Introduction

Wash your hands, introduce yourself, and ask for permission (consent) to examine. Before you begin, ask the patient if they have any pain.

Gait

Look for:

• Spastic gait (a sign of upper motor neurone pathology)
• Weakness

Face

Look for:

• Eye movements +/- nystagmus
• Internuclear opthalmoplegia: Make a fist with one hand , and hold a single finger of the another hand up. Ask the patient to 'look at my finger, then look at fist, and then alternate'. If INO is present, then the abducting eye will show nystagmus, and the adducting eye will fail to adduct and will remain fixed centrally. The reason for this is damage to the medial longitudinal fasciculus, which normally links the VI nerve nucleus (abducting eye) to the III nerve nucleus (adducting eye). A lesion here (caused by demyelination in multiple sclerosis) leads to a lack of this coordinated response during rapid lateral gaze movements.
• Fundi: atrophic discs suggest optic nerve demyelination
• Speech: say words such as "university" etc. (look for patterns of speech seen in cerebellar pathology, or a pseudobulbar palsy)

Arms

Test for:

• Cerebellar function (slightly increased tone and weakness, as well as impaired finger-nose coordination)
• To complete: Thank the patient.