1. How old are you?
2. What time is it? (to the nearest hour)
3. What Year is it?
4. Where are we?
5. I want you to remember this address: 42 West Register Street. Ask to recall later on in test.
6. Do you know who I am? Do you know who that is [point to nurse / family member]?
7. Do you know who the Prime Minister / President is?
8. What is your date of birth?
9. Can you tell me when the second world war ended / the first moon landing was / other memorable date
10. Can you count down from 20 to 1?

MMSE – Mini-Mental State Examination

The Test

• Orientation to time
• Orientation to Place
• Registration
• Attention and Calculation
• Recall
• Language
• Repetition
• Following complex commands

Score

• ≥25 – Normal
• 21 – 24 – mild impairment
• 10 – 20 – moderate impairment
• <10 – severe impairment

References

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Olfactory I

• They notice smells in the morning (e.g. coffee, toast)
• They notice smells that others do
• They think their sense of smell is poor

If they say yes to any of these questions, ask if they have a blocked nose or a cold at the moment, to save you doing unnecessary further investigation! If they say ‘yes’ ask if they think this is the source of their reduced sense of smell.
Also ask about taster here, in case you forget later! Sense of taste is likely to be impaired when the sense of smell is impaired!

• Test one nostril at a time, occluding the other nostril
• If you find any defects, look in the nostril for any polyps or foreign bodies, or infection etc.

Optic II

Assess visual acuity

Start by asking a few basic questions:

• Do you wear glasses or contact lenses?
• Do you have any (other) problems with your vision?

Then, ask the patient to take off their glasses, and have a good look at and around the eyes (e.g. swelling, erythema, ptosis), before beginning your formal examinations:

• Snellen Test – ask them to stand at 6 metres (measure it out if you need to) and read out the lowest set of letters they can see. In a traditional test, there will be 11 rows of letters, the row with 8^th row being the smallest a person with 6/6 vision can read. The biggest letters represent 6/60 vision. Often a smaller 3m Snellen test is used on the ward due to lack of space! Patients should wear their normal glasses – if they have any. You are not an optician – just looking for any serious visual defects! Make sure to test one eye at a time! – ask the patient to cover their eye; just asking them to close it isn’t good enough (as it can be difficult for patient,s and they may partially close the eye you are assessing, which obviously has implications for your results!)
• Near Vision – using the appropriate booklet, ask the patient to read some lines to test near vision
• Ishiahara plates – for colour vision – these are characteristic patterns – usually coloured blobs make up a pattern with a number in the middle. The dots are different colours, but the same brightness. A person with normal vision is able to pick out that the number is a different colour, and can read the number. There are usually several plates with different coloured numbers to test all types of colour defects.

Visual fields 

Sit at arm’s length away from the patient and perform the following tests:

• Visual inattention – test the extremities of the visual fields with both eyes open. Test one side at a time, then both sides together.
• Visual filed defects – test eyes separately. Test the four quadrants of vision for each eye. Cover your opposite eye to compare to your visual fields.
• Assess the size of blind spot

Pupillary Light Reflex

• Shining a light into either eye should constrict both pupils simultaneously.
• RAPD – relative afferent pupillary defect aka Marcus-Gunn pupil– shining light in the affected eye will result in no constriction of either pupil. Often the result of MS, or massive retinal detatchment.
• Horner’s syndrome – responses are normal, but on the affected side there is ptosis, and often the pupil is abnormally constricted in relation to the other pupil. It will still respond to light and ark, however.
• III nerve (efferent) palsy –dilated pupil that does not respond to direct or consensual light. The eye may point down and out (total palsy), or may point in other directions (partial palsy).

Miosis – means ‘constricted pupil’!
Causes:

• Eye drops – pilocarpine
• Unilateral – Horner’s syndrome, Holmes-Adie pupil
• Bilateral – opiate overdose, brain-stem stroke, bilateral Horners

• Eye drops – tropicamide
• Fear or anger
• Brainstem stroke
• Drug overdose – e.g. anticholinergics

Accommodation reflex

• Ask the patient to look at a point in the distance (ideally more than 6m away)
• In a normal accommodation reflex, as the eyes focus on a near object from a far one, the pupils will constrict, and the eyes will converge.
• Hold your finger (or another appropriate object) about 15cm infront of the patient’s face, and ask them to look at this object. Note the response of the pupils and eye alignment.  Diabetes and syphilis can cause a condition whereby the eyes do not constrict in response to light, but do constrict when the accommodation reflex is tested. This is known as Argyll-Robertson pupils.

Fundoscopy

• Look at the optic disc and retina. If the patient wears glasses, they should remove them. Ask the patient to look straight ahead, but slightly upwards (this moves the optic disc into the best viewing position). This is easiest if you ask them to look at the join between the wall and the ceiling behind me.
• Use a medium sized circle of light from the ophthalmoscope. Shine the light into the pupil, and look from a distance to check the red reflex.
• Then, you will have to get very close to the patient to be able to focus on the retina. If you put your hand on the patient’s forehead, and then rest your head on your hand you will probably get close enough (i.e. you are very close – perhaps only a couple of cm away!)
• Once you can see the retina comment on…

The optic disc – is it normal colour? Normal size? Normal shape?

• Papilloedema / optic nerve swelling. It is only truly papilloedema when the cause is raised ICP. In other cases, we just call it ‘optic disc swelling’. The disc will also be a red/pin colour, and its margins will be blurred. Causes:
  • Raised ICP
  • Mass lesion
  • Malignant hypertension
  • Bremember don’t do a lumbar puncture if there is raised ICP – thus if there is papilledema, don’t do lumbar puncture!
  • CT should usually be performed if papilledema is present.
• Optic nerve swelling may be cause by MS – where the optic disc is directly affected by the inflammatory reaction
• Optic atrophy – causes an abnormally pale and small disc
• Optic cup – this is the small circle inside the disc through which the vessels enter. It is normally very small compared to the optic disc. Conditions that increase the size of the cup relative to the disc are called ‘cupping’ . these can include glaucoma and ischaemia of the optic nerve.

The vessels – do they form the normal arc? Are they tortuous? Can you see any haemorrhage?
The retina – any abnormalities (e.g. cotton wool spots, exudates)
Cloudy appearance? – if so, likely to be cataracts.
Ask the patient to look up, down, left and right so you can get a view of all the areas of the retina.
Ask the patient to look directly at the light – so you can see the macula. Don’t do this for too long!
Finally, move away slightly, or refocus the ophthalmoscope to look in the vitreous for floaters, and to look at the iris and sclera.

Background retinopathy

• Hard exudates
• Dot haemorrhages

Proliferative retinopathy

• New vessel formation (away from the normal arcades positions of the vessels)
• Scarring (photo-coagulation scars)

Oculomotor III

Ask the patient to follow your finger. Have your finger about30cm away from the patient’s face, and move it in an H shape to test all the eye movements.
Ask the patient if they experience double vision at any time

Trochlear IV

Suberior oblique – this causes a lot of confusion in medical students. This muscle will point the eye downwards, when the eye is looking medially!
If it was to ever act on the eye alone (when no other muscle are acting on the eye) then yes, it might make the eye look laterally. However, in clinical practice, this never happens!

Trochlear Nerve palsy –this can be difficult to detect as it is subtle. It also often presents with other palsies / lesions.

Trigeminal V

Test their sensory function. Touch patient with cotton wool in the 3 regions (ophthalmic, maxillary, mandibular) on both sides of the face.
The ophthalmic (touch on forehead), the maxillary (touch on cheek bones), and the mandibular (touch on chin). If they can’t feel in an of these regions, then they might have a lesion in the corresponding cranial nerve.
Be wary in the mandibular region – that along the region of the mandibular bone, sensory function is actually due to C2, so it is best practice to touch just laterally to the mouth.
Test the integrity of the motor function of the mandibular (V3) branch of the trigeminal nerve:

• Ask them to clench jaw. You should be able to feel the temporalis and masseter
• Ask them to open their jaw against the resistance of your hand.
• Ask them to move jaw from side to side – this is done by the pterygoid muscles.

Abducens VI

Abducens palsy – patient is unable to abduct the eye

Facial VII

• Test the integrity of the sensory chorda tympani branch of the facial nerve supplying the anterior 2/3 of the tongue. Ask the patient to stick out their tongue. You should dry their tongue with a paper towel. Pipette sucrose onto the tip and sides of the tongue. Then they have to be able to taste it before they put their tongue back in. Then they can put their tongue back in to tell you if they tasted it or not! IF you have time you should do it with all 4 liquids! Sweet, sour, bitter & salty.
• Test the integrity of the deep petrosal nerve (a branch of the facial nerve supplying the lacrimal gland) Ask if they have dry mouth or dry eyes.
• Test the integrity of the main branch of the facial nerve, which has 5 branches and supplies the muscles of the face: from top to bottom: Frown/lift eyebrows (temporal), close eyes tightly (orbits occuli), Smile with lips closed and whilst showing teeth), Purse lips, Blow out cheeks (check the air doesn’t come out when you apply pressure to cheeks!)

Vestibulocochlear VIII

• Test hearing. Whisper and ask them to repeat. Weber’s test. Rinne’s test.
• Ask them to walk in a straight line –heel to toe. Close their eyes and stand on one foot – be ready to catch them if they fall!

• Conduction Deafness – where sound is impaired from reaching the receptors of the inner ear.
• Sensory-neural deafness –  where there is a problem in the receptors of the inner ear, the vestibule-cochlear nerve, or in the brain.

Rinné’s Test

DO NOT HIT THE TUNING FORK ON ANYTHING! Pluck it, or hit in on your hand.
The healthy normal ear is more sensitive to air conducted sound than to bone conducted sound.This test involves places a vibrating tuning fork on the mastoid process behind your ear, then when the sound is no longer heard, bring it round to your ear, and yu should still be able to hear the sound.

Weber’s Test

This can be complete 100% deafness, or any amount between normal hearing and complete deafness. In the vast majority of cases it is caused by degeneration of the hair cells in the organ of corti. This occurs normally in old age and results in loss of high frequencies (above 1 kHz). The higher the frequency, the greater the loss. This type of deafness is known as Presbycusis. Noise trauma can also cause deafness. Typically this has a hearing loss in the range of 4kHz (like the graph on the previous page). Both of these conditions will normally present in both ears. Sensorineural deafness in only one ear is possible due to brain/vestibulocochlear neve damage and should be investigated with an MRI scan.

Glossopharyngeal IX

• Test taste on postierior 1/3 of tongue. Same procedure as facial, but put the stuff on the posterior 1/3 of the tongue.
• Ask if they have a dry mouth. The parotid gland is innervated by this nerve. The facial nerve passes through the parotid gland but does not innervate it.
• Test gag reflex – spatula on the lateral side of the pharynx.

Vagus X

• Test motor function. Ask them to say ‘ahh’ their soft palate should go up, and the dangly bit (uvula) should go down. Infection of uvula is called uvulitis and it should sit on their tongue.
• Test swallowing. Ask them to swallow water if available.
• Test speech – ask them to repeat a sentence. If their voice sounds nasal they may have a defect of the Vagus nerve, because the palate may not be raised, and so the sound may be directed through the nasal cavity.

Accessory XI

Hypo​glossoal XII

References

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Method

• Take a detailed history with any patient that has walking difficulties
• Observe the patient’s gait. Ideally you should observe it as they walk in the room – they may be less self conscious at this time.
• Not if the gait is symmetrical or asymmetrical.
• Observe:
  • Pace size
  • Posture and arm swing
  • Foot separation (left from right)
  • Co-ordination of legs
• Knee lifting (does one lift higher than the other)
• Check if the patient is in pain
• Look for orthopaedic problems.
• If the gait appears normal, you should ask the subject to ‘heel-toe’ walk and check if they are steady.
• If it is abnormal, you should take the observations you have made and try and match it to:

Apraxic gait

Waddling gait

• May be bilateral. In which case, they walk ‘bow-legged’.
• Almost all proximal weakness is due to muscle (and not joint) weakness.

Crossing over/ scissoring gait

Hemiplegic gait

Parkinsonian Gait

• Parkinson’s is always an a-symmetric disorder! It always starts on one side, and then, typically after 3-5 years it spread to the other side.

Ataxic Gait

• Use Romberg’s test to differentiates cerebellar disorder from sensory disorder.
• Ask the patient to put their feet together, close their eyes, and hold their hands out in front of them. If the patient is more unsteady with their eyes closed than with them open, it is a positive Romberg’s, and there is sensory (propriceptive disorder). If they are equally unsteady with eyes open and eyes closed, they are Romberg’s negative.
• Almost all sensory loss is due to lower sensory neuron loss – i.e. peripheral neuropathy.
• Other features of cerebellar disease:
• Speech problems
  • May sound drunk
  • May lose normal flow of speech (eg. Hip.o . pot .o .mus.)
  • Phasic shift
• Nystagmus

High Stepping / Drop Foot Gait

• Muscle disorders are more likely to be unilateral, but nerve disorders (e.g. compression, lesion) can also be unilateral.
• Muscle disorders are more commonly proximal than distal.
• MND is a common cause
• Wasting of lower legs?

• Structural Lesions:
  • Stroke
  • MS
  • Tumor
  • Etc etc etc
• Toxins – particularly alcohol, anticonvulsants and chemotherapy agents
• Autoantibodies
• Inherited disorders

Romberg’s test

• If the patient sways with their eyes both open and closed, then this is due to a cerebellar lesion – a cerebellar lesion can’t be compensated for by input from other systems, but a vestibular or proprioceptive defect can be.
• If the patient sway only when eyes are closed –then this is a vestibular or proprioceptive defect. With eyes open the patient is able to compensate for their poor balance using other stimuli (i.e. seeing, rather than sensing where the limbs are in space), but with the eyes closed, this compensation is lost.

Other disorders that may affect gait

PSP – pseudobulbar palsy

Chorea

• Levodopa
• Anti-psychotics
• Wilson’s disease

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