Cerebellar disease focussed examination

NB: the instructions may be non-specific, for example: ‘Examine this patient with a tremor’, ‘Examine this patient’s gait and then proceed,’ or ‘Examine this patient neurologically’. Approach this situation by first asking a few generic questions (if allowed) or by inspecting for tremor/gait abnormalities. Then proceed with the relevant focussed examination to elicit other signs.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent

Generic questions

• What did you notice first when you developed this condition?
• How is it affecting you?
• When is your tremor worst?
• Do you have other problems, such as problems with balance or co-ordination?
• Do you have problems with buttons and shoe laces? Turning over in bed at night? Getting in and out of your car? (All suggest Parkinsonism.)

Examining for tremor

1. Resting tremor (rest hands on lap on ulnar border and close eyes and count down from 20) 
2. Postural tremor (hold arms out) 
3. Action tremor (finger-nose test) 

General observations

• General inspection
  • Patient, e.g. posture
  • Around bed, e.g. mobility aids/wheelchair, neurological signs, posture, signs of neglect (alcohol)
• Gait (but first check that they can walk and accompany them in case they fall)
  • Stand from sitting with arms folded (truncal ataxia)
  • Walk away and, if stable, walk back heel-to-toe (ataxic gait)
• Posture
  • Stand with feet together 
  • Romberg’s test (only if steady): ask patient to close eyes and assess their stability (reduced stability = sensory ataxia due to proprioceptive deficit)

Now work down the body:

Face

• H-test for extraocular muscle function – look for jerky pursuit movements and pause at lateral gaze for nystagmus
• Saccades test: ask the patient to look back and forth between two widely spaced targets, e.g. your index finder on one hand and thumb on the other, while keeping their head still. Test horizontally and vertically. Check for conjugate eye movements and target accuracy. (Hypometric saccades, i.e. slow movements, and saccadic dysmetria, i.e. difficulty fixing on target, are characteristic.)
• Repeat phrases: ‘West Register Street’, ‘baby hippopotamus’ and ‘British constitution’ (slurring; staccato (broken up into syllables, i.e. jerky); scanning (variability in pitch/volume))
• Tongue: move side to side

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Focussed upper limbs

• Drift: ask patient to hold arms out fully extended with palms facing upwards and their eyes closed (pronator drift = weakness; upward drift = cerebellar pathology) 
• Rebound test: with the patient’s arms still held up, push wrists down briskly and then quickly let go (accentuates upward cerebellar drift)
• Tone (hypotonia)
• Co-ordination
  • Finger-nose test (intention tremor and dysmetria)
  • Dysdiadochokinesia test (inability to perform rapidly alternating movements)

Focussed lower limbs

• Tone (hypotonia)
• Co-ordination: heel-to-shin test (ataxia)
• Knee jerks over side of bed (pendular reflex, i.e. multiple oscillations)

To complete

• Thank patient 
• ‘To complete my examination, I would examine the fundi for papilloedema (space occupying lesion) and perform a full neurological examination, including testing CN 5, 7 and 8 to exclude a cerebellopontine angle lesion.
• ’Summarise and suggest further investigations you would consider after a full history

Viva questions