abducens nerve – CN 3/CN 4/CN 6

- Screening question – “Have you noticed any double vision”
- Inspect for asymmetry of eye position and ptosis
- H test/union jack test
- Ask if there is any double vision during the test
- Check for nystagmus, especially at the extremes
- CN abnormality – double vision or eyes don’t move properly
- CN 4 lesion (superior oblique) – eye cannot move in and down
- CN 6 lesion (lateral rectus) – eye cannot move laterally
- CN 3 lesion (other intraocular muscles) – eye cannot move in other directions

Trigeminal nerve – CN 5
- Sensory division – light touch using cotton wool on jaw (mandibular), cheek
(maxillary), above temple (ophthalmic), then offer sharp touch using neurotip
- Motor division – clench teeth and palpate (muscles of mastication –
temporalis and masseter, can feel contraction), open jaw and keep open

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 against resistance (pterygoids, can keep open), move jaw from side to side
(equal on both sides)
- Corneal reflex (swab on cornea to see if blink which is normal) – CN 5
pathway and efferent pathway of CN 7
- Jaw jerk (tendon hammer on jaw to see if it jerks, exaggerated jerk is bad,
usually towards lesion side)
Facial nerve – CN 7
- Test muscles of facial expression
- Inspect – facial asymmetry
- Raise eyebrows, don’t let me push them down – frontalis
- Squeeze eyes, don’t let me open them – orbicularis oculi
- Smile and show teeth and then purse lips – orbicularis oris
- Blow out cheeks and don’t let me push in – buccinators
- Should be symmetrical on both sides

Vestibulocochlear nerve – CN 8
- “Have you noticed any changes in your hearing, any hearing difficulties”
- Gross hearing – distracting noise in one ear and whisper numbers in other,
ask them to repeat the number
- Rinne’s – is it louder in front of ear or behind the ear, air conduction is louder
than bone (if BC louder then sensorineural, if air louder then normal)
- Weber’s – fork in middle of forehead, which side sounds louder or both the
same, normal = same on both sides, conductive = loud on ipsilateral side,
sensorineural = loud on contralateral side
- Offer to test gait

Glossopharyngeal nerve and Vagus nerve – CN 9 and CN 10

- Test sensations and muscles controlling movement in mouth and throat
- Ask for cough/swallow – cannot cough properly/problems with swallowing in
vagus nerve lesions
- Ask for open mouth, say ahh – look at soft palate, should rise equally, uvula
deviates away from lesion
- Gag reflex – offer, touch posterior pharynx on either side, palate rises and
patient gags (CN 9 is afferent sensory, CN 10 is motor efferent)

Accessory nerve – CN 11
- Test trapezius and sternocleidomastoid muscles
- Shrug – and against resistance, trapezius
- Turn head to either side – and against resistance, sternocleidomastoid
- Power should be equal on both sides

Hypoglossal nerve – CN 12

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 - Test tongue
- Stick out tongue – observe wasting or fasciculations
- Move tongue to either side – should be equal, no deviation
- Put tongue in cheek – against resistance, equal power
- Tongue deviation – towards lesion, inactive fibres overpowered by functioning
fibres on opposite side

End pieces
- Peripheral nerve exams
- MRI/CT head
- Lumbar puncture

Finish the examination

- Thank your patient
- Consider your findings and how to present them in a logical and fluent order
- Then consider the possible clinical significance of these findings

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Peripheral Nerve Examination: Lower Limb

Introduction
● Greet your patient, introduce yourself and your role
Hello, my name is, I am a medical student, can I confirm name and DOB
● Explain what you are going to do and why, and gain consent to proceed with
the examination
Today I shall be doing a leg examination to test the nerves in your legs, have
you had one before… This will involve me having a look and feel of your legs
as well as asking you to do some movements… Does that sound ok with you,
are you ok with me doing this examination on you?
● Ask patient about pain and chaperone

● Clean your hands + PPE

● Ongoing communication to patient

General observation
I will first start by observing the patient and the bedside
Go around the bed and patient
Patient (swift)
- In pain
- Conscious level
- Scars
- Wasting of muscles
- Involuntary movements
- Fasciculations
- Tremor
Bedside
- Walking aids
- Mobility aids

Ask about any pain prior to starting examination as this involves active and passive
movement of the limbs at all joints.

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Gait
- Normal
- Toe to heel
- Tip toe
- Heel walking
- Observe gait cycle, turning, any struggle with walking, gait affected with
pain/wasting, waddling/shuffling/trendelburgs gait
- Broad based ataxic gait – cerebellar lesion
- Spastic gait – hemiplegia
- Shuffling gait – Parkinson’s
- High stepping gait – foot drop association

Tone
- Patient sat on a bed with legs extended in a relaxed position in front of them
- Rolling each leg gently from side to side - observe foot movement to gauge
whether there is any increase or reduction in muscle tone
- Passively flex and extend the knee, then the ankle
- Knee drop test – pick the knee and drop it down, see if foot bounces up
- Clonus – twist ankle round, randomly dorsiflex, if you feel beats then UMN
lesion
Increased tone
- UMN disorders – spasticity, felt as ‘clasp-knife’ spasticity (Initial resistance,
followed by sudden reduction in resistance to movement)
- In disorder of the basal ganglia ‘lead-pipe’ rigidity is detected due to the
sustained resistance throughout the range of movement
- ‘Cog-wheel’ rigidity occurs in Parkinson’s disease because a tremor is
superimposed on the underlying lead-pipe rigidity
Decreased tone
- LMN lesions
- Cerebellar lesions

Power
- Test each muscle group
- First active, then against resistance
- Hip flexion and extension – iliopsoas (L1-L2), glut max (L5-S2)

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- Knee flexion and extension – hamstrings (S1), quads (L3-L4)
- Dorsiflexion – tibialis anterior, (L4/L5 – deep peroneal)
- Plantarflexion – gastrocnemius, soleus (S1/2 – tibial)
- Big toe extension – extensor hallucis longus (L5, deep peroneal)
Extra information
Hip flexion, extension, abduction & adduction: ask your patient to raise
their extended leg from the bed, ask them to keep their leg there whilst you
resist the movement at the quadriceps. Then ask the patient to return their leg
down onto the bed passively, then against resistance.
Knee flexion & extension: ask the patient to bend their knee (and hip).
Stabilise their thigh with one hand and ask them to kick-out their leg, then pull
their heel back in towards them. Then test the same movements against
resistance.
Ankle dorsiflexion & plantarflexion: Ask the patient to bend their foot
towards them and then back down to the bed. Then support their lower leg
with one hand and test the same movements against resistance.
Big Toe flexion & extension: Stabilise the foot, then ask the patient to bend
their big toe towards them, then back down towards the bed. Then test the
same movements against resistance.

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Coordination
- Heel-shin test – patient puts heel on opposite knee, moves heel down to
ankle, back up to knee and again, do movement several times, compare sides
- Toe tapping – tap foot repetitively quickly on floor, compare sides

Reflexes
- You should know which nerve roots are being tested with each reflex
- Patella – below knee tendon, L3/4
- Ankle jerk – knee out and bent, dorsiflex foot, Achilles tendon, S1/2
- Plantar/Babinski – use neuro tip, go from lateral heel curved to big toe, big toe
should flex, extended big toe is UMN lesion

Sensation
- Light touch – cotton wool
- Sharp touch – neuro tip
- Do in each dermatome, compare sides
- Dermatomes

o L1 – hip area, under hip bone

o L2 – epi pen jabbing area
o L3 – medial thigh
o L4 – medial calf
o L5 – lateral calf
o S1 – small toe/lateral foot

Joint position sense/Proprioception:

- DIP joint of the big toe
- Stabilise the base of the big toe
- Patient closes eyes
- Hold from sides, not from nail bed
- Move the tip of the big toe up and down
- Ask your patient where its pointing
- Test 3 times
- If your patient correctly detects movement - joint position sense is intact

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 - Not able to identify - test a more proximal joint e.g. ankle joint, knee until joint
position sense can be accurately detected.

Vibration sense:
- 128 Hz tuning fork – long one
- Test on their sternum
- Patient closes eyes
- Test vibration on the DIP joint of their big toe
- Ask patient to tell you when the vibration stops – stop fork
- Correctly detected – vibration sense is intact
- Cannot detect – test a more proximal joint e.g. ankle, knee, until vibration
sense can be accurately detected.

End Pieces
- Romberg – ask your patient to stand with their eyes open and feet apart
- Then ask the patient to bring their feet together, then close their eyes
- Become unsteady – positive Romberg’s
- Unsteady with eyes open – cerebellar lesion
- Unsteady only when closing the eyes – sensory ataxia

Finish the examination

- Thank your patient
- Consider your findings and how to present them in a logical and fluent order
- Then consider the possible clinical significance of these findings

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Peripheral Nerve Examination: Lower Limb

Introduction
● Greet your patient, introduce yourself and your role
Hello, my name is, I am a medical student, can I confirm name and DOB
● Explain what you are going to do and why, and gain consent to proceed with
the examination
Today I shall be doing an arm examination to test the nerves in your arms,
have you had one before… This will involve me having a look and feel of your
arms as well as asking you to do some movements… Does that sound ok with
you, are you ok with me doing this examination on you?
● Ask patient about pain and chaperone

● Clean your hands + PPE

● Ongoing communication to patient

General observation
I will first start by observing the patient and the bedside
Go around the bed and patient
Patient (swift)
- In pain
- Conscious level
- Scars
- Wasting of muscles
- Involuntary movements
- Fasciculations
- Tremor
Bedside
- Walking aids
- Mobility aids

Ask about any pain prior to starting examination as this involves active and passive
movement of the limbs at all joints.

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Tone
- Hold hand, as if shaking their hand, and with the other hand support their arm
at the elbow
- Flex and extend wrist
- Flex and extend elbow
- Rotate shoulder
- Pronate and supinate the forearm
- Compare sides

Increased tone
- UMN disorders – spasticity, felt as ‘clasp-knife’ spasticity (Initial resistance,
followed by sudden reduction in resistance to movement)
- In disorder of the basal ganglia ‘lead-pipe’ rigidity is detected due to the
sustained resistance throughout the range of movement
- ‘Cog-wheel’ rigidity occurs in Parkinson’s disease because a tremor is
superimposed on the underlying lead-pipe rigidity
Decreased tone
- LMN lesions
- Cerebellar lesions

Power
- Ask if patient is right or left-handed
- Pronator drift – extend arms, palms up, close eyes, UMN lesion affected arm
pronates and falls – positive pronator drift sign
- Test each muscle group
- First active, then against resistance
- Shoulder abduction and adduction (chicken wings) – deltoid and abductors
(axillary C5), teres major lat dorsi pectoralis major (thoracodorsal C6/7)
- Elbow flexion and extension (weights) – biceps coracobrachialis brachialis
(musculocutaneous and radial C5/6), triceps (radial C7)
- Wrist flexion and extension (motorbike hands) – extensors (radial C7), flexors
(median C6/7)
- Finger adduction, abduction, flexion, extension (squeeze fingers and splayed
fingers with sorta MCP squeeze) – 1st dorsal interossei (ulnar T1), extensor
digitorum (radial C7)
- Thumbs abduction and adduction – abductor pollicis brevis (median nerve T1)

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 Shoulder abduction & adduction: ask your patient to flex their elbows, then
abduct their arms against resistance applied to the upper arm. Then ask your
patient to abduct and adduct an outstretched arm from the shoulder.
Elbow flexion & extension: ask your patient to flex their elbows to 90
degrees. Use one hand to support their upper arm, and the other to provide
resistance to their forearm as you test flexion and extension.
Wrist flexion & extension: ask patient to hold out their arms and make a fist,
then to flex and extend at the wrist.
Finger adduction, abduction, flexion & extension: ask your patient to
squeeze your fingers, then open their fist against resistance. Ask them to
spread their fingers wide, then to bring their fingers together.
Thumb adduction & abduction: ask your patient to lift their thumb away
from a flat palm, and then bring it back towards a flat palm.
Finger-nose test
Position yourself so you are facing your patient. Ask your patient to touch their nose
with their index finger. Then ask them to reach out to touch your finger help in front
of them. (You should hold your finger so that they have to fully extend the arm to
reach it). Then ask them to repeat this movement backwards and forwards as
between their nose and your finger as quickly as they can. Compare sides.
Look for past-pointing and intention tremor suggestive of cerebellar lesions, but note
that coordination will also be affected by weakness or sensory disturbance.

Dysdiadokokinesis
Ask your patient to hold one hand out with the palm facing upwards. Then ask them
to place the other hand, also palm upwards, into the other hand. Then ask them to
turn the hand over so the back of their hand faces upwards and repeat as quickly as
possible.
Dysdiadokokinesis is present when these movements are erratic in force and
rhythm.

Rebound phenomena
Ask your patient to flex one arm at the elbow, then stand next to them placing your
arm over their chest to protect them. Ask them to pull against your arm with theirs,
and let go. Usually the antagonist muscles will stop the patient’s arm from pulling
back towards them (and injuring themselves), but this protective mechanism will not
be present in cerebellar disease. This is why it is important to protect the patient with
your other arm.

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Coordination
- Finger-nose test – do movement quickly several times, compare sides, look
for past pointing and intention tremor to suggest cerebellar lesions
- Dysdiadokokinesia – hand one, do movement quickly several times, compare
sides, movements should be in force with rhythm
- Coordination can be affected by weakness or sensory disturbances

Reflexes: You should know which nerve roots are being tested with each reflex.
- Supinator (C5/C6) – above radial bone, on tendon
- Biceps (C5/C6) – ACF, feel for tendon first
- Triceps (C6/C7) – top of elbow

Sensation
- Light touch – cotton wool
- Sharp touch – neuro tip
- Do in each dermatome, compare sides
- Dermatomes

o C3 – neck connecting to shoulder area, above clavicle

o C4 – shoulder tip
o C5 – lateral deltoid muscle
o C6 – palmer thumb
o C7 – palmer middle finger
o C8 – palmer little finger
o T1 – medial ACF, proximal to medial epicondyle

Joint position sense/Proprioception:

- DIP joint of index finger
- Patient closes eyes
- Hold from sides, not from nail bed, stabilise joint below
- Move the finger up and down
- Ask your patient where its pointing
- Test 3 times
- If your patient correctly detects movement - joint position sense is intact
- Not able to identify - test a more proximal joint e.g. ankle joint, knee until joint
position sense can be accurately detected.

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Vibration sense:
- 128 Hz tuning fork – long one
- Test on their sternum
- Patient closes eyes
- Test vibration on the DIP joint of their index finger
- Ask patient to tell you when the vibration stops – stop fork
- Correctly detected – vibration sense is intact
- Cannot detect – test a more proximal joint e.g. MCP, wrist, elbow, until
detected

Finish the examination

- Thank your patient
- Consider your findings and how to present them in a logical and fluent order
- Then consider the possible clinical significance of these findings

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