Examination of fine motor function. 

A and B, The patient alternately touches own nose and the examiner's index finger with the index finger of one hand.

A and B, The patient alternately touches own nose and the examiner's index finger with the index finger of one hand.

Expect the patient's movements to be rapid, smooth, and accurate.

Consistent past pointing (i.e., missing the examiner's index finger) may indicate cerebellar disease.

C, Alternately touches own nose with the index finger of each hand.

Expect the movement to be smooth, rapid, and accurate, even with increasing speed.

D, runs the heel of one foot down the shin or tibia of the other leg.

Expect the patient to move the heel up and down the shin in a straight line, without irregular deviations to the side.

Evaluation of balance with the Romberg test.

• Ask the patient (with eyes open and then closed) to stand, feet together and arms at the sides.

• Loss of balance, a positive Romberg sign, indicates cerebellar ataxia, vestibular dysfunction, or sensory loss.

Evaluation of gait and balance with heel-toe walking (tandem gait) on a straight line.

Note any extension of the arms for balance, instability, a tendency to fall, or lateral staggering and reeling.

Note any shuffling, widely placed feet, toe walking, foot flop, leg lag, scissoring, loss of arm swing, staggering, or reeling.

D, Cerebellar ataxia.

E, Sensory ataxia.

Evaluation of primary sensory function. 

A, Superficial tactile sensation; use a light stroke to touch the skin with a cotton wisp or brush.

B, Superficial pain sensation; use the sharp and rounded edge of a broken tongue blade in an unpredictable alternate pattern.

C, Vibratory sensation; place the stem of a vibrating tuning fork against several bony prominences.

D, Position sense of joints; hold the toe or finger by the lateral aspects while raising and lowering the toe.

Evaluation of cortical sensory function. 

A, Stereognosis; patient identifies a familiar object by touch. 

B, Two-point discrimination; using two sterile needles or two points of a paper clip, alternately place one or two points simultaneously on the skin, and ask the patient to determine whether one or two sensations are felt. 

C, Graphesthesia; draw a letter or number on the body (without actually marking skin) and ask the patient to identify it.

 Location of exiting spinal nerves in relation to the vertebrae. 

A, Posterior view

B, Anterior view of brainstem and spinal cord

C, Lateral view showing relationship of spinal cord to vertebrae.

D, Enlargement of caudal area with group of nerve fibers composing the cauda equina.

Dermatomes of the body, the area of body surface innervated by particular spinal nerves; C1 usually has no cutaneous distribution. 

A, Anterior view.

B, Posterior view. 

It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves. 

C = cervical, T = thoracic, S = sacral, L = lumbar.

Superficial reflexes. 

A, Plantar reflex indicating the direction of the stroke and the Babinski sign—dorsiflexion of the great toe with or without fanning of the toes. 

B, One of several approaches for the abdominal reflexes. Stroke the lower abdominal area downward, away from the umbilicus. Stroke the upper abdominal area upward, away from the umbilicus.

Location of tendons for evaluation of deep tendon reflexes. 

A, Biceps.

B, Brachioradial.

C, Triceps.

F, Evaluation of ankle clonus.

A, Sites for application of the 5.07 monofilament to test for protective sensation. Indicate presence (+) or absence (−) of sensory perception on a drawing of the foot. 

B, Apply the monofilament to the patient's foot with just enough pressure to bend the monofilament.

Loss of sensation to the touch of the monofilament is an indication of peripheral neuropathy.

It also indicates the loss of protective pain sensation that alerts patients to skin breakdown and injury on the foot. 

A, Brudzinski sign, flex the neck and observe for involuntary flexion of the hips and knees. 

B, Kernig sign, flex the leg at the knee and hip when the patient is supine, and then attempt to straighten the leg. Observe for pain in the lower back and resistance to straightening the leg.

A, Decorticate or flexor posture. The upper arms are held tightly to the sides of the body. The elbows, wrists, and fingers are flexed, and the feet are plantar flexed. The legs are extended and internally rotated. Fine tremors or intense stiffness may be present. 

Decorticate or flexor posturing is associated with injury to the corticospinal tracts above the brainstem.

B, Decerebrate or extensor posture. The arms are fully extended with forearms pronated. The wrists and fingers are flexed, the jaw is clenched. The neck is extended and the back may be arched. The feet are plantar flexed.

Decerebrate or extensor posturing is associated with injury to the brainstem.