Welcome. My name
is Dr. Eratula. We will be going over to the bedside neurologic
examination today. This is our [inaudible] patient. My name is Eratula.
What's your name? Susan. Susan. Nice to
meet you, Susan. Nice to meet you. So the basic that bedside neurologic examination
starts off with the mental
status examination. Here we'll be going over a
basic mental set examination. If a full examination
is to be done, that should be done
under ideal conditions with a trained professional. In this case, we're
going to go over some basic functions in a systematic way in order to test out both global and looking for focal
deficits as well. Let's start off with
first level of alertness. As you can see, Susan here is nice alert, eyes are open. She's attentive to me and was able to quickly
give me her name. There'll be many cases when you may encounter someone
that's not fully alert, eyes are closed,
they may be sleepy, drowsy, or in a comatos state. In those cases, you want to
just describe what you see. Sometimes you will need a
soft voice to wake them up, a stronger voice
to wake them up, a tactile stimuli, even stronger tactile stimuli or even sometimes noxious
stimuli to wake someone up. In these cases, I implore you to not use actual
categorical terms. Just say what you saw. After the level of alertness
we'll be checking language. Language testing
involves several things, spontaneous speech,
comprehension, naming, and repetition. A formal language
examination will also include reading
and writing. If the rest of these
steps are done, though, reading and writing are rarely needed in a full examination. Let's start off a
spontaneous speech. Hi, Susan, how are
you doing today? I'm doing fine. Can you tell me anything
about the weather today? It's a little bit cloudy, but it's fairly warm. The first part of language testing is
looking for fluency. Are they fluent? Meaning, is the rate the length
of the sentence? Is it smooth? Is
it speech effort? All these things
go into fluency. After you've figured
that someone's fluent in their native tongue or native language, we will
check comprehension. Susan I'm going to ask you
a couple of questions. Can you touch your left ear
lobe with your right thumb? Can you touch your nose, then point to the door? Then I also ask simple one, two or three step commands, and then I will ask simple, yes or no questions. Susan, do you put your shoes on before your socks? Yes or no? No. Good. The reason for yes or no questions or
just follow simple commands is if someone's
severely [inaudible] that you can't
understand what they're saying or mechanically
ventilated, you can still test comprehension
and language testing. Next is repetition. Susan, I'm going to have you
repeat some phrases, okay? Okay. They heard him speak
on the radio last night. They heard him speak
on the radio last night. Today was a good day. Today was a good day. Repetition can be
paradoxically preserved or there can be a dysfunction
and repetition on its own. That's why it's important
to test repetition. Next, we'll check naming. For naming, if you have the ability of using
an NI stroke sale card. I recommend doing this. This NI stroke sale card has a variety of objects. We'll
just have Susan name here. Glove. Cactus, chair, key, hammock, feather. If you don't have an NI
stroke skill naming card, you can use everyday objects. Here's an example.
What do we call these? Knuckles. Fingers. This finger? Index finger. Pinky finger. Thumb. Collar. What you want to use is
both high frequency objects or objects that are everyday named and low frequency objects
like knuckles, for instance. After you've set up both
alertness and language, now you can go ahead and a test for higher order
cognitive functions. Orientation questions
are frequently tested. These are a basic screening
type questions that are meant to look for really big
global dysfunction. There are no set questions. You can ask whatever you want. I tend to use both easy and hard orientation
questions in this case. Susan, what's today's date? Today is August 6, 2019. Which floor are we on? Third floor. What season are we in? Summer. Good. After orientation,
we check attention. Attention can be checked in
a number of different ways. In this case, I will demonstrate one way of checking attention. Attention is important
because if someone's not attentive to
the task at hand, you can't accurately describe the deficit if they're not going to be
doing it correctly. Attention is always tested in a mental status examination. Susan, can you spell
the word world. W-O-R-L-D. Now, spell the
word world backwards. D-L-R-O-W. That's just one way
of checking attention. Again, attention is
very important as this sets up the rest
of your examination. Next, we'll be checking
spatial attention. The human brain has
unique characteristics of having special attention to your left and right side of your visual field,
of the actuary world. This can be tested in a
number of different ways. What we're going to
be using here is both sensory tactile, and sensory visual attention. Using something called a double simultaneous sensory
examination. In this case, you want to
make sure that there's no deficits in vision or sensory before accurately interpreting
this examination. We will demonstrate
here both. Susan, can I have you close your eyes? Now I'm going to touch the left, right or both sides
of your face. Just tell me which side
I'm touching. Here we go. Left. Right. Both. Great. Open your eyes. That was tactile sensory
attention testing. The next one will
go over vision. Susan, can you just look
straight ahead at me? Now, using your
peripheral vision, I want you just to point to
the finger that's moving. It will be left right or
both, but just point to that. Okay. Excellent. That's
one way or two ways of actually checking attention. There are many others.
Next is memory. Memory can also be tested a
number of different ways. On a bedside examination, the best way of
testing memory is just checking verbal memory. In this case, we will give
a 3-4 item recall test. We will be checking
both immediate recall. And later recall, which is immediate memory
and working memory. We won't be checking
long term memory. Susan, I'm going to give you
three things to remember. Purple Street, 42,
excited pentagon. Can you repeat those for me? Purple Street, 42, excited pentagon. Good. You want to make sure they repeat it so they
start registering it. I usually wait about
10 or 15 seconds afterwards to have
them repeat it again. Purple Street, 42
excited pentagon. Good. This is to ensure that I made it into
the immediate memory. At this moment, you wait
about 3-5 minutes before asking your patient
to repeat the words. It's during this
time, you can go on with the rest of examination. Usually, the cranial nerve examination
can be done next, and then you come back and
ask about those words. This again is checking
both immediate memory, working memory, and then
also short term memory. We will not be asking
long term memory, but in those cases, you can ask historical facts like
past presidents. Both usually I go back
about three presidencies, or depending on the patients
where they're from, any other historical facts
that are of long term. We'll pretend that
this is the three or five minutes have come by. What were those three things? Purple Street, 42
excited pentagon. Great. That's the
mental side examination. The next part is the
cranial nerve examination. We will go cranials 1-12 and we'll be describing on each of
these in succession. For cranial number
1, smell on testing, we don't usually do
this at the bedside. But if you were, you'd be using something like either
coffee or gum, something that's not noxious, and you'll be testing each
nostril independently. Asking for simply, have
you noticed a change in your sense of smell is not accurately described and a
lot of times actually misses an important cranial
number 1 dysfunction. For cranial number 2, I'll check the optic nerve systems. This checks a couple of things. Both we're going to
check visual acuity, visual fields, and
pupilary reflexes. Start off. Susan, do you wear eyelasses
or corrective eye wear? I do. You do. Great. There we go. Thank you. For visual acuity, you want to make sure
that your patient is wearing corrective lessens
if needed and if available. This case, we're
going to use selling charts or near charts. It's important to look
at your near chart to see which one what's
the direction. Here, this one says
use at six feet. This one says use at 14 inches. Please read the directions of
which near chart you have. Susan, can you hold
that about 14 inches away and then read the lowest line in
terms of numbers to me? 9, 3, 7,8, 2, 6. You'll be doing
this both with left and right eyes each
closed to check both sides. Next, we'll be looking
at visual fields. There's a number of way of
checking visual fields. I will be teaching
one manner, which, if done correctly will catch
most major abnormalities. If it's a confrontation test does not come close to
an actual perimeter, formal visual field testing. That should be done in an ophthalmologist or
optometrist office. But in a bedside test is the best way of
picking up deficits. Can you cover up, you now probably take your
eye wear off. I'll take that. Thank you. Cover one of your eyes. Now look straight here
right on my nose. Now, you use your
peripheral vision, and I'm going to come in with a finger from behind your head, and you just tell
me when you see it. You'll be checking
for quadrants. Look right here. Tell me when you start seeing
my finger come into. There. There. There. Good. You'll be checking both sides and comparing
from side to side. Next, is the pupilar exam. For the pupilar exam,
you want to make sure you've noticed what type of
lighting you already have. You'll be looking at the pupils, the size, the shapes
of the pupils. You will notice and
sometimes younger people, the pupils are larger,
and older folks, the pupils may be
already miotic. You want to make sure you have a light
source that's adequate. Meaning poor light
but sometimes may not be enough stimulate
to make the pupils react. Susan, stare off
into the distance. The reason you want someone to stare off in the distance
that you don't get the accommodation reflex.
Is a bright light. And shine at each
pupil independently, looking at the speed and
the degree of reaction. You'll be looking at
the direct response and the consensual response,
meaning the other pupil. If appropriate, you'll be doing a swinging flashlight test. I also use a light source at an oblique angle as this is
better tolerated directly. Next, we'll be checking
under three, four and six. We test this and the
bedside is using our standard H pattern. This is to look at both specific extracular muscles and testing each
of these nerves. Now all of these nerves
actually work together, three, four and six and work together
even at the brain stem. This is a complex
examination that sometimes needs
careful examination. In this case, you'll
be looking not only at the velocity of the eyes but
the degree of movements, and how well they
actually work together? The first thoughts off by looking at the eyes
and primary gaze. Susan, just stare
straight ahead. Now, what I want you to do
is follow my finger here with your eyes to one side, looking at the degree, up, down, across and H pattern. Next to Cranial Nerve 5. For five, we look
at sensory testing. We won't be checking motor five, as it rarely adds
to the diagnosis. In this case, you
do not have to have the patient have the
eyes open or closed, you're just simply looking
for any sensory disturbance. We'll be using a couple
of things, light touch. I'm going to both
sides of your face, tell me if it feels
about the same. V1. Yes. V2. Yes. V3. Yes. Distribution.
You want to avoid the angle of the jaw. That's C2. That's not on Cranial Nerve 5. You'll be doing this with
a number of modalities. That was light touch. You can also do
temperature sensation. Touch both sides of your
face with this cool 24. Just let me know
if it feels cool if it feels about the
same on both sides. Okay. Does that feel cool? Yes. And here? Yes. All the same on both sides? Yes. Here. Yes. Here. And here? Yes. Okay. And pinprick. In this case, we'll be
using a sharp object here. You want to make sure
it feels sharp to them, not just pressure but
actual sharpness. Does this feel sharp? Yes. Does this feel about
the same here and here? Yes. Okay. You'll be doing that in the V1, and 3 distribution. Next is Cranial Nerve 7. For that, we'll be looking at facial musculature
and excursion. You want to look at your
patient's face at rest, looking at if there's any asymmetries in terms
of the palpable fissure, the nose or nasolabial folds. You'll be looking at
patterns and wrinkle. You'll note that in older folks, there may be an asymmetry in wrinkles, that may be normal. Now you'll be checking both
upper face and lower face. Susan, can you give
me a good big smile? Good. And again one more time. At the nasolabial
folds here and here, and the amount of teeth
you see on each side. Now, Susan, can you
lift up your eyebrows? Here you'll be looking at
the wrinkle that happens and how fast she moves up the
eyebrows and to the degree. Now can you close
your eyes tight tight and don't let me open
them. Don't let me open them. Good. When someone close
their eyes pretty tight, you should not be able to open them easily with your fingers. Next, it's Cranial Nerve 8. For that, we'll be just
checking Collar examination. Susan, can you cover up one of your ears with your finger? I'm going to come
in from the side, just rubbing my fingers. Just tell me when
you can hear it. Okay. There. Good. Now the other side. There. Good. You want to know at which point they actually were able to hear their finger rubs. This is a bedside examination. Again, formal
audiogram examination is much better at picking
up subtle deficits. In this case, there should
be a screening examination. If you do have someone you
believe is a hearing deficit, you can do the web and in test. In this case, I will recommend just doing
the Rinne test as this will discriminate between conductive and sensory
neural hearing loss. Here's one quick
way of doing it. Lightly strike your
tuning fork and then place it on the mastoid
process back here. Now, let me know, is this louder than this? Is A or B louder? B. B. And that's a
normal examination. Next is Cranial Nerve 9 and 10. This includes the gag reflex. The gag is not routinely
tested at the bedside, so we will not test
that here today. If one is to test gag, remember that you had to
check gag bilaterally. For 10, that is the
soft palate elevation. In this case, you will
have your patient open up the mouth wide. They'll say, uh, and you're
going to be looking at soft palate as it raises, making sure that both
sides raise equally. So, can you open up your mouth? And then give a big uh. Uh. Okay. Good. Here, I was looking at the soft
palate and the uvula, make sure that the uvula
raised symmetrically. If the uvula deviates to
one side or the other, that suggests that one of the palates is
not raising fully. Next is Cranial Nerve 11. For that, I'll be checking trapezius muscles and
sternocleidomastoid muscles, either or can be tested. The trapezius muscle
is recommended for testing as this one does not receive dual innervation like
the sternocleidomastoid, much like the upper half of the face on facial
nerve testing. Susan, can you raise
your shoulders up. There you go. Now here you're looking at the
degree and how fast. Relax them again, raise
them up one more time. Now keeping them
nice and strong. Good. You should not
be able to move. For sternocleidomastod,
you'll ask the patient to move the head from one side and the
other against force. I want to put my hand here. I want you to push against
it, nice and strong. In this case, is
you're looking at the sternocleidomastoid
and the strength. Now look at the other side.
Now push against my hand, go and you see the belly here of the sternocleidomastoid
and checking the strength. For Cranial Nerve 12, this is purely a
motor of the tongue. In this case, what we'll
be doing is looking at the tongue both at rest
and with movement. Susan, can you just open up your mouth and rest
your tongue in place? Here, you're looking
at the tongue, make sure there's no
furrowing or wrinkle to suggest atrophy on
one side of the other. You're also looking
for facications here. Now, Susan, can you stick your
tongue out straight ahead? Move side to side.
Nice and fast. Excellent. If you
suspect weakness, you can also check
muscle strength. Susan, can you push your tongue on the inside of your cheek on your left side? There you go. Nice and strong. How about the other
side? That's equal. That will be the cranial nerves. Next we will be looking at the
neuromuscular examination. This is again a bed size
screen examination. The neuromuscular
examination can take quite a bit of time. In this case, we'll be going
over a screen examination. If there's any type of deficit that's detected or suspected, please do a more
focus examination around the areas of
suspected deficits. The neuromuscular examination
starts off with inspection. What you want to look
at is muscle bulk. Make sure that
they're symmetric, noting for any atrophy
or fasciculations. This all looks very symmetric. There's no fasciculations. Next, we'll be looking at tone. For tone, you want to make sure that the patient does
not help you out. Make sure this is nice.
Don't help me out at all. I'm going to be moving your arm. What you want to do
is move it slowly, with the full extension
in flexion at the elbow. Then quickly. That's all. This is checking for both
rigidity and spasticity. You will be doing
this in both arms. Next is strength testing. Again, we'll be going over a
basic strength examination. You'll be having more
strength testing lectures on the neuromuscular
portion of this block. We'll be checking a couple
of major muscles here. We'll start off with
deltoids. Susan, can you rip your arms up. You want to make sure
when you're checking any major muscle groups is to go two thirds of the
way from the fulcrum. In this case from the deltoid, about two thirds of the way out. You want to make sure that
you use enough force. You're looking for force
generation, not endurance. What you're looking for
is immediate force, and that's about it. This will help with
discriminating against, especially people who have pain and or just poor endurance. So Susan, on the count of three, I want you to pull up and
I'm going to push down. One, two, three, okay. Another side, 1,2,3,
good. So strong. Again, as you noticed, it's just impact force or that just that force
for that first second. You don't need
endurance testing. We'll go through the
next couple of muscles. Now for biceps, em, have your arms like
this, nice and strong, about two thirds of the way out. You want to make
sure you isolate each individual muscle
group and support it. On a of three, you pull in
I'm going to push out 1,2,3. Good. And 1,2,3. Good. That be biceps. Triceps, I want you
to push out, 1,2,3. You can relax this
side will be doing one side. Let me go. Wrist extension and inflection, make a nice fist, bring it up. One, two, three.
Good. And flex it in. One, two, three. Good.
Finger extension reflection. For finger extension, you
want to make sure that the wrist is a neutral position. Bring your fingers
up nice and high. At the proximal joint, you want to push down strongly. Bring them up nice and
strong, one, two, three. Good. Now for finger flexion, to check the distal joints. Pull in, nice and strong. Abductor pollicis
brevis. For this, I want you to put your thumb up. Nice and strong,
don't push down. Good. At the same time you're
looking at muscle bulk, and comparing both sides. You'll be moving
from side to side, comparing each of
these muscle groups. Next reflexes. For
reflex testing, you'll be checking just a couple of major stretch reflexes. In case, you want to
make sure that the arm and the reflex that
you're checking or the muscle you're checking
is a nice neutral position. If you have the
patient rest arms right on the laps,
it is easily done. You want to feel the tendon
first and then strike the tendon either over
your finger or directly. I tend to use over my finger. I feel the tendon, here's
the bicep tendent. Nice reflex, and you'll be
recording these reflexes. For break your als.
Sometimes it's important to see that muscle.
Can you pull up here? You see the break
your ALS right here, that tendons about
here. Now relax. Okay. Triceps, hold
your arm like this. Again, feel the tendent. You'll be doing this
from side to side comparing and looking
for any asymmetries. This is again, just to cooperate any other findings that
you may have found. You may not that even
normal patients, they may have either no reflexes
or varia brisk reflexes. These on their own do not
suggest any disease process, they must be taking into account with the rest of
the examination. One way of looking
or screening for subtle weakness in
the upper extremities is by checking pronator drift. This is how you test it. Susan, can you stick
your hands out nice like you're
holding up a pizza box. Now spread those fingers.
Keep them there. Here you're looking
for any finger curling or pronation or
flection at the elbow. To make this a little
bit more sensitive, we'll ask you to
close your eyes. Close your eyes. Again,
looking for the same thing. In order to make this test a
little bit more sensitive, you want to distract the patient not only
by closing her eyes, but asking to do something else. Susan, can you shake
your head now? Excellent. As you can see there is no
movement in the arms. Okay, relax. For neuromuscular
testing of the loche, again, you'll be
looking at muscle bulk. Noticing if there's any
asymmetries, Faciculations. Tone is hard to test in Loche so we will not
be testing tone here. For strength testing, again, you'll be looking at the
major muscle groups. Again, if there's a
specific area of concern, you may want to focus in on that area of
concern particular. Much like the upper extremities
and the lower extremitis, you want to go about two
thirds away from the fulcrum. In this case, for hip
flexion, we'll go first. You want to go about
two thirds of a way. Susan, can you
lift up your knee, nice high, There you go. Again, you're checking for
strength and not endurance. At the counter I'm
going to push down, you push up, you can hold go ahead and brace yourself
if you need to. Here you go. One, two,
three. Good. Next side. One, two, three.
Good. You'll be going from side to side in
all major muscle groups. We'll be checking
knee extension. Susan, can you kick out right
here? Hold it right here. Nice and strong,
and only push it in on the count of
three, one, two, three? Good. And pull in against my
hand here. Nice and strong. You want to also make sure that you isolate each of
the fulcrums here. Pull in one, two,
three, nice and strong. Good. Go from side to side. You'll be checking
both plantar extension or dorsal flexion
and plantar flexion. Susan, keep your foot
nice and high there. Don't let me push it
down. One, two, three. Good. Then push down like a
gas pedal, one, two, three. Please note that the gas trucks
are very strong muscles. If you're unable to
get any weakness here, you may want to have them stand up and get on their tippy toes. For the toe, bring up the toe, nice and strong, one, two, three, and you'll
check for foot evers. Now I want you to move
your foot that way. Keep it there, don't move it in. Good. Again, you'll be
going from side to side. For reflexes, you'll be checking a patella reflex and
an achille reflex. Again, you want
to make sure that the patient is nice and relaxed. You want to feel for the
tendon before striking it. These tendons can be strike directly without causing pain. Here we go, relax. You'll be going
from side to side, checking for asymmetry. For the achille reflex, you want to make sure
you do reflex to foot and palpate the
tendon and strike it. Again, you'll be going
from side to side. Next you will
demonstrate something called the Babinski sign, looking at the plantar reflex. I note that there's a number of different ways
this can be tested. This is just one way of testing
for the plantar reflex. In infancy, we have when you
strike the plantar surface, a toe that goes up
through myellination, actually toe starts coming down. In adults, the toe should be going down on
plantar simulation. If the toe goes up, that suggests or can
suggest that there's corticospinal loss of integrity of the cortical spinal tract. In this case, just relax. I'm just going to
strike the bottom of your foot and just rub
the bottom of it out. Okay? In this case, the toe doesn't move,
didn't move at all. Okay. And that also
can be normal. Well, you're looking here
again is if the toe goes up. If the toe goes up and then down it's sill recorded
as an upgoing toe. For sensory evaluation,
this can be one of the most frustrating and most
time consuming examinations in in the neuro exam. I suggest doing a screening
examination first, and then if there's a
deficit that's suspected, having more careful
evaluation in that space. You want to check at
several modalities, both light touch and
pimp or cold sensation. Checking for cold sensation or [inaudible] for
small fiber neuropathy, and then light
touch or vibration for large fiber neuropathy. Start with the light touch. You want to do it in both
proximal and distal segments. So touch your hands
here with this swab. Does that feel about
the same on both sides? Yes. Okay. How about
here and here? Yes. And how about here and here? Yes. Same both sides. Great. For cold
sensation, same thing. Distal and proximal. Feel nice and cool, does that feel cool? Yes. All right. Does this feel about cool on both sides
here in your hands? Yes. How about here
in your shoulders? Yes. Abit cool. Okay. Pinprick. Susan,
do you feel this? Yes. Does that feel sharp to you? Yes. Okay. Do you want to look
for it to make sure there's any asymmetries in both
distal and then proximal. All right Susan,
as I come up here, does that feel about
sharp as I'm coming up? Yes. All right. Does it
feel about the same here? Yes. On that side. All
right. And sharp from your hand to your shoulder? Yes. Okay. Next is
vibration testing. For vibration testing,
you want to put the tuning for vibrating tuning fork on a
bony prominence. In this case, we use this
[inaudible] joint right here. You'll hold your own
finger underneath the joint and you'll
feel both the vibration through her finger
onto your finger pad. A normal test here, you will be asking
the patient to tell you when the vibration
is no longer proceed. If you can still feel that vibration
through their finger, that's an amoral examination. If you lose sensation first,
that should be normal. Do you feel that
vibration there? I do. Tell me when it goes. No. Okay. I had started
feeling before she did, so that's a normal
examination for that. Next, If sensation is normal, you may want to check for
cortical sensory loss. These are higher
order integrations. Sensation is processed
at multiple sites. One important thing
to screen for is that higher order cortico sensory
integration is also normal. This can be done in a
number of different ways, both by checking for
something called a graphesthesia or cyagnosis.
I'll demonstrate one way. Susan, can I get your palm here? And I'm going to
scribble in a number. Without you looking, tell me which number I am scribbling. You can close your eyes or not. Five, six. Good. You want to
check this on both sides. For sensory evaluation of
the lower extremities, you'll be checking again
multiple modalities. Light touch, cold sensation
or pimpex sensation, and checking in a distal
to proximal manner. For light touch, you'll
be again looking at a distal and more proximal
comparing side to side. And I like to use a cold swab. Here we go. Let me know if you feel this and it feels about
the same on both sides. Okay. Here and here.
Feels the same? Yes. Here and here? Yes. Same and here and
here was the same? For cold sensation, I like
to use a cold tuning fork. I will ask Susan if
she feels coldness. Here, I also like to screen
for any type of perforopathy. Moving the cold tuning
fork up the leg and asking if there's any difference in that cold sensation. Feel cold? Yes. On both sides.
As I move it up, does it feel about the coolness? Yes. How about the
side? A coldness? Yes. Okay. Next. Pinprick.
Again, you can use an actual pinprick device
or a broken tongue blade, looking for sharp,
making it sharp. I will ask Susan if this
feels sharp. First off? Yes. Make sure that it's not just pressure that
you're feeling. Then comparing from
side to side both in the distal and proximal groups. Sharp both sides is about
the same here and here, here and here and here and here? Yes. If at any moment, you see
that there's an asymmetry, or there's a difference
between distal to proximal, you may want to do a
more careful examination by going up the leg much like we did with the
coal tuning fork. Does this feel about
the same as I'm going up interms of the sharpness? Yes. Yeah. About the same? Yes. All right, same case, you may want to
go up the back as well, looking for a level. The next step is
cerebellar testing. This can also be done a
number of different ways. Here we'll be looking at
finger nose finger testing, looking for ataxic movements, or dysmetria where the
underpoint or over point. Susan, using your index finger, can you touch your
nose and touch my finger. I want you
to go back and forth. You want to make sure
they go fast enough, and that they're almost
fully extending. Excellent. Can you do
with the other side? And I'm moving so that
there's no learning involved. Excellent. For
cerebellar testing, the lower extremities, again, this can be tested a
number of different ways. Here's one way. We'll do the [inaudible] test. Susan, with this heel here, I want you to start up here and rub it right straight
down your shin. I'll here to your angle
and then come back up again. Back up. Perfect. This case, what you're looking for
is again an ataxia, ensure you're moving this way or overshoot if it come down way too
fast or way too high. Okay. And you want to
do this on both sides. The next part of the neurologic
exam is gait testing. This is an important part of
examination because it tests multiple nervous system
functions at the same time. It also can lend
to diagnosis that cannot otherwise be done. When we look at gait testing, we look at actually the initial
stance of the patients, making sure that the bases, what we call normal
base or narrow based and not wide based. Widebased stans may signify
some disease process. Next, you'll be
looking at walking, making sure that the
normal stride length. It's about normal. You'll be
looking if they're steady. Looking for any abnormalities
in arm swing as well, ensuring that both
arms are swinging normally and there's no
posturing of the arms. At this moment, you can check for forced gait
like tandem gait, which can also help with checking sensory and
muscle weakness. For tandem gait, you want to
have the patient sand toe to toe and walk at several feet. You will know in your
elderly population that this may be difficult,
but that is normal.