Common cases in neurological examination 
the upper & lower limbs

In the medical section of the clinical examination you may be asked to examine the upper or lower limbs. 
These are usually neurological cases with ophthalmic association. The most common cases being:
  • hemiplegia in homonymous hemi/quadrinopia
  • upper motor neurone signs or cerebellar signs in optic atrophy or internuclear ophthalmoplegia
  • wasted muscles of the hand in unilateral Horner's syndrome
In the neurological examination (see the section on common examination techniques for details), 
always remember to:
  • observe for any abnormal posture (common in hemiplegia)
  • test the muscle tone for spasticity and less commonly in ophthalmic examination for flaccidity
  • test the muscle power 
  • test the sensation (pain and temperature, joint position sense; more commonly the examiner 

  • will ask you the distribution of the dermatomes rather than let you test each sensation which 
    can be time-consuming)
  • test the reflexes
  • test co-ordination (for cerebellar signs)
  • observe the gait (if the examination is that of the lower limbs)
Upper limb cases Lower limb cases
Return to the main page

The affected side (contralateral to the involved motor cortex) has abnormal posture with adduction of the shoulder, flexion in the elbow, wrist and fingers. The tone is increased. The power is weak especially on extension. There are hyper-reflexia. The co-ordination and sensation are normal. 

Note: In mild hemiplegia, drifting of the outstretched arms on the affected side may be the only obvious sign of muscle weakness.

Mention to the examiner that you like to:

  • test the visual fields for hemianopia
  • examine the cardiovascular system for possible source of embolism i.e.. pulse for atrial fibrillation, carotid artery for bruit and heart sound for valve diseases.
Return to the top

Cerebellar signs
There is hypotonia on the affected side (ipsilateral to the involved cerebellum). The co-ordination tests show intention tremor, past-pointing and disdiadochokinesia. 

In some patient the signs may be subtle and you can make the test more sensitive by:

  • finger-nose test: hold your index finger at least one arm's length away from the patient. Ask the patient to touch the tip of your finger with his index finger and then his nose. Get the patient to repeat the same test while you move your finger around. Look for intention tremor and past-pointing.
  • Repeated movement: get the patient to pronate or supinate the wrist as though he is twisting a light bulb or ask him to tap the back of his hand with the other palm. You must encourage the patient to perform the test as quickly as possible to bring out disdiadochokinesia in mild cases.

Other cerebellar signs:

  • nystagmus (with the fast phase to the side of the lesion) and dysmetria (in which the eye overshoots the target on saccades)
  • abnormal speech due to dysarthria (get the patient to say' Baby Hippopotamus')
  • pendular reflexes, this is best seen in the knee in which the reflexes swing a few beats after tapping the tendon
  • heel-shin test is abnormal (the patient has problem in moving his heel up and down the sheen accurately).
  • wide-based gait with a tendency to fall to one side (to the side with the lesion)
Return to the top

Wasting of the hand muscles due to T1 lesion
The muscles of the hands are wasted (involving the thenar and hypothenar eminence). The power of the hands is decreased. The sensation over the T1 dermatome is abnormal.

Other signs to look for:

  • Horner's syndrome on the affected side
  • scar over the upper chest from pulmonary surgery
  • tenderness or mass over the upper chest due to neoplasm (for example Pancoast's tumour from apical lung cancer).
Return to the top

The main feature being dissociation of sensation with intact vibration and joint position senses but impaired pain and temperature sensation. You are likely to be asked to concentrate on the sensory examination.

In advanced cases, there is wasting ot he small muscles of the hands with deformed (Charcot's) joints in the elbow and shoulder. The power of the involved muscles are weak. The reflexes are usually absent. Sensory examination shows impaired  pain and temperature sensation but normal vibratory and joint position sensation.

Other signs to look for:

  • syringomyelia may involve the brain stem and give rise to syringobulbia. Patient may have Horner's syndrome, nystagmus (fine rotary) and loss of facial sensation usually start form behind and converge on the nose and upper lip). Motor cranial nerves involvement are rare.
Return to the top

Spastic paresis
The tone is increased in both legs. The lower limb muscles are weak. There are hyper-reflexia with upgoing plantar (positive Babinski's reflex). The sensation is impaired (examine for a sensory level). On attempted walking, there is scissoring of the gait (there is crossing over of the feet with dragging of the toes).

Other examination:

  • There are many causes of spastic paresis, the most important being spinal cord compression either from tumour or trauma. However, in the MRCOphth, most would be caused by multiple sclerosis. Therefore, mention you like to to examine the eyes for optic atrophy, internuclear ophthalmoplegia or nystagmus
  • mention you like to examine the back for any scar. The patient may have neurofibroma of the spine removed and there may be other stigmata of neurofibromatosis.
Return to the top

The affected limb may have abnormal posture with external rotation and extension. The tone of the affected leg is increased. The muscle power is weak. There is hyper-reflexia with upgoing plantar response on the same side. The sensation may be abnormal if the sensory cortex is also involved. On walking the foot tends to circumduct and rotate in a semi-circle with each step.

Other relevant signs:

  • hemiplegia of the ipsilateral upper limb
  • ipsilateral upper seventh nerve palsy
  • hemianopia
  • mention you like to examine the cardiovascular system especially for pulse, heart sounds and carotid artery for possible source of embolism.
Return to the top

Combined upper and lower motor neurone lesion
The patient has absent knee and ankle jerks. The plantar responses are upgoing. The sensation may be normal or impaired depending on the cause. 

When you elicit these signs, consider the following possibilities:

  • diabetes mellitus. This is by far the most common and the signs are caused by peripheral neuropathy and cerebrovascular accident both of which are common in diabetes mellitus. The affected side will have hemiplegia. The sensation is impaired with possible stocking distribution. In severe sensory loss, there may be Charcot's joint of the ankle (due to repeated painless trauma) and foot ulcer
  • Fridriech's ataxia
  • subacute combined degeneration of the spinal cord. This uncommon condition is due to vitamin B12 deficiency. The muscles may be spastic and there may be optic atrophy.
  • motor neurone disease
  • tabes dorsalis
Return to the top

Friedriech's ataxia
The candidates are usually asked to either examine the lower limbs or test the cerebellar function.

The patient has pes cavus (high arches of the feet). There are weakness of the lower legs. The knee and ankle jerks are absent but the plantar is upgoing. There is impaired sensation to vibration and joint sense. The gait is wide-spaced due to ataxia.

Other signs:

  • cerebellar signs are prominent with nystagmus, scanning speech, intention tremor and past-pointing
  • mention that you would like to look for optic atrophy
  • other associated features: diabetes mellitus is common and the patient may have diabetic eye disease and cardiac diseases
Return to the top


Diabetic foot
This is usually an extension of the fundal examination in a patient with diabetic retinopathy. The candidate is usually asked which part of the body he would like to examine to look for diabetes-related complications.

The patient has ulcer over the pressure point of the foot. They may be missing toe due to amputation. The ulcer may be ischaemic or neurotrophic:

  • in ischaemic ulcer, the skin is cold with absent pedal dorsalis and tibilias posterior.
  • in neurotrophic ulcer, there are sensory loss to pain, temperature and light touch typically in a stocking distribution.

Look for:

  • disorganized ankle joint (Charcot's joint) form joint position and vibratory sensory loss.
Return to the top