Clinical learning guide for neurological examination for the second year students Contents:

I. cranial nerve examination II. Sensory system examination 1. Superficial sensations a. Examination of pain sensation b. Examination of temperature sensation c. Examination of touch sensation - Crude touch - Fine touch: i. Tactile localization ii.Tactile discrimination iii. Stereognosis 2. Deep sensations a. Examination of joint movement and position b. Vibration sense III. Motor system examination a. Muscle tone b. muscle power c. Examination of deep reflexes (tendon jerks) IV: Examination of superficial reflexes a. Plantar reflex b. Abdominal reflex V. Coordination and Gait a. Rapid Alternating Movements b. Finger to nose test c. Heel Knee shin test d. Romberg test

Clinical learning guide

Examination of deep reflexes (tendon jerks) General principles - Tendon jerk is a brief contraction of skeletal muscle elicited by tapping the tendon of the corresponding skeletal muscle sharply and strongly using a hammer. - Can be done in both sitting and supine positions. - The limb should be placed in a position at which the muscle under test is mildly stretched. - Valid test results are best obtained when the patient is relaxed and not thinking about what you are doing. After a general explanation, mingle the specific instructions with questions or comments designed to get the patient to speak at some length about some other topic. - After obtaining the reflex on one side, always go immediately to the opposite side for the same reflex so that you can compare them. Note the extent or power of the reflex, both visually and by palpation of the muscle in question. Tendon Reflex Grading Scale Grade 0 1+ or + 2+ or ++ 3+ or +++ Absent Hypoactive "Normal" Hyperactive without clonus Description

4+ or ++++ Hyperactive with clonus Deep reflexes are exaggerated in case of UMNL and diminished or absent in case of LMNL in the affected segment. If it is difficult to elicit the deep reflexes, reinforcement should be done; Reinforcement of the reflex: In the upper extremity, have the patient make a fist with one hand while the opposite extremity is being tested or by clenching of the teeth. If the reflex being tested is the knee jerk or ankle jerk, asks the patient to perform the "Jendrassik maneuver. The patient's fingers of each hand are hooked together so each arm can forcefully pull against the other. Ask the patient to pull his fingers while you are tapping on the tendon.

Reinforcement increases the sensitivity of the gamma fibers which supply the muscle spindle, therefore, make them more sensitive Subject Requirements: Reflex hammer, examination couch. Deep (Tendon) reflexes that are included in the professional skills course are: Biceps jerk, Triceps jerk, brachioradialis jerk, ankle and Knee jerk.

Examination of ankle jerk (Center S1,2)

a. Preparing the patient: 1. Ask the patient to relax 2. Explain what you are going to do briefly. B. procedure (eliciting the reflex) 1.Position of the patient: B1. If the patient can sit Ask the patient to sit at the edge of the examining couch or bed with the legs hanging freely B2: if the patient in bed: Ask the patient to extend both lower limb with the leg to be tested is crossed over the other leg
2- Dorsiflex the foot slightly at the toes

3. Hold the hammer with your fingers and use your wrist, not your arm for the action. 4- Strike the Achilles tendon with hammer sharply and strongly. 5-Distract the attention of the patient by talking with him or asking him questions designed to get the patient to speak at some length about some other topic. 6- Observe and record the response either as - Plantar flexion of the foot - Seeing or feeling the contraction of the calf muscles by your hands. 7- If there is no response, asks the patient to do "Jendrassik maneuver. 8- Do steps from 1-7 in the other foot 9- Compare the response in both sides 10- If the reflex seems hyperactive, test for clonus. Ankle clonus 1. Support the knee in a partly flexed position. 2. With the patient relaxed, the foot is dorsiflexed forcibly and maintained. 3. Observe the response which is clonus of the calf muscle and rhythmic oscillations of the foot. Knee (patellar clonus) 1. This is elicited by forcible maintained pulling of the patella downwards, using the index finger and thumb. 2. Observe the response which is clonus of the quadriceps muscle and rhythmic oscillation of the patella.

Steps/task Examniation of Knee Jerk

(center L3,4)
A. Preparing the patient 1. Ask the patient to relax 2. Explain what you are going to do briefly. 3. ask the patient to expose the whole lower limb B. procedure (eliciting the reflex) 1.Position of the patient: B1. If the patient can sit Ask the patient to sit at the edge of the examining couch or bed with the legs hanging freely B2: if the patient in bed: flex the knee slightly by placing your forearm under both knees. Place one hand on the quadriceps so you can feel its contraction. 2- Identify the patellar tendon by palpation below the patella 3- Hold the hammer with your fingers and use your wrist, not your arm for the action. 4- Tap on the patellar tendon sharply and strongly using the hammer. 5- Distract the attention of the patient by talking with him or asking him questions designed to get the patient to speak at some length about some other topic. 6- Observe the response and rate the reflex (the response is extension of the leg and movement of the leg forward) Notice the contraction of quadriceps femoris muscle by your eyes or the contraction can be felt with your hands. 7- If there is no response, asks the patient to do "Jendrassik maneuver. 8- Do steps from 1-7 in the other side. 9- Compare the response in both sides 10- If the reflex seems hyperactive, test for clonus. Ankle clonus 1. Support the knee in a partly flexed position. 2. With the patient relaxed, the foot is dorsiflexed forcibly and maintained. 3. The response is clonus of the calf muscle and rhythmic oscillations of the foot. Knee (patellar clonus) 1. This is elicited by forcible maintained pulling of the patella downwards, using the index finger and thumb. 2. The response is clonus of the quadriceps muscle and rhythmic oscillation of the patella.

Examination of biceps jerk

Steps/task

Biceps jerk (centerC5,6)

A. Preparing the patient 1. Ask the patient to relax 2. Explain what you are going to do briefly. 3. ask the patient to expose the whole upper limb B. procedure (eliciting the reflex) 1. Ask the patient to sit with the forearm supported, either resting on

the patient's thighs or resting on the forearm of the examiner. The arm is midway between flexion and extension with the palm pronated. 2. Place your thumb finger firmly on the biceps tendon. 3. Hold the hammer with your fingers and use your wrist, not your arm for the action 4. Strike your finger which is placed on the tendon with the reflex hammer sharply and strongly. 5-Distract the attention of the patient by talking with him or asking him questions designed to get the patient to speak at some length about some other topic. 6- Observe and record the response either as - Flexion of the elbow - Seeing or feeling the contraction of the biceps muscle by your hands. 7. If there is no response, asks the patient to do reinforcement. 8 - Do steps from 1-7 in the other side 9- Compare the response in both sides 10- If the reflex seems hyperactive, test for clonus.

Examination of triceps jerk (center C6,7)

Steps/task A. Preparing the patient 1. Ask the patient to relax 2. Explain what you are going to do briefly. 3. ask the patient to expose the whole upper limb

B. procedure (eliciting the reflex) If the patient is sitting or lying down 1. Ask the patient to flex his arm at the elbow (90 degree) and hold it close to the chest with the palm directed toward the body. 2. Hold the hammer with your fingers and use your wrist, not your arm for the action 3. Identify the triceps tendon at its insertion on the olecranon above the elbow. 4. Strike the triceps tendon with the hammer sharply and strongly. 5. Distract the attention of the patient by talking with him or asking him questions designed to get the patient to speak at some length about some other topic. 6- Observe and record the response either as - Extension of the forearm. - Seeing or feeling the contraction of the triceps muscle by your hands. 7. If there is no response, asks the patient to do reinforcement. 8 - Do steps from 1-7 in the other side 9- Compare the response in both sides 10- If the reflex seems hyperactive, test for clonus.

Examination of brachioradialis reflex (center C6)

Steps/task A. Preparing the patient 1. Ask the patient to relax 2. Explain what you are going to do briefly. 3. ask the patient to expose the whole upper limb B. procedure (eliciting the reflex) 1. Ask the patient to sit with his forearm flexed at the elbow and halfway between pronation and supination.

2. Hold the hammer with your fingers and use your wrist, not your arm for the action 3. Identify the brachioradialis tendon at the wrist. It inserts at the base of the styloid process of the radius, usually about 1 cm lateral to the radial artery. If in doubt, ask the patient to hold the arm as if in a slingflexed at the elbow and halfway between pronation and supinationand then flex the forearm at the elbow against resistance from you. The brachioradialis and its tendon will then stand out. 4. Strike the brachioradialis tendon with the hammer sharply and strongly. 5. Distract the attention of the patient by talking with him or asking him questions designed to get the patient to speak at some length about some other topic. 6- Observe and record the response either as - Flexion and supination of the forearm. - Seeing or feeling the contraction of the brachioradialis muscle by your hands. 7. If there is no response, asks the patient to do reinforcement. 8 - Do steps from 1-7 in the other side 9- Compare the response in both sides 10- If the reflex seems hyperactive, test for clonus.