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Clinical examination
This nerve is tested simultaneously with the vagus nerve
(cranial nerve X).
Cranial nerve X (vagus nerve)
This has sensory and motor functions; it provides sensation to
the larynx, and motor innervation to the cricothyroid and the
muscles of the pharynx and larynx. It carries parasympathetic
nerve fibres to the bronchi, heart and gastrointestinal tract.
The glossopharyngeal nerve (cranial nerve IX) and vagus nerve (cranial nerve X) are tested simultaneously by assessment of palatal movement (ask the patient to say ‘Aah’).
Lesions cause reduced palatal elevation on the affected side,
with the uvula pulled towards the normal side.
Check for a gag reflex; this tests the sensory function of
the glossopharyngeal nerve and motor innervation of the
vagus nerve.
Cranial nerve XI (accessory nerve)
This provides motor innervation to some muscles of the
soft palate and larynx and the trapezius and sternocleidomastoid muscles. Test the function of this nerve by asking
the patient to shrug the shoulders, and resist as you attempt
to press them down. Then ask the patient to turn his or her
head against your resisting hand, and test the sternocleidomastoid muscle bulk.
Causes of glossopharyngeal, vagus and accessory nerve
palsies are summarized in Table2.21.
Cranial nerve XII (hypoglossal nerve)
This provides the motor supply to the styloglossus, hyoglossus and all intrinsic muscles of the tongue. Test this nerve by
asking the patient to open the mouth. Look for wasting and
fasciculation. This indicates a lower motor neurone lesion
of the tongue. Then ask the patient to protrude the tongue.
If the tongue deviates to one side, this suggests a hypoglossal nerve lesion. If it is a lower motor neurone lesion, the
tongue will deviate towards the side of the lesion; with an
upper motor neurone lesion it will deviate away from the
side of the lesion.
Table2.21 Causes of glossopharyngeal, vagus and
accessory nerve palsies
Anatomical site Examples
Central (brainstem) Tumour, infarction, syringobulbia,
motor neurone disease
Peripheral Tumour or aneurysm near the
jugular foramen, trauma of skull
base, Guillain–Barré syndrome,
poliomyelitis
CLINICAL NOTES
Upper motor neurone lesions are due to stroke,
tumour or motor neurone disease.
Lower motor neurone lesions affecting the
hypoglossal nerve are due to diseases in the
posterior fossa, skull base and neck, including
tumour, motor neurone disease, syringobulbia,
trauma and poliomyelitis.
Upper limb
Visual survey
When you are performing a neurological examination,
good inspection is key. Look carefully for:
• muscle wasting: seen with lower motor neurone lesions,
muscle disease and disuse;
• fasciculation: a feature of a lower motor neurone
lesion;
• scars, particularly from surgery;
• deformity, which may cause mononeuropathy by
entrapment and contractures may be the result of
neurological disease;
• tremor (Table2.22).
Tone
Reduced tone is a feature of a lower motor neurone lesion
or cerebellar lesion. Increased tone, hypertonia, is a feature
of an upper motor neurone lesion. Hypertonia may manifest itself as either spasticity or rigidity. ‘Spasticity’ describes
the sudden build-up of increased tone during the first few
degrees of passive movement. The resistance lessens as the
movement is continued, and this is characteristic of upper motor neurone lesions. This is often described as the
‘clasp-knife’ phenomenon. ‘Rigidity’ describes the sustained
resistance to passive movement seen in extrapyramidal conditions (e.g. parkinsonism). This may be described as ‘lead
pipe’ rigidity, and when associated with a tremor gives rise
to ‘cogwheel’ rigidity.
Table2.22 Causes of tremor
Type Features Causes
Resting Seen when patient
relaxed with hands
at rest
Postural Seen when hands
held outstretched
Intention Seen when patients
try to touch
examiner’s finger
with their own finger
Parkinsonism
Benign essential
tremor
Anxiety
Thyrotoxicosis
β2-Agonists
Cerebellar disease
28
The nervous system
n
Eversion (S1)Inversion (L4)
Shoulder adduction and
Shoulder abduction and
22
Power
All muscle groups should be tested and scored (Table2.23).
You will need to learn the root value for each movement
(Fig.2.3). Remember to compare muscle power of one side
with muscle power of the other side for each group.
Look for pronator drift by asking the patient to hold the
arms outstretched, hold the palms upward and close the
eyes. Marked weakness will be easily apparent. If an upper
motor neurone lesion affecting the parietal lobe is present,
the arm will drift downwards and the hand will pronate.
Coordination
Ask the patient to alternately touch his or her nose and your
finger. In cerebellar disease, there will be an intention tremor
and past pointing (i.e. the patient overshoots the examining clinician's finger consistently towards the side of the lesion). Ask
lateral rotation (C5)
medial rotation
(C6, C7, C8)
Table2.23 Medical Research Council grading system
for muscle power
Grade Features
0 No muscle contraction and no
movement at all
1 Muscle contraction visible, but no joint
movement
2 Movement only when gravity excluded
3 Movement can overcome gravity but
not resistance from the examiner
4 Movement can overcome gravity and
move against some resistance from
the examiner
5 Normal power against resistance
Elbow flexion
(C5, C6)
Elbow extension
(C7, C8)
Pronation (C6)
Supination (C6)
Wrist extension (C6, C7)
Intrinsic muscles of hand
(T1)
Wrist
flexion (C6, C7)
Hip flexion
(L2, L3)
Hip extension
(L4, L5)
Finger extensio
Finger flexion
(C8)
Dorsiflexion
(L4, L5)
Plantar flexion
(S1, S2)
(C7)
Knee flexion
(L5, S1)
Knee extension
(L3, L4)
Fig.2.3 Nerve roots for each muscle group movement.
29
Clinical examination
Supinator (C5, 6)
Left triceps
Biceps (C5, 6)
C7 C7
Front Back
(light touch, pressure)
(pain, temperature)
)
Dorsal columns
(C7, 8)
Fig.2.4 Eliciting reflexes. Upper limb tendon reflexes.
Right triceps (C7, 8)
the patient to tap one palm with alternating sides of the other
hand as quickly as possible (demonstrate to the patient what
you would like the patient to do). In cerebellar disease, this will
be slow and poorly coordinated and the action of the moving
hand has a high amplitude – this is dysdiadochokinesis.
Reflexes
Practice as often as you can. Test the biceps, triceps and supinator reflex, and learn the root value for the reflex (Fig.2.4).
Reflexes can be reduced, normal or increased. They will be
reduced or absent in lower motor neurone lesions, sensory
neuropathy and severe muscle disease (disruption of reflex
arc), and will be exaggerated in upper motor neurone lesions.
Sensation
Test each dermatome (Fig. 2.5) for the sensation of light
touch, pinprick (and temperature). Then, starting distally,
check vibration and joint position sense. Remember the different pathways these senses take (Fig.2.6). The tests for the
various sensory modalities are shown in Table2.24.
(joint position, vibration, pressure)
Dorsal
spinocerebellar
tract
(reflex, proprioception
Lateral
spinothalamic
tract
tract
Fasciculus
gracilis
Fasciculus
cuneatus
Anterior
spinothalamic
Fig.2.6 Anatomy of sensory pathways within the spinal cord.
Lower limb
Fig.2.5 Dermatomes of the upper limbs.
C3
C4
C5
30
T2 T2
T1 T1
C8 C8
C3
C4
C5
C6 C6
Visual survey
Like the upper limbs, look for wasting, fasciculation and scars.
Specific to the lower limb, take time to look at the feet. Look
for ulceration (may suggest a lack of pain reception). Look at
the soles, for pes cavus, high arched sole a feature of hereditary motor and sensory neuropathy type 1 (formerly known
as Charcot–Marie–Tooth disease) and Friedreich ataxia.
Tone
This is best assessed with the patient relaxed on the bed, and
rolling patient’s leg from side to side. Then pick up the patient’s
knee to a flexed position and note how easy it is to flex the relaxed leg. Test for clonus, present with upper motor neurone
lesion. This is best elicited at the ankle through quick dorsiflexing of the foot of the patient. The patient’s foot will beat up and
down if clonus is present; more than five beats is significant.
The nervous system
Table2.24 Tests for different sensory modalities
Sensation Tested using Pathway Level of decussation
Pain Neurotip Lateral spinothalamic tract At level of sensory root within one spinal segment
22
Temperature Tuning fork for
Light touch Cotton wool Anterior spinothalamic tract At level of sensory root within several spinal
Vibration Tuning fork Posterior columns (fasciculus
Joint position
sense
Two-point
discrimination
cold
Move fixed
joints
Orange stick Posterior columns (fasciculus
Power
In the lower limbs, as for the upper limbs, test all muscle
groups and score them using the Medical Research Council
grading system for power (see Table2.23), and consider the
nerve roots (see Fig.2.3).
Lateral spinothalamic tract At level of sensory root within one spinal segment
segments
gracilis and fasciculus cuneatus)
Posterior columns (fasciculus
gracilis and fasciculus cuneatus)
gracilis and fasciculus cuneatus)
Medulla oblongata
Medulla oblongata
Medulla oblongata
Sensation
Test different modalities of sensation, as per the upper limb.
See Table 2.24. Look for patterns. Is there the glove and
stocking distribution sensation loss (a feature of diabetic
neuropathy), or is the sensation dermatomal (Fig.2.8).
Coordination
To check coordination in the lower limbs, ask the patient
to lift the leg, place the heel on the knee of the opposite leg
and gently run it down the shin and repeat this motion. In
cerebellar disease, this will be slow and clumsy.
COMMON PITFALLS
Make sure the patient does not just run the heel up
and down the shin. The movement should be down
the shin and then up in an arc back to the knee,
otherwise coordination is not being appropriately
assessed.
CLINICAL NOTES
A glove and stocking distribution does not follow
a dermatomal distribution but affects peripheral
nerves. When you are assessing the patient for
this, test sensation distally and work your way
proximally, noting a sensory level. Test the different
modalities of sensation, touch, pain, temperature
and proprioception in this way on both feet and
arms. Lower limbs are more commonly affected
than hands.
Reflexes
Test reflexes at the knee and ankle and check plantar responses. This is normally downgoing but will be upgoing
in upper motor neurone lesions, giving a Babinski response (see Fig.2.7).
HINTS AND TIPS
Reflexes can be hard to elicit, in particular the ankle
reflex. Ensure the patient is at ease and the muscle
is relaxed. Use of reinforcement techniques such as
asking the patient to clench the teeth or pull on clasped
hands when you are trying to elicit the reflex can help.
HINTS AND TIPS
When you are assessing proprioception (joint
position sense), it is best to start with the big toe.
Get the patient to close the eyes. Hold either side
of the interphalangeal joint and move the toe up
and down, telling the patient which is which to
orient the patient. Then move the toe and ask the
patient which way has it moved (up or down?) If the
patient lacks proprioception in the toe, move on
to the ankle. Loss of proprioception is commonly
seen in diabetes, and is a feature of dorsal column
disease.
31
Clinical examination
For upper limbs, ask the patient to clench his or her teeth as you tap the reflex
A
S1
L5
FrontBack
Biceps
supinator
Triceps
(C7, 8)
(C5, 6)
Knee
(L3, 4)
Ankle
(L5, S1)
B
‘Grip tightly as I
tap the ankle/knee’
C
Fig.2.7 Eliciting reflexes. (A) A simple way to remember root values of reflexes. (B) Testing ankle jerk with reinforcement.
(C) The normal response is a downgoing hallux. In an upper motor neurone lesion, the hallux dorsiflexes and other toes
fan out (the Babinski response).
L1
S3
L1
S5
L2
S4
L2
S2
to walk. In clinical practice pay careful attention to how
your patient walks into your clinic room. Observe the symmetry of the gait, the smoothness, how comfortably the
patient turns and how many steps this takes, the height of
the step and whether there is any evidence of pain. To test
gait, ask your patient to walk for 2–3 m, turn and walk back,
then walk heel to toe (cerebellar ataxia) and finally stand on
L3
toes and on heels (any muscle weakness will now manifest
itself).
S2
L5
L4
Whilst the patient is standing, perform a Romberg
test. Do this by asking the patient to stand with the
eyes closed. This assesses posterior column function
(proprioception).
L5
Fig.2.8 Dermatomes of the lower limbs.
S1
PATIENT SAFETY
Gait
An immense amount of information can be gained by careful study of a patient’s gait; for this reason you may wish to
start your neurological examination by getting the patient
Make sure you are ready to catch the patient
should the patient become unsteady with the
Romberg test, and when asking the patient to walk.
32
Skin and lymphadenopathy
22
HINTS AND TIPS
Sensory testing is difficult and subjective. A
thorough inspection and examination of tone,
power, coordination and reflexes may help to
predict which sensory abnormality should be
expected.
MUSCULOSKELETAL EXAMINATION
When you are examining a joint, use a systematic look, feel,
move approach. Look around the bed and at the patient
as a whole, not just the joint in question. Diseases affecting the musculoskeletal system are discussed in detail in
Chapter24.
Visual survey
Look at the patient. Does the patient look well or ill?
Look for any evidence of systemic connective tissue
disorders, such as features of systemic sclerosis (microstoma, telangiectasia, sclerodactyly) or systemic
lupus erythematosus (butterfly rash), or evidence of
long-term steroid use (cushingoid facies, buffalo hump,
thin skin and bruising); see Chapter33. Note the patient’s posture (e.g. any kyphoscoliosis suggestive of
ankylosing spondylitis or osteoporosis) and any rashes
(e.g. psoriatic rash).
Look
• Deformity.
• Scars: previous surgery.
• Erythema: acute inflammation or infection.
• Swelling: osteophytes, gouty tophi, synovial
hypertrophy and acute inflammation.
• Muscle wasting: disuse, nerve entrapment,
mononeuritis multiplex or long-term steroid therapy.
• Is pain associated with movement?
• Is the joint stable? Are there intact ligaments and
supporting musculature?
Assessment of disability
It is very important to get an impression of how limiting the
joint problem is. For example, in a patient with rheumatoid
arthritis, ask the patient to undo some buttons or write their
name with a pen.
HANDS
Examining the hands makes up an important part of the
general musculoskeletal examination and can be very informative when you are looking for evidence of underlying arthritic diseases. It is common for you to be asked to
examine the hands. This should be performed in the same
way as examination of a joint, using the look, feel, move and
assessment of disability approach.
First get the patient to put his or her hands on a white
sheet or pillow. Take time to inspect the hands, nails and
elbows. Note any erythema, rashes, swelling, bony deformity, muscle wasting, scars and rheumatoid nodules (seen
at the back of the elbow). Feel across each joint in turn,
examining them for warmth and swelling. If they are swollen ask yourself if it is a spongy/boggy swelling or if it is
hard and bony. Assess power of movement of fingers and
wrist, in particular abduction of the thumb in the palmar
position, testing the median nerve, and abduction of the
fingers against resistance, testing the ulnar nerve, and interphalangeal extension of the thumb against resistance,
testing the radial nerve. Go on to examine the functional
use of the hand (e.g. ask the patient to undo a button or
pick up a pen). This is particularly important in neurological abnormalities and destructive arthritides (e.g.
rheumatoid arthritis).
HINTS AND TIPS
Feel
• Increased temperature: acute inflammation or
infection.
• Tenderness.
• Effusions.
• Crepitus on movement.
Move
• Assess both active (patient moves his or her own
limb) and passive movement (you move the
patient’s limb).
If the neck is normal, examine the jugular venous
pressure, listen to the carotid artery for bruits and
reexamine the patient for a cervical rib.
SKIN AND LYMPHADENOPATHY
The clinical approach to rashes will be discussed in detail in Chapter25. When you are asked to look at a rash,
you will be awarded marks for giving a good description,
33
Clinical examination
even if you are unable to make a diagnosis. Remember to
describe:
• distribution: this can be diagnostic in itself
• shape
• size
• colour
• consistency
• temperature
• tenderness
• margins
• relation to the surface: raised, flat, or ulcerated
• fixation to underlying structures
When you are examining a patient for lymphadenopathy, it is
important to examine all lymph node sites (Fig.2.9). Always
examine the cervical lymph nodes standing behind the patient.
The causes of generalized and localized lymphadenopathy are
discussed in Chapter21. If lymphadenopathy is present, pay
special attention to examination of the spleen and liver.
BREAST EXAMINATION
Breast examination should be performed in women who have
symptoms of breast disease or when an underlying malignancy
is suspected. Occasionally it is also necessary in men. Follow
the systematic approach of inspection, palpation and movement. Pay close attention to the nipple. Is it inverted? Look for
overlying skin changes or dimpling. Palpate the breast moving
clockwise around the nipple, and feel for any masses. If any
masses are found, note the size, texture, regularity, tenderness
and whether they are fixed to the muscle (see Box2.8). Do
not forget that breast tissue extends into the axillae. Palpate
the breast for lymph nodes. Ask the patient to move his or her
hands behind the head; this can help assess whether the mass
is fixed to muscle. A breast examination must be approached
sensitively with a full explanation. Ask for a female chaperone;
this is important and helps put the patient at ease and protects
you against accusations of inappropriate behaviour.
NECK EXAMINATION
In clinical examinations, when you are asked to examine the
neck, there will usually be a thyroid mass or lymphadenopathy. However, do not forget the salivary glands, branchial
cyst, pharyngeal pouch, cervical rib, carotid body tumour and
cystic hygroma. Causes of lymphadenopathy are described in
Chapter21. Table2.25 lists the causes of thyroid enlargement.
First, look very carefully at the neck. Look for obvious
masses, scars, skin changes or deformity. If there is a mass
in the region of the thyroid gland, ask the patient to take a
sip of water into the mouth and then swallow—a goitre will
move upwards on swallowing. In addition, ask the patient to
open the mouth and then watch as the tongue protrudes—a
thyroglossal cyst will move upwards. Stand behind the patient to palpate the neck for a mass. If a mass is present,
assess its properties as described in Box2.8. Percussion is
useful to determine retrosternal extension of a goitre. Bruits
may be audible in the thyroid gland (thyrotoxicosis) or
carotid artery (atheroma). If you find a thyroid mass, you
should go on to assess thyroid status as shown in Table2.26.
Fig.2.9 Examination of lymph node sites.
34
Table2.25 Causes of thyroid gland enlargement
Form of
enlargement Causes
Diffuse
enlargement
(goitre)
Solitary
nodule
Idiopathic
Physiological: puberty, pregnancy
Autoimmune: Hashimoto and
Graves diseases
Iodine deficiency: endemic, e.g.
Derbyshire neck
Thyroiditis: de Quervain thyroiditis
(viral), Riedel thyroiditis (autoimmune)
Drugs: carbimazole, lithium,
sulphonylureas
Genetic: dyshormonogenesis
(Pendred syndrome)
Thyroglossal cyst
Prominent nodule in multinodular goitre
Adenoma
Cyst
Carcinoma (papillary, follicular,
anaplastic, medullary)
Lymphoma
Neck examination
22
Table2.26 Examination of thyroid status
Hyperthyroidism Hypothyroidism
Mood Irritability, anxiety Depression,
Weight Thinness Overweight
Hands Fine tremor,
Pulse Tachycardia, atrial
Face Lid lag, lid
Skin Pretibial
Neuromuscular Proximal
a
Feature that is specific to Graves disease.
palmar erythema,
sweaty palms,
acropachy
fibrillation
retraction,
exophthalmos,a
ophthalmoplegia,a
chemosis
myxoedema
(shins)
myopathy
a
a
a
slowness
Puffiness, anaemia,
Tinel sign (carpal
tunnel syndrome)
Bradycardia
Loss of outer third of
eyebrow, puffy eyes
and face causing
characteristic
appearance,
xanthelasmata
Dry, thin hair
Slow-relaxing ankle
jerks, cerebellar
signs
HINTS AND TIPS
When you are examining the hands, always look at
the elbows for a psoriatic rash, rheumatoid nodules
or gouty tophi. Most information can be gained from
inspection; do not rush this part of the examination.
Always ensure you do not cause the patient pain.
Ask them if their hands are painful before you start.
Chapter Summary
A good clinical examination relies on good communication. This is crucial to ensure your
patient knows what to expect, consents to the examination, feels as comfortable as
possible and understands what you are asking him or her to do. Take time to appropriately
position and expose your patient. A thorough inspection is key. This includes a visual sweep
of what is around the bed and of the patient, before focusing on the specific examination in
question. Adapt your examination to the clinical situation; it is not safe or appropriate to
perform a full thorough physical examination in a haemodynamically unstable patient when
a systematic A to E approach should be used.
35
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Writing in the medical notes
3
GENERAL PRINCIPLES
Writing in the medical notes includes any form of clinical
documentation that you undertake. It includes ‘clerking’ (a
written summary of the patient's history and examination),
recording the ward round, documenting discussions with
the patient, the patient’s friends and family or other healthcare professionals or any other communication relating to
patient care. Any documentation you make is a legal record,
and should be precise, complete and legible. You will see
many abbreviations in most medical notes you read, and
you will need to be familiar with the most common ones
(Table3.1). If you choose to use abbreviations, you should
consider if the meaning will be the same to other healthcare professionals, if they could be interpreted differently by
professionals in a different specialty or in a different hospital or if a nonmedically trained person were to read them.
Best practice is to avoid the use of abbreviations for these
reasons.
When you are documenting your clerking, the ‘history
of presenting complaint’ section is a useful place to document the most relevant positive and negative historical
points. Less relevant details can be recorded in their appropriate subsection. For example, in the case presented here,
the relevant negative historical points have been included in
the ‘history of presenting complaint’ rather than elsewhere
in the clerking.
At the end of the clerking, the salient points should be
emphasized in a summary statement. You should then compile a ‘problem list’. This is often forgotten by students and
junior doctors alike, but is invaluable in planning appropriate investigations and management. In some patients, it will
not be appropriate, or even possible, to take a full history
and perform a full clinical examination (e.g. in an emergency situation). We have outlined a clinical example.
As a student, it is good practice to be very thorough as it
helps you to learn the relevant questions and to avoid missing anything important. However, with practice, you will
learn to tailor carefully the clinical approach to each patient
based on individual, and often very different, needs.
Table3.1 Common abbreviations used in medical
documentation
Abbreviation Meaning
Titles
• OT
• PT
• RN
• SLT
Dosing
• OD
• OM
• ON
• BD
• TDS
• QDS
• PRN
Examination
• AE
• BS
• CN
• CP
• CR
• DIB
• HS
• MSK
• PEARLA
• SNT
• SOB
• WOB
Other
• CA
• CAMHS
• DNA
• FU
• GA
• RTA
• Occupational therapy/therapist
• Physiotherapy/physiotherapist
• Registered nurse
• Speech and language therapy/therapist
• Once daily
• Every morning
• Every night
• Twice daily
• Three times daily
• Four times daily
• Pro re nata (as required)
• Air entry
• Bowel sounds
• Cranial nerve
• Chest pain
• Capillary refill
• Difficulty in breathing
• Heart sounds
• Musculoskeletal
• Pupils equal and reactive to light and
accommodation
• Soft nontender
• Shortness of breath
• Work of breathing
• Cancer
• Child and Adolescent Mental Health
Services
• Did not attend
• Follow up
• General anaesthetic
• Road traffic accident
37