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Dr Siddique Akbar SattineurologyPhysical and Systemic Examination

Step-wise Cerebellar Examination Guide For OSCE, Viva Examination.

“Now a days, competition has largely increased among the medical professionals, you have to be perfect in your skills in order to be successful in competitive medical examinations, such as FCPS Part II, MRCP USMLE and other exams” Said Dr. Siddique Akbar Satti, Head Department of Medicine Capital Hospital Islamabad and member of board of examination, College of Physicians and Surgeons Pakistan, while teaching his postgraduate trainees “How to do cerebellar examination”. You shouldn’t be doing minor mistakes while examining the patient physically. Because now, a minor mistake can give you a major blow which can be powerful enough to leave you behind. Dr. Siddique Akbar Satti was teaching his student that how should you proceed if you are asked to do cerebellar examination in 5 minutes in exam. “You mustn’t miss even a minor step” said Dr. Satti.

1. Consent

  1. Wash your hands
  2. Introduce yourself to the patient
  3. Explain what you are going to do and why.
  4. After explaining your methods, Take his consent whether he is ok with this.

2. Gait:

Ask the patient to walk from one side of room to the other and you observe his gait.

  1. Unsteady, and broad based gait is usually noted in cerebellar disease, in unilateral disease patient sways to the side of the lesion and in bilateral lesion patient sways to both sides.
  2. Ask the patient to do heal to toe walking. Patient can’t maintain balance if he has cerebellar lesion.

cerebellar ataxia gaitHeal to toe walk in cerebellar examination

3. Romberg Test

  1. Stand close to the patient and ask the patient to close his eyes for 10-15 seconds
  2. Romberg test is positive if patient loses balance and starts to fall.
  3. Romberg test helps to identify the cause of ataxia.
  4. Positive Romberg test means the ataxia  is due to loss of proprioception.
  5. Negative Romberg test means the ataxia is due to localized cerebellar disease.

How to do romberg test for cerebellar examination

4. Ocular examination

  1. Ask the patient to keep his head perfectly still
  2. Ask him to follow the movement of tip of your finger.
  3. Check for nystagmus. Nystagmus is present in 70-80% of patients who have cerebellar lesion.

Nystagmus in cerebellar disease

5. Speech:

  1. Ask the patient to repeat some  complex words in local language. For-example ask him to say British constitution.
  2. A patient of cerebellar disease will break these words in to several pieces, for-example he will say Bri-tish cons-ti-tution. Such type of speech is called scanning speech.

6. Examination of tone of upper limbs.

  1. Asses tone of the muscles of upper limb, shoulder, arm, fore arm and hand. Hypotonia is a characteristic of cerebellar disease.
  2. Check all the tendon reflexes of upper limb, that is biceps, triceps and others.

7. Assess Co-ordination of upper limbs.

  1. Finger nose test (Past pointing). Keep your finger 2 feet away from the patient’s nose and ask the patient to touch his nose and then your finger, ask him to do as fast as he can, make this test difficult by slowly changing the place of your finger. Patient with cerebellar lesion fails to do so. Poor coordination and intention tremor will be present in cerebellar lesion. Finger nose test in cerebellar examination
  2. Dysdiadochokinesia: Dysdiadochokinesia means inability to perform rapid alternating actions. Ask the patient to flap palm of one hand on the dorsum of other, repetitively and alternately. Do the same with the other hand. This test will be abnormal in case of cerebellar lesion.Dysdiadochokinesia, in cerebellar examination and lesion
  3. Assess for Pronator drift. Ask the patient to outstretch his arms in front of him with palm facing upward. After that ask him to close his eyes. You will see a phenomenon called pronator drift, in which the hand of the affected site starts to pronate and whole arm drift down and medially. Pronator drift cerebellar disease APronator drift cerebellar disease B
  4. Assess for Rebound phenomenon. Ask the patient to outstretch his arms in front of him. Tell him that you will try to pull his hands down forcefully, but he should try to resist. While pulling his arm down remove the force suddenly. The arm will move to the initial position.Rebound phenomenon in cerebellar disease

8. Examination of tone of lower limbs.

  1. Assess tone of lower limbs, hypotonia is present in cerebellar lesion. Also check the reflexes.
  2. Pendular Knee reflex: Leg keeps swinging to and fro after knee jerk. But it should swing more than four times as swinging less than four time is normal

9. Examination of Coordination of lower-limbs

  1. Heel to shin test: Ask the patient place his left heel on the right knee, Ask him to move the heel along with the anterior border of tibia (shin) to front of ankle. Repeat it 3-4 times. Do the same for opposite leg. In cerebellar disease, the leg shows coarse tremors and leg sways. Heal to shin test in cerebellar disease

10. Thank the Patient

11. Wash hands again.

You are done. You should do all that within 5 minutes so do practice.

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