Common cases in neurological examination  

of  
the upper & lower limbs
In the medical section of the clinical examination you may be asked to examine the upper or lower limbs.  
These are usually neurological cases with ophthalmic association. The most common cases being:

 hemiplegia in homonymous hemi/quadrinopia

 upper motor neurone signs or cerebellar signs in optic atrophy or internuclear ophthalmoplegia
 wasted muscles of the hand in unilateral Horner's syndrome

In the neurological examination (see the section on common examination techniques for details),  
always remember to:

 observe for any abnormal posture (common in hemiplegia)

 test the muscle tone for spasticity and less commonly in ophthalmic examination for flaccidity
 test the muscle power 
 test the sensation (pain and temperature, joint position sense; more commonly the examiner 

will ask you the distribution of the dermatomes rather than let you test each sensation which  
can be time-consuming)

 test the reflexes

 test co-ordination (for cerebellar signs)
 observe the gait (if the examination is that of the lower limbs)

Upper limb cases Lower limb cases

 hemiplegia  spastic paresis

 cerebellar signs  hemiplegia
 wasting of the hand muscles  combined upper & lower 

due to T1 lesion motor neurone lesion

 syringomyelia  Friedriech's ataxia

 diabetic foot

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Hemiplegia
.  
The affected side (contralateral to the involved motor cortex) has
abnormal posture with adduction of the shoulder, flexion in the elbow,
wrist and fingers. The tone is increased. The power is weak especially on
extension. There are hyper-reflexia. The co-ordination and sensation are
normal. 

Note: In mild hemiplegia, drifting of the outstretched arms on the

affected side may be the only obvious sign of muscle weakness.

Mention to the examiner that you like to:

 test the visual fields for hemianopia

 examine the cardiovascular system for possible source of
embolism i.e.. pulse for atrial fibrillation, carotid artery for bruit
and heart sound for valve diseases.

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Cerebellar signs

.  
There is hypotonia on the affected side (ipsilateral to the involved
cerebellum). The co-ordination tests show intention tremor, past-pointing
and disdiadochokinesia. 

In some patient the signs may be subtle and you can make the test more
sensitive by: 
 
  finger-nose test: hold your index finger at least one arm's
length away from the patient. Ask the patient to touch the tip of
your finger with his index finger and then his nose. Get the
patient to repeat the same test while you move your finger
around. Look for intention tremor and past-pointing.
 Repeated movement: get the patient to pronate or supinate the
wrist as though he is twisting a light bulb or ask him to tap the
back of his hand with the other palm. You must encourage the
patient to perform the test as quickly as possible to bring out
disdiadochokinesia in mild cases.

Other cerebellar signs:

 nystagmus (with the fast phase to the side of the lesion) and
dysmetria (in which the eye overshoots the target on saccades)
 abnormal speech due to dysarthria (get the patient to say' Baby
Hippopotamus')
 pendular reflexes, this is best seen in the knee in which the
reflexes swing a few beats after tapping the tendon
 heel-shin test is abnormal (the patient has problem in moving
his heel up and down the sheen accurately).
 wide-based gait with a tendency to fall to one side (to the side
with the lesion)

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Wasting of the hand muscles due to T1 lesion

.  
The muscles of the hands are wasted (involving the thenar and
hypothenar eminence). The power of the hands is decreased. The
sensation over the T1 dermatome is abnormal.

Other signs to look for:

 Horner's syndrome on the affected side

 scar over the upper chest from pulmonary surgery
 tenderness or mass over the upper chest due to neoplasm (for
example Pancoast's tumour from apical lung cancer).

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Syringomyelia

.  
The main feature being dissociation of sensation with intact
vibration and joint position senses but impaired pain and
temperature sensation. You are likely to be asked to concentrate on
the sensory examination.
 In advanced cases, there is wasting ot he small muscles of the hands with
deformed (Charcot's) joints in the elbow and shoulder. The power of the
involved muscles are weak. The reflexes are usually absent. Sensory
examination shows impaired  pain and temperature sensation but normal
vibratory and joint position sensation.

Other signs to look for:

 syringomyelia may involve the brain stem and give rise to

syringobulbia. Patient may have Horner's syndrome, nystagmus
(fine rotary) and loss of facial sensation usually start form
behind and converge on the nose and upper lip). Motor cranial
nerves involvement are rare.

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Spastic paresis
.  
The tone is increased in both legs. The lower limb muscles are weak.
There are hyper-reflexia with upgoing plantar (positive Babinski's
reflex). The sensation is impaired (examine for a sensory level). On
attempted walking, there is scissoring of the gait (there is crossing over
of the feet with dragging of the toes).

Other examination:
  There are many causes of spastic paresis, the most important
being spinal cord compression either from tumour or trauma.
However, in the MRCOphth, most would be caused by multiple
sclerosis. Therefore, mention you like to to examine the eyes for
optic atrophy, internuclear ophthalmoplegia or nystagmus

 mention you like to examine the back for any scar. The patient
may have neurofibroma of the spine removed and there may be
other stigmata of neurofibromatosis.

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Hemiplegia

.  
The affected limb may have abnormal posture with external rotation and
extension. The tone of the affected leg is increased. The muscle power is
weak. There is hyper-reflexia with upgoing plantar response on the same
side. The sensation may be abnormal if the sensory cortex is also
involved. On walking the foot tends to circumduct and rotate in a semi-
circle with each step.

Other relevant signs:

 hemiplegia of the ipsilateral upper limb

 ipsilateral upper seventh nerve palsy
 hemianopia
 mention you like to examine the cardiovascular system
especially for pulse, heart sounds and carotid artery for possible
source of embolism.

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Combined upper and lower motor neurone lesion

.  
The patient has absent knee and ankle jerks. The plantar responses are
upgoing. The sensation may be normal or impaired depending on the
cause. 

When you elicit these signs, consider the following possibilities:

 diabetes mellitus. This is by far the most common and the signs
are caused by peripheral neuropathy and cerebrovascular
accident both of which are common in diabetes mellitus. The
affected side will have hemiplegia. The sensation is impaired
with possible stocking distribution. In severe sensory loss, there
may be Charcot's joint of the ankle (due to repeated painless
trauma) and foot ulcer
 Fridriech's ataxia
 subacute combined degeneration of the spinal cord. This
 uncommon condition is due to vitamin B12 deficiency. The
muscles may be spastic and there may be optic atrophy.
 motor neurone disease
 tabes dorsalis

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Friedriech's ataxia

.  
The candidates are usually asked to either examine the lower limbs
or test the cerebellar function.

The patient has pes cavus (high arches of the feet). There are weakness
of the lower legs. The knee and ankle jerks are absent but the plantar is
upgoing. There is impaired sensation to vibration and joint sense. The
gait is wide-spaced due to ataxia.

Other signs:

 cerebellar signs are prominent with nystagmus, scanning

speech, intention tremor and past-pointing
 mention that you would like to look for optic atrophy
 other associated features: diabetes mellitus is common and the
patient may have diabetic eye disease and cardiac diseases

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Diabetic foot

.  
This is usually an extension of the fundal examination in a patient
with diabetic retinopathy. The candidate is usually asked which part
of the body he would like to examine to look for diabetes-related
complications.

The patient has ulcer over the pressure point of the foot. They may be
missing toe due to amputation. The ulcer may be ischaemic or
neurotrophic:

 in ischaemic ulcer, the skin is cold with absent pedal dorsalis

and tibilias posterior.
 in neurotrophic ulcer, there are sensory loss to pain, temperature
and light touch typically in a stocking distribution.
Look for:

 disorganized ankle joint (Charcot's joint) form joint position and

vibratory sensory loss.

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