Dr Raymond Chang
Subtitles in English for this video can be displayed by clicking on 
(first button on the bottom right hand corner of the video).
After adequate exposure, one should then lay the patient’s arms out comfortably.
The examiner should stand at the end of the bed / facing the patient if the patient is sitting, and inspect for any obvious asymmetry, wasting or abnormal posturing. If the patient is lying down, one should then stand on the right hand side of the patient and inspect the upper limbs in greater detail, focusing on whether there is any muscle wasting (proximal and / or distal muscles), fasciculations, scars and tremor. If the patient’s arms initially laid in the prone position, the examiner could then place them at the “palm-up position” and examine the ventral aspect of the upper limbs. The opposite could be done if the patient’s arms are initially laid in the “palm-up position”.
If there are no fasciculations visible on inspection, one can tap onto the muscle bulk gently, which may bring out the fasciculations in a patient with an underlying lower motor neuron disorder. However, one common pitfall is that students often rush through tapping of the muscle bulk, but do not observe long enough for the fasciculations to appear. Often a time, the fasciculations may be visible without tapping if the muscle bulk was examined in detail (see videos of a patient with fasciculations under ‘lower motor neuron signs’).
The tone of the upper limbs could be determined via examining the elbow and wrist joints as shown in the video. The patient’s tone should then be classified as normal, hypertonic or hypotonic. One may also be able to delineate whether the patient has lead-pipe rigidity, cogwheel rigidity (e.g. in parkinsonism), or spasticity (e.g. in patients with an upper motor neuron lesion).
The power of the upper limbs could be determined as shown in the video. One should examine the power of muscles involved in abduction and adduction of the shoulders as well as flexion and extension of the elbows, wrists and fingers. The power of the small hand muscles: finger abduction, thumb abduction and thumb opposition should then be elicited. Further detailed examination of other muscles could also be performed if the clinical history or physical examination raises clinical suspicion.
The power of the muscles should then be graded according to the Medical Research Council (MRC) scale for muscle strength as follow:
The reflexes of the upper limbs including the biceps, triceps and supinator reflex should be examined as shown in the video. The patient’s upper limbs should be fully relaxed. To elicit the biceps tendon reflex, roll the thumb along the biceps tendon and gently tap onto the thumb with the tendon hammer. The tendon hammer should be held towards the end and the wrist should be used to ensure a good swinging motion.
If the reflex is absent, one should proceed by performing the reinforcement maneuver (Jendrassik maneuver) by asking the patient to clench his or her teeth tightly upon tapping the tendon with the tendon hammer. The patient’s reflex should then be classified as normal, brisk (hyper-reflexic), hypo-reflexic or absent.
A video of how rebound is elicited is also shown here.
The patient’s coordination should be assessed by the finger-nose test (to elicit intention tremor and dysmetria) and asking the patient to perform rapid alternating movements of the hand (to elicit dysdiadochokinesia).
Once again, clear, simple instructions are vital. Common pitfalls of medical students, is that during the finger-nose test, the examiner’s finger is either held too close to the patient (thus intention tremor could not be accurately assessed) or too far away. The examiner’s finger should be ideally at arm’s length from the patient. It is useful to hold onto the patient’s hand and perform the test with the patient first before asking the patient to perform it himself.
Subtitles in English for this video can be displayed by clicking on (first button on the bottom right hand corner of the video).
After positioning the patient on the bed and ensuring adequate exposure, the lower limbs should be inspected as follow:
The examiner should stand at the end of the bed and inspect for any obvious leg length discrepancy, asymmetry, wasting or abnormal posturing. One should then stand on the right hand side of the patient and inspect the lower limbs in greater detail, focusing on whether there is any muscle wasting (proximal and / or distal muscles), fasciculations, scars, tremor, pes cavus and clawing of toes.
If there are no fasciculations visible on inspection, one can tap onto the muscle bulk gently, which may help bring out the fasciculations if an underlying lower motor neuron lesion is present. However, one common pitfall of medical students is that they often rush through the tapping of the muscle bulk, but do not observe long enough for the fasciculations to appear.
The tone of the lower limbs could be determined first of all by gently rolling the lower limb on the bed as if it was a log. In patients with hypertonia, there would be increased resistance with this manoeuvre. The normal swinging motion of the foot will also be reduced. This should be followed by gently lifting up the thigh of the lower limb and releasing it back onto the bed. In patients with hypertonia, the heel of the foot would often elevate from the surface of the bed. The tone of the lower limb is classified as normal, hypertonic or hypotonic.
The power of the lower limbs could be determined as shown in the video. One should examine the flexion, extension, adduction and abduction of the hip muscles, followed by extension and flexion of the knee muscles. Finally, foot dorsiflexion, dorsiflexion of the big toe, foot plantar flexion, foot inversion and eversion should be examined.
Again, the power of the muscles should then be graded according to the Medical Research Council (MRC) scale for muscle strength as follow:
One should then compare the muscle power between the right leg and left leg, as well as between proximal and distal leg muscles.
The reflexes of the lower limbs including the knee jerk, Achilles tendon reflexes and plantar reflexes can be examined as shown in the video.
The heel-shin test is performed as demonstrated in the video shown here.
The non-contrast CT brain shown is from a patient with bilateral watershed infarct. Here, chronic ischaemic changes can be seen along the external or cortical watershed zones 
(Figures 1 and 2). These “borderzones” is where the terminal vasculature of the anterior cerebral artery and middle cerebral artery meet as well as where the middle cerebral artery and posterior cerebral artery meet. Watershed infarcts are commonly due to hypotension with or without underlying severe arterial stenosis or occlusion.
Intention tremor can be elicited by the finger-nose test. In normal patients, the movements between the physician’s finger and patient’s nose should be smooth, but adjustment is allowed according to the patient’s upper limb power. This man has intention tremor and impaired finger-nose test on the right side, whilst the left side is normal.
This sign indicates a lesion at the ipsilateral cerebellum. It has been postulated that this sign is due to a loss of movement stabilisation by the cerebellum.
Common causes resulting in cerebellar signs include: stroke, tumour, demyelinating diseases, alcohol or anticonvulsant toxicity.
There are a few points to note for the test: