Pearls in PACES (CNS- Cerebellar)

Adel Hasanin

1

CNS – CEREBELLAR

STEPS OF EXAMINATION

Step 1: Approach the patient

• Read the instructions carefully for clues (almost always there is problem with coordination or

equilibrium)

• Approach the right hand side of the patient, shake hands, introduce yourself

• Ask permission to examine him

• Expose the upper and lower limbs completely and keep the patient descent (genital area is covered)

Step 2: General inspection:

•••• Bedside: walking stick, shoes-callipers, built-up heels

•••• General appearance: scan the patient quickly looking for:

���� Nutritional status (under/average built or overweight)

���� Cachexia (paraneoplastic cerebellar syndrome, alcoholic cerebellar syndrome), unkempt

appearance and stigmata of liver disease (alcoholic cerebellar syndrome)

���� Kyphoscoliosis (Friedreich’s ataxia)

���� Intention tremors

���� Pyramidal posture (MS, Friedreich’s ataxia)

���� Myxoedematous facies

���� Abnormal facial movements (hemifacial spasm, facial myokymia, blepharospasm, oro-facial

dyskinesia)

���� Facial asymmetry (hemiplegia)

���� Nystagmus (towards the side of the lesion)

���� Skew deviation of the eyes

���� Radiotherapy burn (paraneoplastic cerebellar syndrome)

���� Pacemaker scar (Friedreich’s ataxia)

���� Pes cavus (Friedreich’s ataxia)

•••• Face (mouth): look for gingival hypertrophy (phenytoin), high arched palate (Friedreich’s ataxia)

•••• Hands: tell the patient and demonstrate “outstretch your hands like this (palms facing downwards)”…

then “like this (palms facing upwards)”

���� Check for clubbing and tar-stained fingers (paraneoplastic cerebellar syndrome)

���� Feel the radial pulse (hypothyroidism)

•••• Legs: pes cavus (Friedreich’s ataxia)

Step 3: Cerebellar dysarthria: Ask the patient some general questions to get him talking: “Please could

you tell me your name? Your age? Are you right handed or left handed? Where do you live?” In cerebellar

dysarthria, speech is slurred, slow, jerky and explosive (lalling, staccato, scanning), with irregular breaks in

articulation and equal emphasis on each syllable. There may be inspiratory whoops indicating the lack of

coordination between respiration and phonation.

Step 4: Nystagmus: see “Ch 18. Eye – General”

Step 5: Pronator drift test: see “Ch 7. CNS – Upper Limb”

Step 6: Coordination in UL: see “Ch 7. CNS – Upper Limb”

Step 7: Coordination in LL: see “Ch 6. CNS – Lower Limb”

Step 8: Gait and Romberg’s test: ask the examiner’s permission to examine the patient’s gait and

perform Romberg’s test (see Ch 9. CNS - Gait)

Pearls in PACES (CNS- Cerebellar)

Adel Hasanin

2

Step 9: Examination of lower limbs: see “Ch 6. CNS – Lower Limb”

•••• Inspection

•••• Tone

•••• Power

•••• Reflexes

•••• Sensory

Step 10: Examination of upper limbs: see “Ch 7. CNS – Upper Limb”

• Inspection

• Tone

• Power

• Reflexes

• Sensory

Step 11: Cranial nerves: see “Ch 8. CNS – Cranial Nerves”

Step 12: Additional signs:

•••• Ipsilateral deafness and cranial nerves V and VII affection (cerebellopontine angle lesion, usually

acoustic neuroma)

•••• Fundal examination: optic atrophy (MS, Friedreich’s ataxia), papilloedema (posterior fossa space

occupying lesion)

Step 13: Thank the patient and cover him (her)