For education and revision only. Not individual medical advice; check current NICE/BNF and local guidance before clinical use. Clinical safety and terms.
Clinical Examination III: Neurological, eye, ENT and musculoskeletal
🩺 Clinical examination III: neurological, eye, ENT and musculoskeletal. Neurological and musculoskeletal examinations are often the most feared OSCE stations because there is a lot to do in a short time. A fixed routine helps: for neurology - inspection, tone, power, reflexes, coordination and sensation, then localise the lesion; for joints - look, feel, move, special tests, function. This chapter covers the upper and lower limb neurological examination, cranial nerves, cerebellar examination, gait, the eye and fundoscopy, ear, nose and throat, and the GALS screen and regional joint examinations. Your four questions after a neurological examination: Is the problem upper motor neuron, lower motor neuron, sensory, cerebellar, extrapyramidal or a combination? Where is the lesion (brain, brainstem, cord, root, plexus, nerve, junction, muscle)? What is the likely pathology (vascular, inflammatory, degenerative, neoplastic, metabolic)? What investigation will confirm it?
Upper Limb Neurological Examination
Inspection - posture (flexed arm in hemiparesis), wasting (small muscles of the hand, shoulder girdle), fasciculations (LMN - MND), tremor, involuntary movements, scars (carpal tunnel release, neck surgery). Pronator drift - arms outstretched, palms up, eyes closed for 20–30 seconds: pronation and downward drift (UMN); upward drift (cerebellar); searching movements of fingers (pseudoathetosis - proprioceptive loss).
Tone - shoulder, elbow and wrist movements with the patient relaxed: spasticity (velocity-dependent, "clasp-knife" - UMN), rigidity ("lead-pipe" or "cogwheel" with tremor - extrapyramidal), hypotonia (LMN, cerebellar, acute UMN).
Power (MRC scale 0–5): 0 no contraction; 1 flicker; 2 movement with gravity eliminated; 3 against gravity; 4 against some resistance; 5 normal.
Sensation - dermatomes (L2 anterior upper thigh, L3 anterior knee, L4 medial leg and medial malleolus, L5 dorsum of foot and great toe, S1 lateral foot and sole, S2 posterior thigh, S3–5 perianal - saddle anaesthesia); vibration (start at the great toe), proprioception, monofilament (diabetic foot).
Romberg's test - stands with feet together, eyes open then closed: falling with eyes closed = sensory ataxia (dorsal column or large fibre neuropathy - B12, tabes dorsalis); cerebellar patients are unsteady with eyes open.
Completion - "I would examine the upper limbs and cranial nerves, check for a sensory level (cord lesion), perform a rectal examination for anal tone and saddle sensation if cauda equina is suspected, and examine gait."
Pyramidal - extensors weaker in arms, flexors in legs
Muscles supplied by the root or nerve
Reflexes
Brisk
Reduced or absent
Plantars
Extensor
Flexor
Mixed UMN and LMN signs - motor neuron disease (no sensory signs), cervical myeloradiculopathy (LMN at the level, UMN below), subacute combined degeneration (B12 - absent ankle jerks with extensor plantars), Friedreich's ataxia, conus medullaris lesion, taboparesis.
Patterns of sensory loss: glove and stocking (peripheral neuropathy), dermatomal (radiculopathy), single nerve territory (mononeuropathy - carpal tunnel - median), sensory level (spinal cord), dissociated (syringomyelia - "cape" loss of pain and temperature with preserved light touch; Brown-Séquard - ipsilateral weakness and dorsal column loss with contralateral spinothalamic loss), hemisensory (thalamus or cortex), crossed (brainstem - ipsilateral face, contralateral body).
Common peripheral nerve lesions:median at the wrist (carpal tunnel - thenar wasting, weak thumb abduction, sensory loss over lateral 3½ fingers; Phalen's and Tinel's), ulnar at the elbow (hypothenar and interosseous wasting, claw hand of ring and little fingers, Froment's sign), radial (wrist drop - Saturday night palsy), common peroneal at the fibular head (foot drop, weak dorsiflexion and eversion, preserved inversion - distinguishes from L5 radiculopathy; sensory loss over dorsum of the foot), lateral cutaneous nerve of thigh (meralgia paraesthetica).
I (olfactory) - ask about smell (formal testing rarely); loss with head injury, COVID-19, Parkinson's, frontal tumours.
II (optic) - acuity (Snellen chart, with glasses/pinhole), colour vision (Ishihara - early in optic neuritis), visual fields (confrontation; the patient covers one eye), pupils (direct and consensual light reflexes, swinging light test for a relative afferent pupillary defect - optic neuritis, optic nerve compression), accommodation, fundoscopy.
III, IV, VI (eye movements) - "H" pattern, ask about diplopia; III palsy - eye "down and out", ptosis, ± dilated pupil (surgical third - painful, dilated pupil - posterior communicating artery aneurysm - urgent CT angiography; medical third - pupil-sparing - diabetes, hypertension); IV - vertical diplopia worse looking down (stairs), head tilt; VI - failure of abduction (raised intracranial pressure - false localising sign); internuclear ophthalmoplegia (MS - failure of adduction with nystagmus of the abducting eye); nystagmus.
V (trigeminal) - sensation in V1, V2, V3; muscles of mastication (clench teeth, open jaw against resistance - deviates towards the weak side); corneal reflex (V1 afferent, VII efferent); jaw jerk (brisk in pseudobulbar palsy).
VII (facial) - raise eyebrows, close eyes tightly, puff cheeks, show teeth. LMN lesion - whole half of the face including forehead (Bell's palsy - prednisolone within 72 hours, eye protection; Ramsay Hunt - vesicles in the ear; parotid tumour; cholesteatoma). UMN lesion (stroke) - forehead spared (bilateral cortical supply).
VIII (vestibulocochlear) - whisper test, Rinne's (512 Hz fork - air conduction louder than bone normally; bone > air in conductive loss) and Weber's (lateralises to the affected ear in conductive loss, to the better ear in sensorineural loss); head impulse test, Dix–Hallpike (BPPV).
IX, X (glossopharyngeal, vagus) - palate movement ("ahh" - uvula deviates away from the side of a lesion), gag reflex (if indicated), voice, cough, swallow.
XI (accessory) - shrug shoulders (trapezius), turn head against resistance (sternocleidomastoid).
XII (hypoglossal) - tongue at rest (wasting, fasciculations - MND), protrusion (deviates towards the side of the lesion).
Cerebellar signs - "DANISH":Dysdiadochokinesia, Ataxia (gait and truncal), Nystagmus (towards the side of the lesion), Intention tremor (finger–nose), Slurred (staccato, scanning) speech, Hypotonia/heel–shin abnormality. Unilateral cerebellar lesions cause ipsilateral signs.
Drug-induced parkinsonism - antipsychotics, metoclopramide, prochlorperazine - symmetrical, often with tremor.
Essential tremor - bilateral postural and action tremor of the hands (and head, voice), family history, improves with alcohol; propranolol or primidone.
Other movement disorders - chorea (Huntington's, Sydenham's, pregnancy, drugs), hemiballismus (subthalamic stroke), dystonia, tics, myoclonus.
Visual acuity - Snellen chart at 6 metres (e.g. 6/6 normal; 6/60 - largest letter); pinhole improves refractive error; record each eye.
Visual fields - confrontation testing with a red hatpin; patterns: monocular loss (retina, optic nerve), bitemporal hemianopia (chiasm - pituitary adenoma, craniopharyngioma), homonymous hemianopia (optic tract/radiation/occipital - stroke), superior quadrantanopia (temporal lobe), inferior quadrantanopia (parietal lobe), central scotoma (optic neuritis, macular disease), tunnel vision (glaucoma, retinitis pigmentosa).
Pupils - size, shape, symmetry; light reflexes, RAPD. Horner's (small pupil, ptosis, anhidrosis - sympathetic chain: stroke, Pancoast, carotid dissection - painful Horner's is an emergency), Holmes–Adie (large, slowly reactive pupil, young women, absent reflexes), Argyll Robertson (small irregular pupils that accommodate but do not react to light - neurosyphilis, diabetes), third nerve palsy (dilated).
Fundoscopy - dim the room, ideally dilate pupils (tropicamide 1% - check for angle-closure risk); your right eye for their right eye; red reflex (absent - cataract, retinoblastoma in children), optic disc (colour, margins, cup:disc ratio - >0.5 suggests glaucoma), vessels (AV nipping, silver wiring, emboli), each quadrant of retina, macula (ask the patient to look at the light).
Finding
Cause
Papilloedema (swollen disc, blurred margins, loss of venous pulsation, haemorrhages)
Diabetic retinopathy - background (microaneurysms, dot and blot haemorrhages, hard exudates), pre-proliferative (cotton wool spots, venous beading), proliferative (new vessels), maculopathy (exudates near the macula)
Ear - inspect the pinna and surrounding skin (scars, discharge, vesicles - Ramsay Hunt); otoscopy (pull the pinna up and back in adults, back in children; largest speculum that fits): canal (wax, otitis externa - swollen, painful; foreign body), tympanic membrane - colour, light reflex, perforation, retraction, fluid level or bubbles (glue ear), bulging red drum (acute otitis media), white keratin debris in the attic (cholesteatoma); hearing tests (whisper, Rinne, Weber).
Nose - external shape, septal deviation, anterior rhinoscopy (septal haematoma after trauma - drain urgently to prevent septal necrosis; polyps - grey, insensate, mobile; Little's area for epistaxis), airflow on each side (misting a metal spatula), smell.
Mouth and throat - with a light and tongue depressor: lips, teeth, gums, buccal mucosa, tongue (including underneath), floor of mouth, hard and soft palate, tonsils (size, exudate, asymmetry - quinsy displaces the uvula; unilateral enlargement - lymphoma or carcinoma), posterior pharyngeal wall; palpate any lesion (with gloves) and the salivary glands (parotid, submandibular - bimanual for stones).
Neck - lymph nodes, thyroid, salivary glands; red flags for head and neck cancer - persistent unexplained neck lump, hoarseness >3 weeks (smokers, over 45), non-healing mouth ulcer >3 weeks, red or red-and-white oral patches, unilateral ear pain with normal otoscopy (referred), dysphagia, unilateral nasal obstruction with bloody discharge (NICE NG12).
Gait, Arms, Legs, Spine - a rapid screen for musculoskeletal disease.
Three screening questions: Do you have any pain or stiffness in your muscles, joints or back? Can you dress yourself completely without difficulty? Can you walk up and down stairs without difficulty?
Gait - symmetry, smoothness, arm swing, stride length, ability to turn.
Spine - inspect from behind (scoliosis, muscle bulk), side (cervical lordosis, thoracic kyphosis, lumbar lordosis), and front; ear to shoulder (lateral cervical flexion), Schober's test (lumbar flexion - mark L5 and 10 cm above; increase <5 cm on bending suggests reduced flexion - ankylosing spondylitis), press over the midpoint of each supraspinatus (fibromyalgia tenderness).
Arms - hands behind head (shoulder abduction and external rotation), arms straight out (elbow extension), hands palms down then up (inspect for swelling, deformity, rashes, nail changes), squeeze the MCP joints (tenderness - inflammatory arthritis), make a fist (grip), pinch (fine precision), touch each finger to thumb.
Legs - inspect (quadriceps wasting, swelling, deformity), passive hip flexion and internal rotation (hip arthritis - first to be lost), knee crepitus and patellar tap (effusion), squeeze the MTP joints, inspect the soles (callosities - abnormal loading).
Record as a table of appearance and movement for gait, arms, legs and spine.
Look (skin - scars, erythema, psoriasis; swelling; deformity; muscle wasting; posture), feel (temperature with the back of the hand, tenderness, effusion, synovial thickening, crepitus), move (active then passive, range in degrees; pain; compare sides), special tests, function; examine the joint above and below; neurovascular status.
Hand - rheumatoid arthritis (ulnar deviation, swan neck and boutonnière deformities, Z-thumb, MCP and PIP swelling, rheumatoid nodules at the elbow, wasting, scars - joint replacement, tendon repair, carpal tunnel release); osteoarthritis (Heberden's nodes - DIP, Bouchard's nodes - PIP, squaring of the thumb base); psoriatic arthritis (DIP involvement, dactylitis, nail pitting, arthritis mutilans); gout (tophi); Dupuytren's; carpal tunnel tests (Tinel's - tap over the median nerve; Phalen's - wrist flexion for 60 seconds).
Shoulder - movements (flexion, extension, abduction, adduction, internal and external rotation); painful arc 60–120° (supraspinatus tendinopathy/impingement); loss of external rotation (adhesive capsulitis - frozen shoulder; glenohumeral arthritis); rotator cuff tests (empty can - supraspinatus; external rotation against resistance - infraspinatus/teres minor; lift-off or belly press - subscapularis); Hawkins–Kennedy and Neer's (impingement); apprehension test (instability).
Hip - gait (antalgic, Trendelenburg), Thomas' test (fixed flexion deformity), leg length (true - ASIS to medial malleolus; apparent - umbilicus to medial malleolus), range of movement (internal rotation lost first in OA), Trendelenburg test (stand on the affected leg - the pelvis drops on the opposite side if hip abductors are weak).
Knee - effusion (patellar tap, sweep test), quadriceps wasting, tenderness along joint lines (meniscal), range (flexion about 140°, full extension), ligaments - anterior and posterior drawer tests and Lachman's test (ACL), posterior sag (PCL), varus and valgus stress at 20–30° (collateral ligaments); McMurray's test (meniscal tears); patellar apprehension.
Ankle and foot - deformities (hallux valgus, pes planus/cavus, claw toes), Achilles tendon (Simmonds' (Thompson's) squeeze test - no plantar flexion when the calf is squeezed = rupture), Ottawa ankle rules for X-ray.
Special tests - straight leg raise (L4–S1 root irritation - sciatic pain below the knee at 30–70°, worsened by ankle dorsiflexion - Bragard's/Lasègue), femoral nerve stretch test (prone, knee flexion - L2–4), crossed SLR (disc herniation).
Neurological examination of the lower limbs (myotomes, dermatomes, reflexes) and, if cauda equina is suspected, perianal sensation and anal tone.
Red flags for serious spinal pathology: age <20 or >50 at onset, history of cancer, unexplained weight loss, fever, immunosuppression, IV drug use, thoracic pain, night or constant pain, trauma (or minor trauma with osteoporosis), progressive neurological deficit, cauda equina features (bilateral sciatica, saddle anaesthesia, bladder or bowel dysfunction, sexual dysfunction) - emergency MRI.
Wasting of the thenar eminence and numbness of the thumb, index and middle fingers worse at night. → Carpal tunnel syndrome.
Fasciculating tongue, wasted hands and brisk reflexes with normal sensation. → Motor neuron disease.
Swan neck and boutonnière deformities with ulnar deviation. → Rheumatoid arthritis.
A young woman with headaches, obesity and bilateral swollen optic discs. → Idiopathic intracranial hypertension.
Unilateral hearing loss with Weber lateralising to the good ear and Rinne positive on both sides. → Sensorineural hearing loss - MRI for vestibular schwannoma.
Shuffling gait, urinary incontinence and cognitive decline. → Normal pressure hydrocephalus.
Scenario. Present: increased tone in both legs, bilateral weakness of hip flexion and ankle dorsiflexion, brisk knee and ankle reflexes, extensor plantars, sensory level at T10, impaired vibration and proprioception.
Answer: "This patient has a spastic paraparesis with a sensory level at T10, indicating a thoracic spinal cord lesion. Causes include compression (metastatic spinal cord compression, disc, abscess, haematoma), inflammatory myelitis (MS, NMO), B12 deficiency (though a sensory level suggests a structural lesion), and vascular causes. I would arrange an urgent whole-spine MRI, check bladder function and anal tone, and give dexamethasone if malignant cord compression is suspected."
Scenario. How do you distinguish a common peroneal nerve palsy from an L5 radiculopathy?
Answer: Both cause foot drop and sensory loss over the dorsum of the foot. In L5 radiculopathy, ankle inversion (tibialis posterior - L5 via the tibial nerve) and hip abduction (gluteus medius) are also weak, and there is often back pain and a positive straight leg raise. In common peroneal palsy, inversion is preserved and there may be a history of compression at the fibular head (crossed legs, plaster cast, weight loss).
Scenario. An older patient presents with sudden painless loss of vision in one eye; the retina is pale with a cherry-red spot. What do you do?
Answer: Central retinal artery occlusion - an ophthalmic and stroke emergency. Urgent same-day ophthalmology and stroke assessment; check ESR/CRP and ask about headache, jaw claudication and scalp tenderness (GCA - start high-dose steroids immediately if suspected); assess for embolic sources (carotid Doppler, ECG for AF, echo).