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the so that I can show you my slides. And I will just check with Hannah that we are then going to, uh that were then going to be able to see it. All right, so hopefully, hopefully you can see my slides there. And if I just start them now Hannah, could you confirm that my slides are showing? We'll just check there just in case. Hannah's replied in the chat. Yes. Visible. Lovely. Excellent. Thank you. I was muted. Yes, it's visible. Excellent. So thank you very much for having me today. Brief word about who I am. So I'm Tim Doctor Tim Young. I've been a neurologist in the UK for over 20 years. I'm currently an associate professor at Queen's Square in London. UCL uh, specifically in the area of teaching neurology. Now I'm going to be covering a few things today. It's the neurological examination, so that's quite a lot. So I will try and push through it. I believe you will have access to the slide set afterwards, so don't think you need to scribble down every word. It's more that I get the overview. Here's a brief overview of what we'll be covering we start, then we stop because we need to think about what we're doing. First. Cranial nerves, upper limbs, lower limbs and a summary and a brief word. Sorry, just there. Um, I just needed to to add that there, that if you see the point at the bottom, it's a technical little thing. I need to add that some of the power testing slides I used by kind permission of the Medical Research Council as part of UK research and innovation. You'll see why that's relevant a bit later. Okay, so the neurological examination doesn't have to be scary. When I started as a medical student many, many years ago, that was one of the things that scared most medical students and still scares many doctors but doesn't need to be scary. Traditionally, there are three basic blocks to the neurological exam. Cranial nerves, upper limb and lower limb. However, there are obviously other elements, depending on what you're examining, things like cognition and language we won't cover today. You typically informally assess those with the history and with the examination. Obviously, if it's more relevant, you need to examine them. Some people, many traditional neurologists, start the exam with the gait exam. I tend to leave it till last, but it's important you're aware about that, particularly if a patient is walking into the room, you may start with the gate. The aim of a neurological examination is to find a lesion and then localize it. So we'll be covering, as I said, cranial nerves, upper limbs and lower limbs. The images I've taken there on the right and you'll see quite a few of those are from quite a useful resource. As I said you should be. We should be sharing the slides so you might well see that there's a There's a Web link there to our course page at UCL. You don't need to worry about our course, but a third of the way down is access to this video we made. It's a 50 minute free video you can access anywhere in the world, and it goes through in great detail. You can actually watch us going through the neurological examination. So before we jump in with the cranial nerves, there's a danger of just jumping into fast. So listen carefully. First, before you start examining, it might be listened to the patient's history so you can focus your examination when you're a medical student. Listen to the examiners instruction. A classic is the examiner would say, examine this patient's hand and then perhaps a student would examine the whole upper limb in great detail. So listen, first, ensure you've got permission for the examination. So obviously the patient isn't just an object. You need to ask advice. You need to ask permission from the patient, their medical team and, if relevant, even the relatives, as with a cardiac arrest, when you're approaching a patient for the first time approach with caution, have they got an illness like covid? Could you danger them? Maybe if they're immunocompromised, explain what you're going to do before the examination and don't hurt the patient and finally thank them. Leave them comfortable and appropriately covered. Even with the cranial nerves, we don't jump straight in. Stop to look first. Now I'm going to ask you I won't have much time for this. I'm afraid if any of you want to put in the chat what you think might be happening here. So this is well, imagine a patient. We're just about to examine their cranial nerves, but you look first, Um, and you can have a little peep. You can have a little look. Yes, and I think someone might have put that in the chat. Let's see. Let's see what they put. Um, so and what's that? What's that? An answer. I'm not sure if that was an answer, but I'll probably dive in for time's sake. So this is actually a left sided Tosis. So you can probably see that that the left eye, the upper lid, is droop down. In fact, technically, it's likely this is a subtle Horner's syndrome. I'm not going to go into great detail here except to say that the upper lid is droop down. But just possibly you might think, Well, maybe the up the under lid is slightly pushed up, so called upside down Tosis and with a bit of I have faith because it's not obvious there may be a little miosis there. Okay, so always try and reference when you use things like that, it's just an example of looking first and just going back through there. Sorry about this. Just going to go back to my slideshow there and the cranial nerves. Okay, so you'll almost certainly know what the cranial nerves are. If you don't yet, don't worry, but they are important to learn at some stage. The important thing to remember is we normally examine them in a slightly different order. You'll understand why, when I go through the cranial nerves, so we don't actually tend to do much with the olfactory nerve that smell if you need to test it at all, probably a bit of coffee ground and just say, Can you smell this? What is it? Some people shut one nostril than the other, but in reality it probably doesn't matter with Covid. Of course, we're a bit more interested in that. But usually the first cranial nerve is quickly dealt with optic nerve. There's plenty with it, and I'll explain why in a moment. Then we group together the three cranial nerves to do with eye movements. Then we look at five, then seven, then eight with eight. It's mainly about hearing not about balance in terms of our quick testing. Then you do the open the mouth type exercises, and then you look at the vagus nerve glossopharyngeal hypoglossal and finally, the accessory nerve, which is the sort of the movements around the side. Optic nerve A really obvious thing, but it's honestly easy to forget. If you're examining someone's optic nerve, remember to keep one eye closed. Suppose someone was unfortunate enough to be blind in one eye, but you examined one eye with both eyes open. Then they might report perfect vision because they're looking with the other eye. So one at a time there are several components to the optic nerve, and it's easy to forget one. When you're a medical student, I'm sure I did so broadly speaking, I would say How well can they see? So that's unaided or with glasses or pinhole. You notice that that they're using a chart that may be a near chart or a far chart for Snell in unaided first. But if they're having trouble say, do normally wear glasses if they do or don't, you might want to use a pinhole, which is amazingly effective, like a cheap pair of glasses. The reason that's important is if you can correct it. It's unlikely to be a neurological problem after seeing how well they see. Then you see, see how wide they see you use confrontation. You'll probably be aware of this. You know, when you do this kind of business now, traditionally, as you see here, people use a moving target. I'm going to briefly explain that at the medical school level, there's something really useful to know which I'll show you now to make it look a bit smoother. If you'd all like to. If you're able to cover your right eye, look straight at the screen and I'll do the usual. Tell me when you see it moving. Tell me when you see it moving. Now look at this bit. This is a bit You should practice the swap over. Tell me when you see it moving. Tell me when you see it moving. I'll do that quickly again. So cover your right eye due from the side. And what you don't do is you don't then do this kind of business. You need to swap pants. So tell me when you see it, move. Tell me when you see it move cross over practice that bit because it makes it look really good for the exams. If you do it in reality, this is a bit crude moving target. So a red pin is usually used How wide a spectrum can they see of the, uh, if you look at their at the color spectrum, uh, color vision can be effective. For example, in optic neuritis, then you actually look at the nerve itself or the nerve head with a with an ophthalmoscope. And then finally we think about the reflexes. When you're linking the second cranial nerve and the third cranial nerve, the two main ones, you need to think about a light reflects and convergence. So the light reflects. In reality, you're probably going to test with the ophthalmoscope at the same time you're looking. Don't shine right in front of the eye because then the eyes will converge on it and that creates narrowing of the pupils. So do it from the side shine on this I is there a direct reaction and then shine again, looking at the other eye for consensus reflex. Finally, it might be useful. This is small print stuff to then swing the light from one eye to the other. Normally, each time you shine in an eye, both that I and the other I will constrict the pupils. However, if one eye is very weak, to put it bluntly. For example, if have bad optic neuritis, then you shine in the good eye. It will constrict the bad. I will constrict. Then you swing to the other side and the bad. I will dilate to to the light. And that's you can think of simply because if the acuity is very badly affected, the reaction is mainly driven by the good eye. So when you move the light from the good eye, it's as if the good eye is going into darkness. Small print. But this this Marcus gun pupil I've just described or relative afferent pupillary defect is a classic marker in M s. That small print. Then we go onto ocular movements now ocular movements. Um, it's very important to remember that you should examine these not with an cross, you know, follow my finger up and down, but with an h. So follow my finger all the way to the side, then up, then down, then all the way to the other side, Then up then down. The reason for that is by doing that, you isolate individual nerves and to individual muscles. Let's start by looking on your on the left eye in this image you see for the left eye. Here, the patient is looking right out to the side. Now we probably all know that that is the sixth cranial nerve, the Abdu since abducting the eye out. If they're still looking all the way out, getting to look up, which is the superior rectus and then look down. And that's the inferior rectus, both of those the third nerve. Once you've done that, then think about the movement of the eye when it's going right in. For example, the right eye here looking all the way in is the medial rectus, which is the third nerve. When you're looking all the way in. It's slightly odd. It's almost counterintuitive, because if you then look up, it's the inferior oblique, which does that movement looking up when you're looking in and that's the third cranial nerve, and when you look you're looking all the way in and down. That's the superior oblique, and that's the other oddity here. That's the fourth cranial nerve. So all of these are third cranial nerve, except for a Doosan Abdu since which is sick and the superior bleak, which is four. There are a couple of oddities. I want to briefly mention if the eye movement outcomes seem very complex. Then think of testing for fatigue ability. If I can just explain what that is if you think you know what, these movements are very odd here. Then it could be something more general like myasthenia. So simply get them to look at your finger. Look up for 10 seconds and you might well see the eyes and eyelids drooping down if they're complex movements but not fatigue. A ble. Think about something like a cavernous Sinus lesion, which can affect multiple, um, eye movements, cranial cranial nerves. Um, I'm just I'm just double checking is to check. There's not a problem here with the vision. Um, yeah. Oh, sorry. Sorry. Beg pardon. I just wanted to make sure that people could see All right, um, so there's one other little oddity which I want to mention here. This is this is small print, by the way. Here is not a critical thing to remember, but it's a classic in neurology. Imagine someone's looking straight ahead, and then they look to the right and it's all fine. And then they look to the left, and this happens the outer. I can move all the way to the left. But this I can't move immediately, and you might even see a bit of catch up nystagmus here. This is a classic sign in neurology, which is called an internuclear ophthalmoplegia. I will briefly mention this because it's an absolute classic sign in neurology, typically suggesting Ms the third cranial nerve is what's needed to move the I immediately as we've just covered. And the sixth cranial nerve is what's needed to move this I outwards. So you've got to link the third cranial nerve from the mid brain with 1/6 cranial nerve nucleus in the ponds. That's a bit of distance, but if you want to see a car coming towards you, you have to move those eyes instantly. So you need that to be really heavily myelinating that link. That link is the medial longitudinal fasciculus. It's one of the most heavily myelinating fibers in the body, and that may be a reason why it's so susceptible to Demyelination. Let's look at the trigeminal nerve now try think about three. There are three separate nerves within the trigeminal nerves or divisions as you can see from this image. There's not thalamic branch. There's a maxillary branch and there's a mandibular branch. These these are sensory, and to test these is quite simple. Use a bit of cotton wool twist. So you've got a little whisper at the end, touch over the sternum and just say, Can you feel this is light, light touch? And if they say yes, you then explain you're going to touch over the face, get them to shut their eyes and say, Tell me when you feel that same sensation, this side, yes, and then this side. So like with like when you've done all that, remember, trigeminal trigeminal is not just about sensation. Importantly, trigeminal also is about motor actions chewing in particular. Now these muscles temporarily mass it er and the pterygoid is that you can't see are important Now. If you've ever bitten your tongue, you'll know that those chewing muscles are strong and there's no way you're going to test someone's power by putting your fingers in someone's mouth. However, if you've ever stuck your mouth trying to open it, when you've got chewing gum in there, you know that opening the mouth is much weaker normally, so that gives you a better chance to pick up weakness. So a better way of testing these muscles is to put your arm and put your hand under their their jaw with their mouth closed and say, Try and open it as with any time you touch the patient or test power check, they're not in pain. There are two reflexes, Um, and just if you can think there may not be time to go through all of these in the chat. But just trying to think Which part of the I do you think you touch with the cotton world for the corneal reflex? Is it the white bit, the colored bit or the black bit? So you probably heard of the corneal reflex. You got your little bit of sterile cotton whisp. You're not going to come in from the front because they're blink just from the side. You want to see if they blink on this side and then consensually, which is a normal reflex. It's a perfect test of V one sensation, and also the facial nervous would come on. It's actually the colored bit of the eye because that's the corn era sits on front of that, There is a second reflex, which is the George jerk. Now, this is where you get the tendon hammer and you put your finger on their jaw. Ask them to relax and just tap down quite briskly. Most patient's will be scared when you do that because they think they're gonna You're gonna whack them on the jaw, so just reassure them it doesn't hurt and the jaw jerk. Normally, nothing happens if you do it, and that kind of thing happens, which is buying like a spring, then that's brisk, and that's abnormal. It usually means an upper motor neuron lesion could be a stroke or a brain tumour above the level of the brain stem. Or it's commonly seen in motor neuron disease as well, although not diagnostic of that facial nerve. Now you probably remember that the drill here, the facial nervous about muscles of facial expression. So raise your eyebrows shut your eyes smile, puff your cheeks, grimace, all that kind of thing. You should do that for an examiner, but really, what you're looking at is the smile and shut your eyes. The smile usually tells you if there's a facial nerve weakness quite early on. So you might see there's a bit of weakness on one side. And the shut your eyes is particularly important to see if a facial nerve weakness is peripheral, like a bell's palsy, where you're just hitting the nerve or central like a stroke. So if we look at this image here, you can see hopefully that there are two examples here on this side. You've got the first picture there is of a facial nerve lesion, and if you damage the facial nerve like a bell's palsy, then that whole half of the face will be weak. And they won't even be able to shut their eyes properly, which can lead to eye damage. However, if it's a stroke or some central cause, then because there's some degree of bilateral innovation of the of the front Taylor's, it means there's some sparing, so people with a stroke may not be able to smile, but they can usually shut their eye on that side. That's where this picture could be improved, I think. Which is why I've added a little I to remind you Bell's palsy, the I may not close properly and you should test that by just asking them to close their eyes and gently try and open them. Don't force them open, but just gently. There are a couple of things there, which we're not going to cover. The facial nerve also does taste from the anterior two thirds of the tongue and also salivary gland and tear. Now we come on to the lower cranial nerves, the vestibular Cocula nerve. We usually only test quite quickly by the bedside. It's quite simple. Make a masking noise in one ear and whisper a number in the other ear. Ask the patient to repeat it and then change the sides. The vagus nerve is considered mainly a motor nerve, particularly for the cranial nerve exam is got a vast autonomic function, which we don't typically test now. Importantly, the vagus nerve basically lift up the palette at the back of the mouth on each side. So here's an example in the picture of a left vagus nerve palsy, Can you see? They're saying, Ah, but actually, the palate on that side isn't raised up properly. Important point about the uvula. You know that thing that hangs down the middle when you go. Uh, that can do whatever it likes, so don't be fooled. Some people say it moves this way or that way. It can do whatever it likes to ignore it. Just look at the palatial movement. The Glossopharyngeal nerve nerve nine is sensory, so you have to touch it to test it. But that's not very nice, So don't do it unless you have to. And if you do have to explain to the patient, it may be a little bit uncomfortable. And be careful in doing it when you use a blunt wooden spatula and make sure you directly see where you're gently touching on the upper arch, not behind the arch, and it should elicit a strong gag response, which will obviously involve the pallets going up. Finally, the hypoglossal nerve, the muscle of the tongue. Firstly, the moment you get them to first open their mouth. Really? When you're looking at the arch, look at the tongue. A senior professor years ago told me that the moment you say the word tongue, people start moving their tongues, which is not helpful if you want to look for fasciculation zones, so when you first get them to open their mouth, you quietly to yourself, look at the tongue to see if those fasciculation are wasting that can be seen in a number of conditions. For example, maybe seen in motor neuron disease. Then you ask the patient to poke their tongue out. The muscles of the tongue are pushers, so if one side is weak, the tongue deviates to the weak side. The accessory nerve is the final one. We consider the sternocleidomastoid. That's when you turn your head to one side. This is a bit of a trick one, because it's almost like a pusher. What I mean is, if I'm moving my head this way, it's actually this sternocleidomastoid, which is doing it. As you can see in this example, the examiners holding the sternocleidomastoid, which is active as the patient moves too. There, right, the trapezius shrugged their shoulders. And, of course, you test with your hands on top, asking if there's any pain. So just checking their up with time, lower limb examination. Now, make sure, as with any examination, you've exposed them adequately, and then you inspect first, so don't go in and dive in. You look first. You're looking for a number of things with the upper the upper limbs. One thing you look for is pronator drift. Can you put your arms out in front? Shut your eyes and then this is pronator drift. It's a classic sign of an upper motor neuron lesion, which is often seen in strokes or brain tumors and things like that. So it's a really good quick test. Also, when you're looking, you would look for for Circulation's. Maybe there's a tremor like Parkinson's wasting. Or again if you'd like to answer in the chat quickly. Does anyone know what this is or what this is showing? And what syndrome might be going on here that explains what's being seen here. I may not be able to wait long, I'm afraid. But if you have a quick think about that, this is actually quite marked Thena wasting. If you look at your thumb, probably there's going to be a lot more bulk of the muscle there, and that's because the median nerve innovates this and can be damaged within with carpal tunnel syndrome. So just moving on. There we go, tone now importantly with tone tone, is not you doing a little dance with the patient because then they've got that they'll be trying to resist you. Instead, it's doing sudden, quick movements that they can't predict. That can be uncomfortable. So let them know. First, ask if they've got pain. Ask them to really relax is the sudden movements, which count as well as the slow ones. If there's a Parkinson's or extrapyramidal increase of tone, however fast you move it, it's always stiff, like a lead pipe. If there's a spastic increase in tone, like with a stroke, it gets stiffer, the quicker you move it, that's where you do the quick movements as well. To look for spasticity, A quick word about power testing so you might go over and see Patient X and say to your colleague, they're weak, but that's not much use, so you can give a specific score. This is the Classic Medical Research Council score, and that's important because they're power may change. They may be getting worse as they come into hospital. They may be improving with rehabilitation, so score each muscle movement with these grades. Zero no movement. One is just a flicker of movement, but they can't actually move the joint to they can move the joint, but they can't move against gravity. Three They can move against gravity, but they can't move against resistance. Four They can move against resistance, but not fully. Sometimes four is broken into four minus or four plus, depending on how strong you think it is. Here are the pictures I alluded to earlier. These may seem old, black and white, but they're from a classic. And forgive me for mentioning it, but it's very pertinent to the situation in Ukraine. This is from the classic aid to the examination of the peripheral nervous system which was designed in the Second World War. In response sadly to the large number of peripheral nerve injuries, which is very sadly of course can be seen in warfare. So this shows shoulder abduction, which is the first muscle you typically test with the upper limb. So with each muscle you test, you should ideally think muscle root nerve. Okay, now, I don't want to necessarily to scribble all of these down because these slides should be made available for you. So I'm going to go over these quite quickly. So shoulder abduction, deltoid muscle C five axillary nerve elbow flexion biceps. Please note the way that the hand is held is like fist up and C 56 muscular, cutaneous nerve. Does anyone know and apologize again? I may not be able to get to the chat in time before I reveal it what muscle this is. This also is elbow flexion, But can you see the position of the hand? This is more like a sort of thumbs up position. It's more like forgive me for giving the analogy like you're drinking a pint of beer. So this is not biceps, even though it is C five C six area. This is actually breaker radial ISS. It's the radial nerve. You wouldn't routinely test this. The reason it's relevant is when it comes to reflexes, which I'll explain later. Next we come onto elbow extension. That's mainly C seven triceps, radial nerve wrist extension. This is quite small print stuff, I would say. Basically, this is when you test one side of wrist extension and the other side, but I would say in broad terms if you just test wrist extension, remember, Ideally, you should use one hand to stabilize above the joint and then test, ideally like with like like wrist against wrist. The reason it's important is Wrist-drop is quite common with radial nerve pauses, some types of stroke again. With that in mind, when you do get wrist-drop or subtle cases of wrist-drop, you may get finger drop, which is why it's a good idea to test here again. Okay, finger flexion. There are a number of ways you can test finger flexion. I quite like this. If you got to pick one, this is the flexor digitorum profundus. I always thought about it is being very profound because it goes right to the tips of the fingers. It only moves the tips of the fingers. It's also profound because it's got two heads, if you remember, and that's quite useful because you get two for the price of one. The two fingers. If you can see here, the the index finger and the ring finger one and two. Here they're the anterior interosseous nerve, and then these two, the little finger and the little finger on the ring finger here, and those are the ulnar nerve. You can test them at once by doing that, so that's quite simple and flex a digital and profundus is up here so it won't be affected by anything, such as a carpal tunnel syndrome. Then we come onto finger abduction again. There's quite a bit of detail on this slide, but broadly speaking, this is probably sufficient. Can you push your fingers out against my fingers? And that's because actually, both abduction and adduction are both see 81 on the nerve. If you really wanted to remember something more about them, you might remember pad and dab Palmer Palmer interossei. I adducted and then you go to dorsal interossei. I abduct. Okay, there's a bit more detail there, but it's not critical thumb abduction there, lots of movements of the thumb. But I would suggest the only critical one for most cases unless they've come in because of a thumb problem is thumb abduction. So hand flat point up toward your nose, try and push them down. This is important because this is classically can be harmed with carpal tunnel syndrome. Now we're going to come onto the reflexes. A couple of points here about the reflex is you have to remember that you test one side and then the other, ideally, to compare sides, it's important that the patient relaxes, not spelled correctly. They're the limb or the reflexes. Maybe marked again. As with the power testing, there is actually a set way of recording. You don't just say, always a bit brisk or it wasn't brisk, so no is not. Zero is no reflex, which is always abnormal. So if that occurs, maybe try again with them biting their teeth at the same time to give reinforcement. Plus is just detectable. Two plus is normal to brisk, and both plus and two plus is normal. Typically three plus maybe normal in a young, anxious patient. Or maybe abnormal. Four is definitely abnormal and may well have clonus. Where there's repeated beats, important things are, Is there? Is there any asymmetry? In other words, reflexes brisk on one side and not the other is really important. See Bicep C 56 Supinator C. Five. You can see where the where they're where they're being hit and then triceps C seven. You'll see with all of them. The arm is being rested to relax. I mentioned earlier that I'd come back to the reflexes. The Supinator reflex, in fact, actually tests breaker radial iss, not supinator muscle and therefore, if you remember, Brachioradialis flexes the elbow. However, if there's a cord compression around C five, which is the level of the supinator reflex, then that will kind of take out the reflex of that level. However, below that level, if it's like a disc just at that level, pressing the cord, the reflexes of brisk. So that means you tap on this side. The front side is there, but there'll be no flexion. Instead, you'll get extension because you actually activate the brisk triceps, the so called inverted supinator reflex. Finally, you can put your fingers under their fingers and tap your own fingers with the tendon hammer to look for a finger jerk. If it's slight, that could be normal. If it's absent, it could be normal. But if it's brisk, then try doing this. Flick the finger and look at the thumb that's normal. That's a Hoffmann's Hoffman's reflex, which is a pathological sign it said to be the equivalent equivalent of an upgoing toe or plant a response for the upper limb sensation for the upper limb. I would suggest you go over it as follows. Get the wisp of cotton wool, use it on the stern, and that's light touch. Can you feel it to get them to shut their eyes? Say, Can you feel it's light touch and go through In order? I'd probably put C five a little bit higher than this, but C four C four on the other side. C five C five on the other side, C six, c six and so on. When you've done the light, the light touch, then I'll take pinprick a sterile, semi blunted needle, and I'll start from the fingers up. So fingers try and cover the radial nerve distribution and ulnar nerve distribution, so start there as soon as it's normal. Stop ulnar nerve as soon as it's normal. Actually, use that as soon as it's normal. Stop. But if it's not normal, go up to where it becomes normal. To get a level, then you think about joint position sense. So a joint position sense. You look at the lowest possible joint. You stabilize it there with one hand. You don't do this because it adds pressure. You do this from the side. Say this is up. Remember, stabilize. That's down. Shut your eyes. Which way is this? Which way is this? Which way is this? Then you keep going up until it's normal. Vibration is similar. One. Bony point again. Put on the sternum first. This is vibrating. Can you feel it? Shut your eyes. Is it vibrating? Tell me when it stops and until it's normal, you just keep going up and up and up. Okay. Coordination in the upper limbs. Finger nose testing will all be aware of. Um, try for nearly full extension when you're testing this. Keep the patient's elbow away from their body because if they do this, they're getting extra information and move your finger. The target when they're moving their finger back to their nose, don't move your finger when they're going for it, because that's difficult for anyone to do. If they can't see you can as long as it's safe and they don't poke their eyes, just ask them to move their hands out the side and touch the tip of their nose. Super nation and pro nation you're probably aware of as well. It's best demonstrated to the patient rather than describe Don't let them cheat again. That's cheating has to be up and over lower limbs now and I think we're just about on schedule. So again, Adequately exposed. Inspect for fasciculation movement, disorders wasting and scars. This, for example, is Paez Cavus with hammer toes tone, and I would talk through the tone as always. If you're going to touch and move the patient, ask them first if they have pain. So first you can roll the legs, so get them to relax. Roll the legs and you look at the ankle there to see how relaxed it is as it flops about. Then you put a hand under a slightly bent knee as here, and you lift it up suddenly and drop it suddenly and see how freely it flops down. And finally looking for ankle clonus, you slightly bend the knee and then you explain to the patient what you're gonna do can be a little bit uncomfortable. You push up the forefoot quickly and hold it up. But don't hurt the patient and you're looking for the foot too beat down. You're actually allowed a couple of beats of clonus up to three, which can be normal, but more than that is abnormal, suggesting an upper motor neuron lesion go through the muscle testing as before. Hip flexion. Here is a muscle you don't actually see. Remember that you can't see the muscle that does this. It's the iliopsoas in the abdomen. This is femoral nerve. L1 l 23 Hip extension. This is an interesting one. This is the one example of a muscle power where you test across two joints. The ideal is you only test across one joint, but this is hip extension, but you'll notice you're not testing it at the thigh. The reason is it's too powerful. You're just using your hand. So you use mechanical advantage by testing right at the end. It's like a lever effect to give you more power. You can only do this if the knee is straight, because then it fixes and it takes it out of the equation. And there you go. There's the That's the Gluteus Maximus, and those are the details. They will be on the slide show knee flexion. Then that's the hamstring muscles. Typically s one knee extension. This is also incredibly powerful. If ever you've been kicked on a football field, you know how powerful it is. And you're using your hands. So you know this picture. They're trying to put their trying to really bend the knee up and put the hand in to use some mechanical disadvantage for the patient to give you a chance of picking up weakness. That's the quadriceps as arid with the white arrow, and that's L 345 Ankle plantar flexion When you're standing down again is really strong. You can stand on your on your 1 ft. You maybe up to stand on your toes. So again, this is something you can go back to when they're standing in the gate exam. That's the gastrocnemius. As you can see, they're mainly and ankle Dorsiflexion, as you can see, is tibialis anterior at the front of the lower leg. And this is the parent deep peroneal nerve l, 45, so that can be damaged. Peroneal nerve can be damaged with compression or car accidents and cause a foot drop. So if someone's got a foot drop, it's particularly important to test these. The big toe is mainly L5 in a bit of L4, and the ankle version is perennial, so you might. It might help you a little bit to help differentiate an l 45 lesion from a perennial lesion. By testing these ankle e version is simply ask the patient to push their whole foot outwards. Okay, let's go on to the reflexes. So remember as before you test one side, then the other get them to relax. You see the position I've used here for the knee reflexes l 34 and then for the ankle reflex s one. As medical students, I'd advise you to repeatedly practice the left ankle jerk. In the old days, when examiners were running short on time, they would often say to a student, Show me the left ankle jerk because it's really hard to do it. Not really hard, but it takes practice. And to get used to doing that, there is another reflex, the adductor reflex. And here, if you look at the first picture, imagine instead of me putting my hand on the other leg, I'll just put it just above whether thigh is just above the knee and then hit my own hand with the tendon hammer. It's normal if that leg a ducts in slightly. But if both legs are duct in, that's called across the doctor sign, which is pathologically brisk. And then, of course, we have to come onto the plantar response. The babinski sign. Okay, you all have heard of that or a positive plantar response. Importantly, a lot of people actually get this wrong what it is, it is an upgoing great toe. But it's not only that the reason we have a babinski sign when we're when we're little Children before we learn to walk is a protective mechanism. So if something touches your foot, you don't as as an infant, you move the whole foot away and the whole leg bends up and pulls away. And so when people get upper motor neuron damage and they get a positive babinski sign, all the rest of that comes back to. So it's not just the toe. If you look at this diagram, a shows that Tibialis anterior will contract to pull the whole foot up be shows that shows that the hamstring tendons that the back will contract to try and bend the knee and see shows tensor fasciae later. And all of these you can see with an upgoing truly up going, uh, plantar. You classically licit with an wooden orange stick or a tip of a tendon hammer the medial side of the of the sole going up in an arc over 1 to 2 seconds and then take off underneath the great toe is very ticklish. So if people are very ticklish, you might try the chat doc method. Where you if you look at the picture there where the hand is, that's the lateral malleolus, and you just do a little arc underneath the lateral malleolus scraping there. Um, interesting enough. Although Babinski described that in 18 96 the up going plantar in infants has been described in art for hundreds of years, there's a fascinating paper describing it there. And this is from the Virgin with the with the Christ child in 14 76 you see the angel touching the foot and the up going plantar. We're nearly there. Sensation in the lower limbs. As before, I'd recommend the sterile cotton wool. Just go sternum. That's like touch. Then you go sequentially through the dermatome is probably starting. L1 L1 L1 L2 L2 here. You do need to look at the back of the leg as well. Then, after you've done that pin prick start from the toes. Say, Is this sharp on the sternum? Yes. Shut your eyes. Is it sharp? And as soon as it's normal, you go on to the other side. You're looking particularly for peripheral neuropathy. Then, as before, joint position sense stabilize above. Don't do that, Do that. That's up. That's down. Shut your eyes. What's that? What's that? What's that? Three out of three is what you're looking for. Vibration sense. This is vibration sense on the sternum. Shut your eyes. Tell me when it stops, and so on. Superficial abdominal reflexes. I suggest you look at that a bit later. That's really small print, but when you qualify, it's really important. Okay, we have superficial abdominal reflexes if you flick over the tummy. Although they're absent in about 15% of the population, particularly after surgery, those don't become brisk with upper motor neuron lesions like cord lesions. They tend to go, and if they're absent on one side, that may be a suggestion of a cord lesion. And look on the other side. There are dermatome over the tummy. If there's any pathologic pathology in the legs, think, could it be a cord compression, which is so easily missed if you then to use a pinprick to go up the tummy until it's normal. And if you find a level, it could be a strong indicator to think of a spinal cord lesion. Coordination of the lower limbs. You start with ankle shin, and that's where you ask the patient to lift their heal up, bend the knee, touch their knee with the heel and slide the heel back. As with finger nose testing, it has to be moving through the air to hit the target, not just scraping up and down the shin as you get additional sensory information. The final path exam now gate remember, for some people is the first part of the exam, so you might want to check with your examiner. If that's relevant, don't assume they can stand if they're by the bedside or they could fall over. That's actually why I like examining Gate last, because I'll know if they can stand a lot from the power testing and joint position sense testing. So, firstly, see if they can stand safely. If there's a wide base, maybe they've got a cerebella problem. The Romberg test, you know, stand with your feet close together but not touching and your eyes shut. It involves the patient doing just that, but they could fall. So before they do that, put an arm before and behind them and explain what you're doing. Excessive swaying is positive as, of course, is if the fact if they fall, this is not Cerebella sign. This is suggesting there's a problem of joint position or appropriate reception. Then you get them to stand on their toes. As I said, ankle plantar flexion is very strong, so this is a truer sense of it. And then, if you can stand on their heels, which may be a good way to look for a subtle foot drop, you get them to walk normally across the room, look at their stride, look at their arms swing. If it's asymmetrical, think of Parkinson's. If they when they turn, they do it in multi steps. Think of Parkinson's, and then you get them to stand in tandem, and if they can do that, then you can get them to try and walk in tandem, looking for a subtle cerebellar lesion. So that is the end. I think I stuck to my time. I hope I can answer some questions. And I hope you managed to see and hear that. All right, thank you. I will stop talking now. And perhaps Hannah, if you could help. If there any questions? Um, sure. I haven't seen any so far. So if anyone has any questions now that they'd like to post? Um, no, I'm not seeing any questions. OK, that's fine. That's fine. There's no there's no rush about that. And apologies, then. I was sort of going at a fairly fast speed then, in case there were questions at the end. But I would like to just mention a few other things about the neurology exam. Just in general terms. Obviously, if there are questions, Hannah let me know. There are sorry. There are questions I've just popped up now. Excellent. Um, so the first one is what is the difference in examination of cranial nerves between an adult and a child slash infant? Mm, Yes, a good point. I would actually say that The key difference actually there is. It's obviously far harder in a child, I would say. Although we don't tend to do pediatric work where I am in general terms, pediatric examinations are much more making the most of the situation. For example, it may be that you have to ask the you don't say the child look to your left. You may actually say Put a toy to the left hand side and you know that can also be used for matters of looking for neglect and cortical reasons. It is a lot more challenging in a child, but there are a few objective things that you can try and do with the parent's permission. One of those is obviously to shine a light at the back of the eyes. The ophthalmoscope Children won't like that, but it's a really important one, because that's a very objective test. It's also very helpful with the parent's permission. If you're able to use, the Corneille reflects if it's relevant, because again, that's actually fairly objective test of what you're actually looking for there. So it is a lot more difficult, and you have to use the moment. For example, if the child were to cry or to laugh, you make an opportunity to look at the back of the mouth, and when they're crying in particular, you'll see the palate going up. So it's a lot more tricky with a younger child. But I wouldn't say that the overall principles are that different. Um, thank you. There's so there's two questions now. Um, how do you test gate if the patient cannot walk? And there's also, um, is gait part of up or lower limb lesion? Yes. OK, so, firstly, how do you test gate if they can't walk? Well, you can't really You you basically what? My analogy sometimes. And this is really what what I'm saying. I have to let people be aware that many old traditional neurologists get the patient to walk. First of all, that's mainly because they see people in clinic walking in. But if they can't walk, of course, if you get them to try and walk, they'll fall over. And that's a disaster. That's why I use the analogy of a car in a garage. You want to test the motor fully before you send it for a spin. That's why I get them to stand first. Before they walk. I make sure they can stand with their eyes closed. I make sure that they can stand with their standing on their toes, if possible, and on their heels and with the tandem gait. I don't just send them off around the room, walking heel to toe. I get them to stand tandem first, so it's checking and going as far as you can. Obviously, then you then do your examination of the lower legs on the bedside of the legs, and that will also help give you an answer. Um, as to what? Where the problems of Gates had to do with upper upper limb, I think. Was it upper or lower? Sorry, Could you just repeat that question? Actually, Hannah the one about upper or lower for gait? Um, the question is, is gait part of upper or lower limb lesion? That's it. Yes. So, basically, it's part of lower limb lesion's. However, as I briefly alluded to, you can get problems with gates from lots of reasons above the legs. The classic one, which I'm sorry to say, is really not often taught, certainly in UK medical schools and is, sadly, very often missed on the wards a spinal cord lease. So it looks like they're just weak in the legs, so people examine the legs. Maybe at most If they have a scan, they have a scan of the lumbar sacral spine, whereas it could be that there's a cord lesion, particularly that the Rasic cord, because the thoracic cord will cause problems in the legs. But it's too low down to cause problems in the arms, so people don't always think about that. It's also true to say that strokes and almost any illusion in central lesion in the brain can cause problems with gait. And then, finally, more complex lesions like Parkinson's disease neurodegenerative ones can cause problems with the gait. Many problems, however, will reside in the lower limb in the lower limbs. For example, sensory testing. You may show that they've got a very bad peripheral neuropathy, and that may give them this high stepping type of gate where the patient's not really sure of where the ground is. Or they may get a positive Romberg's test if they can't feel where their toes are again. If you're allowed to examine them on the bedside first, you'll know if they're going to have a positive Romberg's test, but they say I can't feel one of my toe and ankle are so that would be my general response to that. Um, thank you very much, Doctor Young. For your answers and for your excellent lecture. I'm I just like to remind everyone that we really do need the feedback and you need to complete in order to get the certificate at the end. So it's in the chat now. It's been post a few times. Um and we've got about five minutes left, so if you could fill that in and then right at the end, you'll get certificate. Excellent. I'm just going to stop sharing. They're actually just in case there. Any questions? Otherwise, I'm showing so So That's very good. So so thank you. Some kind comments there. I hope it's a views, and I'm sorry.