Makindo Medical Notes.com

Introduction (Use the acronym WIPER to prepare for the examination)

• W - Wash your hands
• I - Introduce yourself and confirm patient details
• P - Permission - gain consent to proceed with the examination, including explaining relevant details
• E - Expose the patient appropriately, gather Equipment
• R - Position the patient lying back at 45 degrees comfortably

• Inspection
  • Posture (truncal instability, titubation of the head)
  • Walking aids
  • Catheters
• Eye examination
  • Assesses eye movements for nystagmus
    • Asks patient to keep their head still while they follow student's finger from side to side and then up and down. A few beats of nystagmus can occur at the extremes of gaze - this is normal
  • Assesses articulation (dysarthria)
    • 'Baby hippopotamus'/'British Constitution'
  • Tests for cerebellar drift in the arms:
    • Asks patient to hold their arms out in front of them with the palms facing up - 'like holding a plate'. (The ipsilateral arm will drift upwards and hyperpronate - Riddoch's sign - due to hypotonia)
    • Tests for cerebellar rebound:
    • Patient holds arms out in front of them but now with palms facing down. Student briskly pushes down on each hand. (Positive rebound will result in the arm bouncing up higher than its neutral position)
  • Finger-nose test
    • Ask patient to touch heir nose and then your moving finger
    • Lok for intention tremor and past-pointing - dysmetria
  • Assesses for dysdiadochokinesis
    • Asks patient to clap quickly while turning top hand back and forth
    • Test is positive if patient is unable to smoothly perform rapidly alternating movements
  • Assesses precision movements of the fingers (patient touches each finger to their thumb and 'plays the piano')
  • Heel-shin test (coordination - can be done while in seated position)
    • Asks patient to place one heel on the opposite knee, then run it down the front of the shin, lift it off and then place it back on the knee.
    • Asks them to do this three times quickly and then repeat on the other side.
    • Movement will not be smooth in cerebellar disease)
  • Assesses tone in the limbs (for hypotonia)
  • Assesses reflexes in limbs (for hyporeflexia):
    • Knee reflex. (Pendular reflex in cerebellar disease - the lower leg swings back and forth like a pendulum)
  • Assesses gait
    • With a walking aid if required
    • Asks patient to walk to end of the room, turn around and walk back
    • Asks the examiner to walk alongside patient ready to support them if required, or offers to do this themselves
    • Notes which direction patient deviates towards (falls towards side of lesion in cerebellar disease)
    • A wide stance (base) may signify ataxia (hence widening the feet for stability) Assesses heel-toe (tandem) gait:
    • Demonstrates heel-toe gait while explaining the test - 'walking on a tightrope'
    • By lowering the base, tandem gait will reveal inner ataxia that would otherwise be missed
  • Examinations: Romberg test
    • Asks patient to stand with feet together and arms by their sides, and then to close their eyes
    • Test will help to differentiate between sensory ataxia and cerebellar ataxia
    • Positive result occurs when patient is more unstable with the eyes closed - sensory ataxia due to dorsal column damage. (Patients are unable to use visual feedback to steady themselves)
    • Negative result signifies cerebellar disease (unstable with the eyes open) States intent to complete the examination with the following
  • Full examination of central and peripheral nervous systems
  • Examination of the fundus for signs of optic atrophy in cases of multiple sclerosis
  • Examination of speech