Pearls in PACES (CNS- Cerebellar)

Adel Hasanin
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 (Friedreichs ataxia)

Intention tremors

Pyramidal posture (MS, Friedreichs 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 (Friedreichs ataxia)

Pes cavus (Friedreichs ataxia)
Face (mouth): look for gingival hypertrophy (phenytoin), high arched palate (Friedreichs 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 (Friedreichs 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 Rombergs test: ask the examiners permission to examine the patients gait and
perform Rombergs test (see Ch 9. CNS - Gait)

Pearls in PACES (CNS- Cerebellar)

Adel Hasanin
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, Friedreichs ataxia), papilloedema (posterior fossa space
occupying lesion)
Step 13: Thank the patient and cover him (her)