FINALS- 1st SEMESTER

• Arrive at the place 5 mins earlier.

• Drink water and relax.
• Avoid reading new topics at the last minute.
• Ask your partner to co-operate before hand.
• Read through well and watch videos, they might help.
• Remember what are the specific tests and how you should report them.
• Please take note of the methods of each test as the methods vary with each preceptor.
• Make sure you have all the tools or at least one per room.
• Finally thank your patient and the preceptor after the completion of the exam.
• Mini mental status examination form
• Covered vial with coffee to test the CN I (Olfactory N.).
• Jaeger chart – Requires 13 inches, while Snellen entails 20 feet; near vision; very
convenient
• Ophthalmoscope, Otoscope, Penlight
• Pin/needle/cotton balls/ice cube -for sensation
• Covered vial of sugar for CN7 -For taste sensation of anterior 2/3 of tongue
• Tuning fork, Ideally 256 cycle - For CN VIII (Vestibulocochlear N.) and vibratory
senses
• Tongue depressor - For CN IX (Glossopharyngeal n.) & CN X (Vagus n.)
• Reflex hammer
• Tape measure
• Ishihara plates
• Cotton Pledget
• Begin with greeting your preceptor and your patient.
• Introduce yourself .
• Speak and instruct your patient clear and loud.
• Explain the procedures to your patient.
• Interpret the results and report it to your preceptor.
• Finally thank both your patient and your preceptor.
STEP 1:
• Test one nostril at a time (for standardization, test the right nostril first)
• Compress/Close the Pt’s (patient’s) left nostril.
• Ask patient to close their eyes, sniff, and try to identify this odour.
• Hold the vial in front of the open nostril and ask the Pt to sniff.
• Wait a moment for the Pt to perceive the odour and then identify it.
• Asking the patient to identify the odour in writing is preferred, but it is okay to ask the patient to just identify it.

STEP 2:
• For the second trial, compress the opposite nostril and this time do not present the stimulus.
• Withholding the stimulus, tests the Pt’s suggestibility and attentiveness.
• Wait a moment for the Pt to perceive the presence or absence of odour.

STEP 3
• For the third trial, present the stimulus to the untested nostril (left nose).
• Wait a moment for the Pt to perceive the presence or absence of odour.
 • HYPOSMIA- Partial loss of the sense of smell.
• ANOSMIA (anospharasia)- Complete loss of the
sense of smell.
• HYPEROSMIA- Increased olfactory acuity, hysteria,
psychotic state, in migraine, hyperemesis gravidarum
(most common cause)
• PAROSMIA- Perversion of smell (sweet smell is
interpreted as bad odour).
• CACOSMIA-Disagreeable odours, appears in psychic
state, follow head trauma especially to the uncus.

REPORTING:
• The olfactory sensation of the patient is intact as he/she was able to identify the test material correctly on both nostrils/sides.
• If the patient is not able to identify the odour then use an otoscope to check for any blocks are damages.
The Optic nerve is tested in the following ways:

1. Visual Acuity
• Visual acuity is tested using Snellen charts.
• If the patient normally wears glasses or contact
lenses, then this test should be assessed both
with and without their vision aids.
• Start from the bigger letters going down.
2. Colour
• Colour vision is tested using Ishihara
plates which identify patients who are
colour blind.

3. Visual Inattention
• Visual inattention can be tested by
moving both fingers at the same time
and checking the patient identifies this.
4. Visual Field- Confrontation test
• Station yourself directly in front of the patient.
• Start with your left eye directly in line with the Pt’s right eye, at a
distance of about 50 cm.
• The Pt covers the left eye with the left hand.
• Hold up your left index finger just outside your own peripheral
field, in the inferior temporal quadrant. Patient should not see your
finger initially.
• Hold the finger about equidistant between your eye and the Pt’s.
Wiggle the finger slowly and move it very slowly toward the
central field.
• Request the Pt to say “now” as soon as the wiggling finger is seen.
• Try to match the perimeter of the Pt’s visual field against your
own.
• Test all quadrants of each eye separately, each time starting at the
limit of the field.
• You can also ask the patient to tell how many digits does he see
instead of wiggling your finger.
5. Visual Reflexes- Pupillary reflex
• Visual reflexes comprise direct and concentric
reflexes.
• Place one hand vertically along the patients
nose to block any light from entering the eye
which is not being tested. Shine a pen torch
into one eye and check that the pupils on both
sides constrict. This should be tested on both
sides.
• Alternately swing the light from one eye to
the other and hold it on the new eye for 3- to
5-second intervals.
• Watch for equal reactions of both pupils.
• If the Pt has an afferent defect in one optic
nerve (e.g., due to o optic neuritis), the pupils
will dilate as the light swings from the normal
to the affected eye. (Marcus-Gunn pupil or
relative afferent pupillary defect) rather than
maintaining the same degree of constriction.
6. Fundoscopy:
• Finally, fundoscopy should be performed on both eyes.
• Direct the ophthalmoscope 15 degrees from center and look
for the RED REFLEX.
• Simply follow the red reflex in until you see the retina. If
you lose the red reflex, come back until you find it again
and repeat.
• Focus on a retinal vessel.
• After locating a retinal vessel, follow it along until you find
the optic disc.
• Next, identify the pigment ring around the disc (grayish
pigment around the disc), note the disc colour (usually
yellowish or pinkish), and the presence or absence of a
physiologic cup.
• If present, the physiologic cup is white as compared with
the rest of the disc and occupies about 30% of the disc.
• Identify the arteries, the thin, brighter appearing vessels,
and the thicker, duller appearing veins.
• Look for venous pulsations
• Normal AV ratio is 2:3
REPORTING:
• Visual acuity (II) is good bilaterally with 20/20 vision on hand-held
chart (while wearing his corrective lenses, if relevant).
• No color blindness is noted.
• Visual fields are full to confrontation in all quadrants.
• Pupils are equally round and reactive to light.
• Normal red-orange reflex is noted.
• On fundoscopic exam, the optic disc is visualized without any
abnormalities.
• Ask the patient to keep their head perfectly still.
• Draw a large ‘H’ in front of your patient using your fingers
and instruct them to follow your fingers with their eyes only.
• Observe for the movements of the eyes.
• Hold your index finger in front of the patient and ask the
patient to concentrate on your finger.
• Slowly advance your index finger until you reach the root of
the nose. (test for Accommodation)
• Observe for the movements of the eyes.
• Test for Pupillary light reflex in both the eyes.
• Also note for any abnormalities in the patients eyelids as the
levator palpebrae superioris muscle is also innervated by the
CN-3. This muscle helps in elevation of the eyelid.

*** Patient should not move their head while following the
examiner’s finger.
• Lateral rectus - Look to the sides
• Medial rectus – Look nasally/Inside/Inward
• Superior rectus – Look up
• Inferior rectus – Look down
• Inferior oblique - Look up, Adduction, Extorsion
• Superior oblique - Look down, Abduction, Intorsion.
Abnormal Findings:
• Esotropia – eyes turn in
• Exotropia – eyes turn out
• Hypertropia – one eye is higher than other
• Internuclear Ophthalmoplegia – infarct/demyelination in between CN III and VI nucleus.
• Diplopia – double vision

REPORTING:
• Extraocular movements are intact (III, IV, VI), with no ptosis and palsy.
• Normal pupillary reflex is noted.
• Inspection: Inspect the temples and cheeks for
atrophy of the temporalis and masseter muscles.
The temporal muscle fills out the temple. Even
when the Pt bites, the muscle is difficult to palpate,
but after temporalis muscle atrophy, the temple
sinks in. In myotonic dystrophy, the chewing
muscles and sternocleidomastoid muscles atrophy.
The masseters of some individuals undergo
hypertrophy and stand out strongly.

• Palpation: To test for masseter atrophy, ask the Pt

to clench the teeth together strongly and unclench
several times, while you simultaneously palpate the
muscles of the two sides as they mound up and
relax under your fingertips.
• Testing for weakness of jaw closure
• Ask the Pt to clench the teeth strongly.
• Place the heel of one palm on the tip of the Pt’s mandible
and the other hand on the Pt’s forehead. Press hard on the
tip of the mandible. You must brace the Pt’s head with
your opposite hand because jaw closure is a very strong
movement and you do not want to test the strength of the
neck muscles and jaw closure at the same time.
• If the Pt complains of fatigability when chewing, as in
myasthenia gravis, have the Pt chew for a period before
testing.
• The principle is to test the strength of one muscle or one
limited set of muscles at one time.
Please hold the patient’s head with your other
arm
• Testing for weakness of the lateral pterygoid
muscles
• Ask the Pt to forcefully open the jaw. Note whether its tip
aligns with the crevice between the upper, medial incisor
teeth. Weakness of one lateral pterygoid muscle would
cause the jaw to deviate to the ipsilateral or contralateral
side.
• Then ask the Pt to move the jaw from side to side.
• Ask the Pt to hold the jaw forcefully to the side as you
try to push it back to the center with the heel of your
palm. Brace the Pt’s head by pressing your other hand
against the opposite cheekbone.
• A word of caution: Do not jerk or apply sudden
force in testing jaw muscles, particularly in elderly
or edentulous Pts. The temporomandibular joint
may dislocate.
• Finally perform the jaw jerk on the patient by placing your left index
finger on their chin and striking it with a tendon hammer.
• This should cause slight protrusion or closure of the jaw.
• If the mouth is open, it will close slightly
• If the mouth is closed, it will open slightly.
Sensory Tests
1. Light Touch
• Ask the Pt to say “touch” (or “now”) in response to each touch by a wisp of
cotton.
• After the Pt closes the eyes, lightly brush each area of the three sensory
divisions of CN V with a wisp of cotton.
• Touch alternate areas and sides of the face randomly.
• Then ask if it was equal on all divisions
2. TEMPERATURE/PAIN
• For screening purposes, testing one tests both due to the fact that both are
being carried by the same sensory fibres
• Test temperature discrimination first. If the Pt discriminates temperature
normally, and the history does not suggest neurologic disease, you do not
need to test pain.
• Ask your patient to close his/her eyes before you begin.
• For temperature use your finger- warm sensation and tuning fork –
cold sensation
• But if you need to test for pain, then what you could use is a tongue
depressor and break it into two. Use the sharp edges.
3. CORNEAL REFLEX
• The corneal reflex consists of closure of BOTH eyelids in response to
touching one cornea with a wisp of cotton. It is entirely distinct from the
corneal light reflection.
• It tests the integrity of two cranial nerves, (afferent arm) CN V (for corneal
reflex) and (efferent arm)
REPORTING:
• Sensory over the face (V) is intact and equal bilaterally in all three CN
V divisions for sharp, dull, and light touch stimuli.
• Temperature sensation is normal.
• Motor is intact with midline location of the jaw and equal contraction
during mastication.
• Normal jaw jerk reflex.
• Facial inspection begins upon meeting the Pt and continues while
taking the history.
• Notice the overall play of facial muscles during speech and
emotional expression. The face may move too much or too little.
Many disorders, such as muscular dystrophy, parkinsonism, and
depression, reduce all facial movements, a condition called
masked facies, as if the Pt wore an immobile mask.
• Next, search for asymmetry of facial movements, asymmetry of
blinking, and asymmetry of the movement and depth of the
nasolabial skin creases. The nasolabial creases begin just lateral to
the lips and bow upward to the nares.
• This nerve is therefore tested by asking the patient to crease up
their forehead (raise their eyebrows), close their eyes and keep
them closed against resistance, puff out their cheeks and reveal
their teeth (Smile).
• You can like wise test the strength of the muscle by applying resistant in the
opposite direct. (E.g. trying to open the patient’s eyes when he closes,
collapsing a full puffed cheeks, etc,.)
• Test for taste sensation in the Anterior 2/3rd of the tongue using a
vial with the patient’s eyes closed.
 Upper Motor Neuron lesion (UMN): spares the Frontalis muscle. Stroke in one side of the brain, the facial
asymmetry would always include the contralateral side of the face but spares the frontalis muscle.
Lower motor Neuron lesion (LMN): include the Frontalis muscle causing inability to raise eyebrows.

REPORTING:
• Facial muscle (VII) strength is normal and equal
bilaterally.
• Taste sensation is normal
• No abnormal facial movements were noted
• Assess gross hearing
• Ask the patient to close his/her eyes
• Now whisper in his ears and ask if he/she hears
something with the other ear closed
• You can also ask your patient to repeat what you said
if your are using numbers or words.
• You can also rub your fingers instead of whispering
but make sure the patient’s eyes are closed and test
both the ears.
It is better if you ask you patient to close
his/her eyes and you will be the one to close the
ear not being test.
• Always strike your tuning fork against a surface that doesn’t make noise. (E.g
your palmar surface)

1. Weber’s Test
2. Rinne’s Test

Once the patient is unable to hear the sound via the

mastoid process move the tuning fork to approximately 1
inch or cm from the external auditory meatus
3. Schwabach’s Test
4. Romberg’s Test- for balance
Positive test: patient has a tendency to lean on one side
For Doc Sarfati:
• Feet together. Both hands up parallel
to the ground, one knee up. Close
eyes.
• Repeat on other side.
• If patient has balance problem,
he/she will fall to the abnormal side.

You can ask the patient to do Jendrassik's manoeuvre

5. Unterberg’s Test

• Ask patient to march on the spot with arms outstretched and eyes closed
RESULTS:
• Normal – patient remains in the same position
• Vestibular lesion – patient will turn towards the side of the lesion
6. Dix-Hallpike Manoeuvre

• Head turned 45 degrees to maximally stimulate posterior semicircular canal.

• Head is supported and rapidly placed into head hanging position. Neck is hyperextended while at a 45
degree angle.
• Used to provoke nystagmus and Vertigo.
REPORTING:
• Hearing (VIII) is grossly intact bilaterally.
• Weber does not lateralize and AC > BC (normal Rinne) in both ears.
• Vestibular function intact (motor/gait), no swaying nor turning was
noted.
• Assess soft palate and uvula:
• Symmetry – note any obvious deviation of the uvula
• Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation? (deviation away from
side of lesion)
• Also access the movement of the palate if they are symmetrical at the same time as accessing the uvula.
• Gag reflex (afferent IX, efferent X) – Use your cotton pledget not your tongue depressor.
• Make sure you stroke as light as possible or your patient might spit or vomit on you
• Ask patient to cough or say “Kah kah kah” – damage to nerves IX and X can result in a bovine cough or
difficulty in say “Kah kah kah”
• Swallow – ask patient to take a sip of water usually 30 ml – note any coughing / delayed swallow.
• Test for taste sensation by placing the vial on the posterior 1/3rds of the tongue.
• Also ask the patient to read a sentence and if his voice is hoarse, may be there is a problem with his
Vagus nerve.
REPORTING:
• Patient has normal quality of speech able to say “kah kah kah” with ease, Uvula
midline on phonation with equal palatal elevation, Bilateral gag reflex intact, able
to swallow with ease, able to identify test material on the posterior aspect of the
tongue.
• Also ask the patient to flex and extend the head at the neck against resistance
• You can test for hoarseness of voice under the examination of the Cranial nerve 11 also.
REPORTING:
• Intact SCM and Trapezius muscles, able to move head against
resistance, able to flex and extend head against resistance, able to
shrug shoulders against resistance and no hoarseness of voice noted
• Inspect tongue for wasting and fasciculations at rest
(minor fasciculations can be normal)
• Ask patient to protrude tongue – any deviation?
(deviates towards side of lesion)
• Place your finger on the patient’s cheek and ask to
push their tongue against it – assess power
REPORTING:
• No tongue atrophy, no tongue fasciculations, tongue midline on protrusion,
able to push tongue against resistance.
SUMMARY
NERVE FUNCTION FORAMEN
I - Olfactory Smell Exits at the cribiform plate
II - Optic Vision Exits via optic canal
III - Oculomotor Moves the eye (4 of 6 extraocular muscles) Exits via superior orbital fissure
IV - Trochlear Moves the eye down & out (innervates superior oblique) Exits via superior orbital fissure
V - Trigeminal Sensation to the face. Motor innervation to the muscles of V1 exits via the superior orbital fissure. V2 exits via
mastication. foramen rotunda. V3 exits via foramen ovale.

VI - Abducens Moves the eye laterally. (Innervates lateral rectus muscle) Exits the skull via the superior orbital fissure.
VII - Facial Muscles of facial expression. Taste to the anterior 2/3 of the tongue. Exits the skull via the internal acoustic meatus and the
Tear & salivary ducts. Innervates stapedius muscle. skull itself via the stylomastoid foramen.

VIII - Balance (vestibular division). Hearing (cochlear division). Exits the skull via the internal acoustic meatus.
Vestibulocochlear
IX - Taste for posterior 1/3 of tongue. Sensation to pharynx. Innervates Exits via the jugular foramen.
Glossopharyngeal stylopharyngeus.
X - Vagus Parasympathetic innervation to all viscera above splenic flexure. Exits via the jugular foramen.
Innervates laryngeal muscles and controls cough reflex.

XI - Accessory Spinal portion innervates SCM & Trapezius. Cranial portion runs Exits via the jugular foramen.
with Vagus nerve.
XII - Hypoglossal Innervates all tongue muscles apart from palatoglossus (innervated Exits via hypoglossal canal.
by the vagus nerve).
1. 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”

2. 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”
.
3. 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” Finger extension

4. Fingers
• Finger extension (C7) and flexion (C8) – “Put your fingers out Finger flexion
straight and don’t let me push them down”
• Finger ABduction (T1) – “Splay your fingers and don’t let me
push them together”
• Be mindful to use the same finger/ hands as that of your patient
5. Scapular
• Adduction:
• With the hands on the hips, the patient forces the elbows backward
as hard as possible. Standing behind the patient, the examiner tries to
push them forward at the elbow

• Winging:
• Have the patient try a push-up or lean forward against a wall, supporting the body with outstretched
arms
6. 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”

7. Knee
• Flexion (S1) – “bend your knee and stop me from straightening it”
• Extension (L3/4) – “kick out your leg”
8. 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”
• Inversion (L4) – “push your foot in against my hand”
• Eversion (L5/S1) – “push your foot out against my hand”

9. Big toe
• Extension (L5) – “don’t let me push your big toe down”
10. Back muscles
• Pt prone, ask the Pt to arch the back and rock on the stomach. Inspect and palpate the paraspinal muscles.
• Have the pt bend forward at the waist and straighten up. If you try to oppose the pt’s straightening up from a bent
waist (you may cause a back sprain or herniation of an intervertebral disc)

11. Beevor's Sign

• Strike inwards towards the umbilicus or just ask the patient to raise his/her head.
• Abdominal muscle dysfunction indication Thoracic nerve damage.
• When a Pt with a T10-level cord lesion contracts the abdominal muscles (during head lift, the umbilicus migrates
upward
REPORTING:
• Good muscle bulk and tone. Strength 5/5 (deltoid, biceps, triceps,
quadriceps, hamstrings).
• No atrophy of muscles were noted.
• No scapular winging was noted.
1. Light Touch – Anterior Spinothalamic tract

• The patient’s eyes should be closed for this

assessment
• Touch the patient’s sternum with the cotton wool
wisp to confirm they can feel it
• Ask the patient to say “yes” when they are touched
• Using a wisp of cotton wool, gently touch the skin
(don’t stroke).
• Assess each of the dermatomes
• Compare left to right, by asking the patient if it
feels the same on both sides.
2. Temperature and Pain – Lateral Spinothalamic tract

• Patient’s eyes should be closed for this assessment

too.
• Repeat the previous assessment steps, but this time
using the sharp end of a neurotip or a pin.
• Make sure it is not too sharp to cause pain or too
blunt not to elicit pain.
• Also assess for temperature using your fingers –
warm and tuning fork - cold following the same
procedure.
3. Vibration Sense Test - Dorsal/posterior columns.
• Ask the patient to close their eyes
• Tap the tuning fork
• Place onto the patient’s sternum and confirm they can
feel it buzzing
• Place onto the distal interphalangeal joint of the
forefinger and ask them if they can feel it buzzing
• If vibration sensation is impaired, continue to assess
the bony prominence of more proximal joints
(interphalangeal joint of thumb → carpometacarpal
joint of thumb → elbow → shoulder)
• Same for the legs
• Ask patient to tell you when they can feel it on their foot
and to tell you when it stops buzzing
• Place onto the distal phalanx of the great toe If sensation is
impaired, continue to assess more proximally – e.g.
proximal phalanx
4. Proprioception - Dorsal/posterior columns

• Hold the distal phalanx of the 4th digit (ring finger) by

its sides
• Demonstrate movement of the ring finger “upwards”
and “downwards” to the patient (whilst they watch)
• Then ask the patient to close their eyes and state if you
are moving the ring finger up or down
• If the patient is unable to correctly identify direction of
movement, move to a more proximal joint (finger >
wrist > elbow > shoulder) Please use the 4th Digits.
• Same for the Legs
• Hold the distal phalanx of the 4th toe by its sides
• Demonstrate movement of the 4th toe “upwards” and
“downwards” to the patient (whilst they watch)
• Then ask patient to close their eyes and tell you if you are
moving the 4th toe up or down
• If the patient is unable to correctly identify direction of
movement, move to a more
proximal joint (toe > ankle > knee > hip).
5. Two- Point Discrimination test.
• Ask the patient to close his eyes
• Test the patient’s two point discrimination by touching the patient’s hand (finger pads) alternately with
1 point stimulus/2 point stimulus (you can use a small stick and break it into 2). Distance should be
more than 5 mm
• Touch two different areas at the same time and then let the patient identify where

6. Romberg’s Test – tests Dorsal columns

7. Graphesthesia
• Ask the patient to close his/her eyes
• Write any number from 0-9 on the palm of the patient’s hand and let the patient identify.

8. Point Localization
→Ask the patient to close his eyes
→Touch patient’s skin
→Ask the patient to open eyes and point where he was touched
→Test symmetrically
9. Extinction
→Ask the patient to close his eyes
→Simultaneously stimulate both sides of the body (touch the patient on both sides of the body:
arm
→Ask how many points felt and where (let the patient identify whether it’s left, right or both
REPORTING:
• Intact bilaterally for pain (spinothalamic tract), position & vibration
(posterior columns), along with light touch.
• Cortical discrimination intact with: localization, 2-point
discrimination, graphesthesia.
• Romberg’s test is negative with no pronator drift.
Different methods for evaluating the Patellar reflex
 Cremasteric reflex for males.
• The testis on the side of
stimulation ascends
REPORTING:
• Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4
bilaterally.
• No clonus was noted.
1. Finger to Nose test - Dysmetria

Abnormal- over shoot

2. Rebound phenomenon
• Whilst the patient’s arms are still outstretched, and
their eyes are closed:
• Ask the patient to keep their arms in that
position as you press down on their arm.
• Release your hand.
• When resistance is suddenly removed, a
healthy patient’s limb normally moves a
short distance in the desired direction and
then rebounds (jerks back in the opposite
direction)
3. Rapid alternating movement – Dysdiadochokinesia, Finger tap test

4. Knee reflex test

→Abnormal if pendular
5. Co-ordination test - heel to shin test
6. Gait observation

• Observe normal gait

• Heel and Toe walk
• Tandem gait
• Romberg’s test
REPORTING:
• Cerebellar—rapidly alternating movements (RAM), finger-to-nose
(F→N), and heel-along-shin (H→S) intact.
• Romberg—maintains balance with eyes closed. No pronator drift.
Gait with normal base.
• Coordination is good as measured by tandem walk, heel walk, and toe
walk.
• No asterixis.
1. Tripod Phenomenon
• When asked to sit up, the patient will form a tripod pose.

2. Nuchal Rigidity:
• Procedure: While the patient is in supine position, the neck is first flexed side to side to rule out neck paratonia which may be
due to conditions other than meningeal irritation.
• Positive sign: The extensors tense up and the trunk is maintained in a straight position as you lift the back
of the head from the bed even with just one finger.
3. Brudzinski’s Sign:
• Procedure: Passive neck flexion or turning it to one side.
• Positive sign: Passive flexion of the knees and hips.

4. Kernig’s Sign
• Procedure: one hip is flexed at 90 degrees and the other leg
remaining in the neutral position on the bed. The examiner
tries to extend the flexed knee.
• Positive sign: resistance or pain in the lower or back or
posterior thigh. The leg cannot be fully extended at the
knees.
***It must be bilateral, otherwise it might be due to a lumbar
radiculopathy.

5. Head-jolt test:
• Procedure: Ask the patient to turn his or her head
horizontally at a frequency of two to three rotations per
second.
• Positive sign: worsening of a baseline headache
REPORTING:
• The patient has no signs of meningeal irritation with all the tests
bearing a negative result
1. Dix-Hallpike Manoeuvre
• Rotate patient’s head 45 degrees to the right
• With the head supported and eyes open, the patient lies down rapidly and placed into a head
hanging position (Right ear down position, Chin pointed upward)
• Note occurrence of vertigo; repeat on the contralateral side.
• Observe direction, latency and duration of nystagmus
2. Head-Thrust Test
• Patient is instructed to focus on examiner’s nose.
• Head is quickly moved 5-10 degrees to one side.
• Abnormal response if there is a corrective saccade.
3. Epley’s Manoeuvre – Posterior Canal

• Begins with the px sitting with the head rotated 45

degrees to the right.
• The examiner lays the patient into a supine position
with the head hanging over the end of the table.
• The head is then rotated 90 degrees to the left.
• The head and body are rotated together an
additional 90 degrees until the patient is 135
degrees from the initial supine position.
• The px is brought to a sitting position while the
head remains tilted.
• Finally, the head is brought forward and downward
to an angle of 20 degrees.
3. Lempert Manoeuvre – Lateral Canal

• The patient should lie supine on the

exam table, affected ear down
• Quickly turn the head 90° towards the
unaffected side, facing up
• Wait 15-20 seconds between each head
turn
• Turn the head 90° so affected ear is up
• Have patient tuck arms to chest, roll
patient to a prone position with face
down
• Have patient turn on side as you roll
their head 90° (returning to original
position, affected ear down)
4. Brandt Daroff exercise

• Start sitting upright on the edge of the bed.

• Turn your head 45 degrees to the left, or as
far as is comfortable.
• Lie down on your right side.
• Remain in this position for 30 seconds or
until any dizziness has subsided.
• Sit up and turn head back to centre.
• Turn your head 45 degrees to the right, or
as far as is comfortable.
• Lie down on your left side.
REPORTING:
• There is no nystagmus seen in the patient
• The patient does not complain of syncope, disequilibrium and vertigo
1. Level of Alertness, attention and cooperation

1. Level of Alertness
• Alert and oriented
• Disoriented/drowsy
• Somnolent
• Stuporous
• Comatose

2. Attention: To test, Let the patient do either of the following:

• spell “WORLD” backward,
• recite months: January to December (forward and backward)
• digit span: Let the patient memorize a series of numbers (forward and backward) serial seven
(100, 93, 86, 79, 72…)
2. Level of Orientation
• Ask full name, location, date and note exact
response
• Alert and oriented to person, place and time

3. Memory
1. Immediate memory
• word lists (manga, mesa, pera)/number lists and let the patient repeat
2. Recent memory
• Memory for 3 items after a 3-minute distraction task. How to distract: perform serial seven, recite months
backwards
3. Working Memory
• normal digit span for adults is 7 digits
• Forward digit span (742, 25814679)
4. Remote memory/Long term memory
• These are important events that took place decades earlier. Engraved in cerebrum.
• Short term memory is stored in limbic system only. Remote memory already engraved to frontal lobe
• Last to go when the patient has dementia
4. Language
A. Test for Aphasia
1. Fluency
• phrase length and rate, abundance of spontaneous speech, word finding difficulty, paraphasia
substitute unnecessary syllables like apple to papple, seen in Wernicke’s aphasia),
neologisms(non sensical words or completely novel wordlike people to spodle. Seen in
Wernicke’s aphasia, not Broca’s), errors in grammar
• Neuroanatomical correlate: dominant frontal (Left), temporal or parietal, subcortical white
matter, thalamus, caudate
2. Comprehension: ask simple questions & commands (raise your arms; put your left hand to
your right ear)
3. Naming: name simple things (watch, ballpen)
4. Repetition: patient is told to repeat: “No ifs, ands, or buts,” or “ Walang pa peropero pa.”
5. Reading: how they pronounce and how well they comprehend
6. Writing: ask the patient to copy something you write or from a book/paper.
B. Test for Apraxia
• Inability to follow a motor command that is not due to a primary motor deficit or a language
impairment
• Caused by a deficit in higher-order planning or conceptualization of the motor task
1. Ideomotor Apraxia: ask patient to show you how to “brush his teeth” or “blow a match”
2. Ideational/ Conceptual Apraxia: Give objects and ask how to write, put on lipstick or comb hair
3. Bucco facial/Orofacial Apraxia: Ask patient to lick, pucker lips or whistle
4. Oculomotor Apraxia: difficulty moving the eye, especially with saccade movements that direct the
gaze to targets
5. Constructional Apraxia: Ask patient to copy a drawing or a complex figure
6. Gait Apraxia:
• Ask patient to stand up and walk (positive result: patient stands up but cannot walk)
• Test for strength: ask patient to lie down and ask them if they can kick, there is no problem involving
weakness but there is a problem in motor planning
7. Speech Apraxia: Difficulty planning and coordinating the movements necessary for speech
• Eg. Instead of saying Potato patient says Totapo.
5. Sequencing tasks
• Patients with frontal lobe dysfunction may have particular
difficulty in changing from one action to the next when asked to
perform a repeated sequence of actions.
1. Perseveration: Alternating triangles and squares: problem in frontal
lobe indicates that you have perseveration, instead of alternating
triangle and squares, there is perseveration of either triangles or squares
2. Luria sequencing task: test of frontal lobe; perform the “fist-slice-
palm” ; demented persons are not able to perform this.
3. Inhibition Response: Go No Go test: test for the ability to suppress
inappropriate behaviours
• If examiner taps table once, patient taps twice if examiner taps the
table twice patient does not tap
• Test for inhibitory control, frontal lobe controls the inhibitory
mechanism
• Adolescents have poor impulse control because frontal lobe is not
fully myelinated.
• If you have a problem in your frontal lobe then you won’t be able to
do this.
MMSE → Mini-Mental State Exam
• Measures cognitive impairment such as in a
person with suspected dementia
Interpretation:
• 23 and above – normal
• 22 and below – dementia
MoCA → Montreal Cognitive Assessment test

• Similar to the MMSE, but the MoCA tests a variety

of different cognitive functions and the MMSE
focuses mostly on memory and recall
Interpretation:
• 23 and above – normal
• 22 and below – dementia