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- [Matthew] Hello, my
name is Matthew Davies,

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and today, we will be discussing

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the neurological examination.

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The clinical neurological
exam is used to assess

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the overall function
of the nervous system,

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including the central and
peripheral nervous systems.

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To assess the central nervous system,

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the examination covers functions
of five major divisions,

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the cerebrum, the
diencephalon, the brainstem,

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the cerebellum, and the spinal cord.

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The diencephalon is not easily examined

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and will not be included in
this clinical examination.

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We begin with an
assessment of the cerebrum.

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To do so, we assess general
cortical functioning

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covering the following domains,

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level of consciousness,
orientation, language,

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memory, Broca and Wernicke's area,

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and the frontal eye field.

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The level of consciousness can be assessed

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just by observing your patient.

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Orientation can be assessed by
asking a few simple questions

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such as,

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can you tell me your full name, please?

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- Monica (indistinct).

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- [Matthew] And where are we today?

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- Burlington.

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- [Matthew] Okay, and what's today's date.

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- August 13th.

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- [Matthew] Very good.

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Language can be assessed

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by having the patient repeat phrases

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and to name objects with their functions.

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Could you repeat a phrase for me?

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Could you repeat the phrase
no ifs, ands or buts?

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- No ifs, ands or buts.

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- Okay.

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And you can also have them
name a few objects such as...

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Can you tell me what this is?

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- A hummer.

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- And what do you do with the hammer?

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- Hit stuff.

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- Very good.

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And what is this?

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- A pen.

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- And what do you do with the pen?

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- You write?

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- [Matthew] Very good.

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You can also assess short-term
and long-term memory.

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To assess long-term memory,

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you can ask the patient
about a specific event

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in their life.

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Could you tell me when
your birthdate is please?

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- 9/15/72.

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- [Matthew] Very good.

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And for short-term memory,

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you can assess by naming three objects

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and having them repeat those
back to you at five minutes.

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Could you repeat it three objects for me?

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I'm gonna have you remember
them for five minutes

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and I'll ask you again later.

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Can you repeat ball, cat and tree?

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- Ball, cats and tree.

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- Very good.

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This gives you roughly enough time

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to complete your cranial nerve examination

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and ask for these objects again later.

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To test for Broca's area,

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you will also listen to
the patient's speech.

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This patient will be able to understand,

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but will not be able to vocalize words,

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and this is known as expressive aphasia.

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With Wernicke's area,

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the patient will have no understanding,

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but will be able to mouth sounds

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and it will come out in
something known as a word sound.

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To assess frontal eye fields
you assess two functions,

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smooth pursuit and saccades,

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which is the ability to
look from point to point.

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I will ask you if you
can just follow my finger

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while I move it slowly
from side to side, please.

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With this, you're looking
for a nice, smooth movement,

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all the way to the left and
all the way to the right.

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To test the cards,

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you have the patient look
from one finger to the other

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quickly as possible.

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Very good.

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And you can see the quick
movements of the eyes.

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This is a good time to point out

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that when you're looking right

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you're just controlled by the left cortex,

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and when you're looking at left,

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you're just controlled
by the right cortex.

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Also these eye movements

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involve cranial nerves III, IV, and VI.

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The next thing that we assess

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in the neurological examination
is brainstem function

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through assessment of the cranial nerves.

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This consists of 12 nerves,
somewhat similar functions,

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which necessitates multiple tests.

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What we do first is at
rest we assess ptosis,

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and we also make sure that
the pupils are equal and round

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and that the face is symmetric.

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Cranial nerve I or the olfactory nerve

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is not assessed during the
clinical neurological examination

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as this is the sense of smell

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and it's objective and
can vary significantly

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from person to person.

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Cranial nerve II test visual acuity

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and it also tests visual fields.

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This is the coolest cranial nerve of all

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as you can look directly at this nerve,

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through the fundoscopic exam.

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We will not be showing you

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that part of the examination today.

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What we will show you is the
assessment of visual fields.

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Can I ask you to tell me how
many fingers I'm holding up

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when I hold them up.

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- Two, well, four.

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- Four, total, okay.

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- Two.
- Good.

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- Two.

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Four.
- Very good.

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And as you can see, all of
her visual fields are intact.

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The next cranial nerves
that we will discuss

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are cranial nerves III, IV, and VI,

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which control the extra ocular
movements and accommodation.

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The easiest way to check all
the extra ocular movements

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is to make an H with your finger

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and have the patient
follow with their eyes.

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Can you please follow my finger?

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As you can see, she has full
range of motion of her eyes.

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Okay.

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One other function of cranial nerve III

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is the pupillary reflex.

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And you can attest this
by shining a bright light

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into the patient's eye

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and to look for pupillary constriction.

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I'll just ask if you can
look right at my forehead

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while I shine a light in your eye.

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And both of her pupils constrict equally.

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The next cranial nerve that we all test

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is cranial nerve V or
the trigeminal nerve,

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which tests for facial sensation.

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It also innervates the
muscles of mastication

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used for chewing.

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To assess for facial sensation,

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you can ask for the patient
to close their eyes, please.

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And let me know if it feels equal

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on both sides of your face.

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Does it feel the same?
- Yes.

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- And here?
- Yes.

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- And here?
- Mm-hmm.

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- The trigeminal nerve gets its name

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because it innovates three
different portions of the face

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as seen with the forehead,
over the cheekbone

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and over the jaw.

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Cranial nerve V also controls
the muscles of mastication,

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which can be tested by having
the patient clench their jaw

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and feeling directly
over the masseter muscle.

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In her, you can feel the muscle contract.

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The next cranial nerve that we test

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is cranial nerve VII or the facial nerve,

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which constitutes facial strength

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involving wrinkling of the forehead,

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being able to smile and
being able to close the eyes.

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Wrinkling of the forehead
is the most important

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because this can distinguish
between central nervous system

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and peripheral nervous system lesions.

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With the peripheral nervous system lesion

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of cranial nerve VII,

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the patient will be unable
to wrinkle up the forehead.

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With a central nervous system lesion,

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the patient will still be
able to wrinkle the forehead,

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essentially, this is
innervated bilaterally.

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So can I have you do a few things for me?

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Can you give me a big smile
with your teeth, please?

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Very good.

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And can you close your
eyes nice and tight?

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Very tight, don't let me open them.

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Good, you can open your eyes.

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Can you wrinkle up your forehead?

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Good.

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And the last thing you can have them do

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to test for subtle facial weakness

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is to have them puff out their cheeks

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and don't let me push the air out.

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Very good.

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The eighth cranial nerve or
the vestibular cochlear nerve

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test both hearing and
the vestibular reflex.

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The vestibular component is
tested via the Romberg exam,

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which we will do it later on.

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To test for hearing,

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you can have the patient occlude
one ear with their finger.

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Can you put your right
finger in it right ear?

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And then can you please tell me

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when you hear the rubbing sound?

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- Now.
- Okay.

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And then you can put your
finger in the other ear.

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And let me know when
you can hear the sound.

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- Yes.
- Very good.

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- Now.

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- Her hearing is intact.

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Cranial nerves IX and X,

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the glossopharyngeal and the vagal nerves

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are involved in palate movement

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such as when a patient says, ah,

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and also are involved in the gag reflex.

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So this can be assessed by
having the patient say, ah,

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and looking at the palate movement.

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Can I have you stick out your
tongue please and say, ah?

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- Ah.

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- Very good.

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And in her, her palate
elevates symmetrically.

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You can also assess the
functions of cranial nerve VII,

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IX, and XII, by having them
say a simple three word phrase.

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Can you repeat the phrase pa?

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- Pa.

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- Ka.
- Ka.

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- And ta.
- Ta.

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- Pa, ka, ta, a very unique
and interesting phrase,

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gives you a lot of information

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about the function of cranial nerves.

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The pa sound is the function
of cranial nerve VII.

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As you need the...

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You need that nerve intact to make a P.

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Cranial nerve IX is involved
in making the ka sound

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or the K, and cranial nerve XII

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is involved in making
the ta sound or the T.

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A key point is that swallowing

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involves cranial nerves IX, X and XI.

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So this requires analysis
of other components

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of these cranial nerves.

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Cranial nerve X also controls
blood pressure and heart rate.

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This can be used to assess other functions

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of cranial nerve X.

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Cranial nerve XII, which we'll test next

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can be assessed by doing shoulder shrugs

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and by turning the neck.

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During these motions,

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what you're trying to
assess is for atrophy

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of either the trapezius or the
sternocleidomastoid muscle.

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So to test cranial nerve XI

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you can have the patient look at the left,

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turn the head to the left,
and then push back towards me.

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Good.

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And then look to the right
and push back towards me.

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What you're looking for is
the sternocleidomastoid muscle

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right here.

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You're looking for some atrophy.

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To test another function
of cranial nerve XI

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you can have the patient
shrug their shoulders

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and don't let me push them down.

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Very good.

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Cranial nerve XII,

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or the hypoglossal nerve
controls tongue movement,

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which is very easy to test.

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What you can do is just have the patient

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stick their tongue out at you.

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Very good.

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And assess for deviation and for atrophy.

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Now is the perfect time for your patient

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to repeat the three objects

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that we talked about early to
test the short-term memory.

264
00:10:44,940 --> 00:10:46,210
Can you repeat those three objects

265
00:10:46,210 --> 00:10:47,570
that we spoke about earlier?

266
00:10:47,570 --> 00:10:48,960
- Cat, ball and tree.

267
00:10:48,960 --> 00:10:49,793
- Very good.

268
00:10:51,350 --> 00:10:53,950
The next part that we will
assess is the motor function,

269
00:10:53,950 --> 00:10:55,600
which is an assessment of both cortical

270
00:10:55,600 --> 00:10:57,290
and spinal functioning.

271
00:10:57,290 --> 00:10:59,890
Assessment includes the
following components,

272
00:10:59,890 --> 00:11:03,860
muscle bulk, muscle tone, pronator drift,

273
00:11:03,860 --> 00:11:05,800
and muscle strength.

274
00:11:05,800 --> 00:11:09,060
Muscle bulk can be assessed
just by looking for atrophy

275
00:11:09,060 --> 00:11:10,660
of any major muscle group,

276
00:11:10,660 --> 00:11:13,653
which would be a sign of a
lower motor neuron disease.

277
00:11:15,520 --> 00:11:19,493
Muscle tone can be
assessed by the following,

278
00:11:21,510 --> 00:11:23,140
can I have your wrist please?

279
00:11:23,140 --> 00:11:25,620
And you can just have
your wrist nice and loose.

280
00:11:25,620 --> 00:11:27,540
And you're looking for either rigidity

281
00:11:27,540 --> 00:11:29,970
or spasticity of the muscle groups.

282
00:11:29,970 --> 00:11:31,020
You can test both sides

283
00:11:31,020 --> 00:11:32,870
to make sure that there's symmetrical

284
00:11:38,480 --> 00:11:39,673
The pronator drift,

285
00:11:41,330 --> 00:11:44,222
which helps distinguish between
upper motor neuron sign.

286
00:11:44,222 --> 00:11:46,750
When the patient's arms are extended,

287
00:11:46,750 --> 00:11:50,350
their arms tend to pronate
versus a muscular disease

288
00:11:50,350 --> 00:11:51,540
such as shoulder weakness,

289
00:11:51,540 --> 00:11:53,740
where their arm would
drop without pronating.

290
00:11:53,740 --> 00:11:54,573
This can be assessed

291
00:11:54,573 --> 00:11:55,950
by having your patients
stick their arms out

292
00:11:55,950 --> 00:11:59,480
in front of them with their
palms up and closing their eyes.

293
00:11:59,480 --> 00:12:01,980
Typically, you would do
this for about 30 seconds.

294
00:12:04,390 --> 00:12:05,940
All right, thank you very much.

295
00:12:07,770 --> 00:12:10,110
The last component of
the motor function exam

296
00:12:10,110 --> 00:12:11,580
is the muscle strength.

297
00:12:11,580 --> 00:12:13,870
What you want to assess
is major muscle groups,

298
00:12:13,870 --> 00:12:17,490
such as the biceps,
the triceps, the quads,

299
00:12:17,490 --> 00:12:20,170
and then the ankle dorsi
and plantar flexion.

300
00:12:20,170 --> 00:12:23,020
We will just show you an
example of a few of those today.

301
00:12:23,990 --> 00:12:26,260
Can I have you make a nice big fist?

302
00:12:26,260 --> 00:12:28,183
And don't let me pull your arm away.

303
00:12:29,130 --> 00:12:29,963
Good.

304
00:12:29,963 --> 00:12:31,940
And then you wanna test on both sides

305
00:12:31,940 --> 00:12:33,330
and look for symmetry.

306
00:12:33,330 --> 00:12:34,163
Very good.

307
00:12:34,163 --> 00:12:36,650
And can you lift this leg up in the air?

308
00:12:36,650 --> 00:12:37,483
Very good.

309
00:12:37,483 --> 00:12:39,300
Don't let me push.

310
00:12:39,300 --> 00:12:42,240
And same with this side,
don't let me push down.

311
00:12:42,240 --> 00:12:43,470
Good.

312
00:12:43,470 --> 00:12:46,420
In the muscle groups that we
tested, she has full strength.

313
00:12:47,670 --> 00:12:49,840
The next part of the
neurological examination

314
00:12:49,840 --> 00:12:51,340
is to assess coordination,

315
00:12:51,340 --> 00:12:54,230
which gives us important
information about the cerebellum.

316
00:12:54,230 --> 00:12:56,480
This assessment includes finger tapping,

317
00:12:56,480 --> 00:12:59,910
rapid alternating movements
and the finger to nose test.

318
00:12:59,910 --> 00:13:04,414
Finger tapping, which we'll
demonstrate shortly (coughs)

319
00:13:04,414 --> 00:13:06,580
is an assessment of dexterity.

320
00:13:06,580 --> 00:13:09,263
Can I just have you
rapidly tap your fingers?

321
00:13:10,170 --> 00:13:11,003
Very good.

322
00:13:11,003 --> 00:13:13,650
In her it's quick and symmetrical.

323
00:13:13,650 --> 00:13:17,090
The next part to assess is
rapid alternating movements,

324
00:13:17,090 --> 00:13:18,880
which tests cerebellar function.

325
00:13:18,880 --> 00:13:20,360
This can be assessed by having the patient

326
00:13:20,360 --> 00:13:22,880
put their hands with their
palms down on their legs

327
00:13:22,880 --> 00:13:25,580
and having them quickly
flip back and forth,

328
00:13:25,580 --> 00:13:27,750
and then to go as fast as possible.

329
00:13:27,750 --> 00:13:29,503
Again, you're looking for symmetry.

330
00:13:30,486 --> 00:13:32,150
Very good.

331
00:13:32,150 --> 00:13:35,140
The last part of this cerebellar
and coordination function

332
00:13:35,140 --> 00:13:37,113
is the finger to nose test.

333
00:13:39,770 --> 00:13:41,600
A tremor in the horizontal direction

334
00:13:42,960 --> 00:13:45,210
is a finding in cerebellar disease

335
00:13:45,210 --> 00:13:48,470
versus a resting tremor such
as in Parkinson's disease

336
00:13:48,470 --> 00:13:51,553
can actually improve with
movement during this exam.

337
00:13:52,420 --> 00:13:54,360
So what you have the patient do,

338
00:13:54,360 --> 00:13:56,680
is take their right index finger

339
00:13:56,680 --> 00:13:58,670
and then go towards my index finger

340
00:13:58,670 --> 00:14:01,893
and back towards their nose
and keep going back and forth.

341
00:14:03,240 --> 00:14:06,240
Make sure that you move
far and make you difficult.

342
00:14:06,240 --> 00:14:07,330
And then you can assess

343
00:14:07,330 --> 00:14:08,430
the left index finger
(Monica laughs)

344
00:14:08,430 --> 00:14:09,283
and do the same.

345
00:14:12,920 --> 00:14:13,753
Very good.

346
00:14:18,090 --> 00:14:19,650
Next, we will assess reflexes,

347
00:14:19,650 --> 00:14:22,820
both deep tendon and superficial reflexes.

348
00:14:22,820 --> 00:14:26,930
Deep tendon reflexes are
assessed with a reflex hammer.

349
00:14:26,930 --> 00:14:30,730
Hyperreflexia is a sign of an
upper motor neuron disease,

350
00:14:30,730 --> 00:14:35,083
whereas hyperreflexia is a
sign of a motor neuron disease.

351
00:14:36,550 --> 00:14:38,710
You can test several muscle groups

352
00:14:38,710 --> 00:14:41,330
and several deep tendon reflexes this way.

353
00:14:41,330 --> 00:14:42,820
The one that we will give an example with

354
00:14:42,820 --> 00:14:44,223
is the patella reflex.

355
00:14:45,885 --> 00:14:46,730
Okay.

356
00:14:46,730 --> 00:14:48,970
So you can just ask the
patient to just relax

357
00:14:48,970 --> 00:14:51,623
and I'm gonna tap on your
knee with the reflex hammer.

358
00:14:55,550 --> 00:14:56,383
Very good.

359
00:15:04,761 --> 00:15:06,910
Yeah, her reflexes are intact.

360
00:15:06,910 --> 00:15:09,293
Superficial reflex is
involved with Babinski

361
00:15:09,293 --> 00:15:12,070
when you scratch the
undersurface of the toe,

362
00:15:12,070 --> 00:15:15,280
a positive the Babinski sign
or present Babinski sign

363
00:15:15,280 --> 00:15:16,400
is this simple.

364
00:15:16,400 --> 00:15:19,000
An example of an upper
motor neuron disorder.

365
00:15:19,000 --> 00:15:21,350
We will not be testing
that in this exam today.

366
00:15:22,440 --> 00:15:24,260
Next, we will assess body sensation,

367
00:15:24,260 --> 00:15:26,160
which is another
assessment of both cortical

368
00:15:26,160 --> 00:15:27,690
and spinal functioning.

369
00:15:27,690 --> 00:15:30,780
Similar to cranial nerve
V and facial sensation,

370
00:15:30,780 --> 00:15:32,780
we need to test the function
of the spinal nerves

371
00:15:32,780 --> 00:15:35,410
controlling sensation
to the rest of the body.

372
00:15:35,410 --> 00:15:36,243
Most importantly,

373
00:15:36,243 --> 00:15:38,060
again, is to note the
differences between the right

374
00:15:38,060 --> 00:15:39,723
and the left side symmetrically.

375
00:15:40,580 --> 00:15:43,630
The different modalities that
you can test are light touch,

376
00:15:43,630 --> 00:15:47,760
sharp sensation,
proprioception, and vibration.

377
00:15:47,760 --> 00:15:48,760
To test light touch

378
00:15:48,760 --> 00:15:53,580
you can simply touch on
different surfaces of the body.

379
00:15:53,580 --> 00:15:55,850
And can I have you
close your eyes, please?

380
00:15:55,850 --> 00:15:57,890
Does it feel the same when
I rubbed my fingers on here

381
00:15:57,890 --> 00:15:58,835
on both sides?

382
00:15:58,835 --> 00:16:00,010
- Yes, it does.

383
00:16:00,010 --> 00:16:01,930
- And the same on the feet?
- Mm-hmm.

384
00:16:01,930 --> 00:16:02,763
- Very good.

385
00:16:03,820 --> 00:16:07,100
To test sharp you can use
the end of a reflex hammer,

386
00:16:07,100 --> 00:16:09,510
or you can use any other sharp object.

387
00:16:09,510 --> 00:16:12,143
Just make sure that it's not
dangerous for the patient.

388
00:16:13,670 --> 00:16:15,610
I'm gonna be putting a
sharp object on your hand,

389
00:16:15,610 --> 00:16:17,150
it will feel like this.
- Mm-hmm.

390
00:16:17,150 --> 00:16:18,920
- And I just want you to let
me know when you can feel it,

391
00:16:18,920 --> 00:16:20,240
okay?

392
00:16:20,240 --> 00:16:21,073
- Yes.

393
00:16:22,020 --> 00:16:23,210
- And here?
- Yes.

394
00:16:23,210 --> 00:16:24,810
- And then on your foot as well.

395
00:16:26,330 --> 00:16:27,163
- Yes.

396
00:16:28,599 --> 00:16:29,566
No.

397
00:16:29,566 --> 00:16:30,399
- Okay.

398
00:16:31,767 --> 00:16:33,710
And you can open your eyes for a second.

399
00:16:33,710 --> 00:16:36,240
We'll demonstrate how to
do a proprioception exam.

400
00:16:36,240 --> 00:16:39,460
If you stick your hand out
with your thumb up in the air.

401
00:16:39,460 --> 00:16:42,240
And I want you to tell
me whether it's up, down,

402
00:16:42,240 --> 00:16:43,990
or in the neutral position.

403
00:16:43,990 --> 00:16:46,090
And now we'll do it with your eyes closed.

404
00:16:47,080 --> 00:16:48,560
- Up.

405
00:16:48,560 --> 00:16:49,820
Down.

406
00:16:49,820 --> 00:16:50,890
Neutral.
- Very good.

407
00:16:50,890 --> 00:16:52,840
And we can test the other hand as well.

408
00:16:53,880 --> 00:16:54,713
- Up.

409
00:16:55,590 --> 00:16:56,540
Down.

410
00:16:56,540 --> 00:16:57,520
Neutral.

411
00:16:57,520 --> 00:16:59,743
- You can also assess the toes this way.

412
00:17:01,260 --> 00:17:05,330
And the last modality to
test is the vibration sense,

413
00:17:05,330 --> 00:17:07,180
which can be done with a tuning fork.

414
00:17:08,190 --> 00:17:10,990
So we'll do this with the eyes
open first to demonstrate.

415
00:17:10,990 --> 00:17:14,140
So you would be feeling for
a vibration sense like this.

416
00:17:14,140 --> 00:17:15,510
I'm gonna ask when you can feel it

417
00:17:15,510 --> 00:17:17,700
and when you don't feel it anymore.

418
00:17:17,700 --> 00:17:20,490
The key to this is doing it
over a bony part of the hand.

419
00:17:20,490 --> 00:17:22,543
So can I have you close your eyes, please?

420
00:17:26,150 --> 00:17:26,983
- Yes.

421
00:17:26,983 --> 00:17:29,283
- And let me know when
you don't feel it anymore.

422
00:17:30,560 --> 00:17:31,465
- No.

423
00:17:31,465 --> 00:17:32,570
- Okay.

424
00:17:32,570 --> 00:17:33,820
Same with the other side.

425
00:17:35,190 --> 00:17:36,023
- Yes.

426
00:17:37,640 --> 00:17:38,560
No.

427
00:17:38,560 --> 00:17:39,393
- Very good.

428
00:17:40,300 --> 00:17:43,490
Last we will be assessing stance and gait.

429
00:17:43,490 --> 00:17:45,810
This includes the Romberg exam.

430
00:17:45,810 --> 00:17:47,840
To test the Romberg the
brain requires input

431
00:17:47,840 --> 00:17:51,030
from two out of three
domains to maintain balance.

432
00:17:51,030 --> 00:17:56,030
These domains are proprioception,
vestibular and vision.

433
00:17:56,220 --> 00:17:58,160
Romberg takes away the vision component,

434
00:17:58,160 --> 00:18:01,100
so we have a complete
assessment of proprioception

435
00:18:01,100 --> 00:18:03,490
and vestibular reflexes.

436
00:18:03,490 --> 00:18:04,323
To test Romberg,

437
00:18:04,323 --> 00:18:06,460
you can have the patient stand

438
00:18:06,460 --> 00:18:08,760
with their feet close together,

439
00:18:08,760 --> 00:18:10,600
with the hands at their sides,

440
00:18:10,600 --> 00:18:12,160
and then ask them to close their eyes

441
00:18:12,160 --> 00:18:14,993
while you help them
maintain their balance.

442
00:18:18,240 --> 00:18:19,610
She has a negative Romberg

443
00:18:19,610 --> 00:18:22,530
as she is able to maintain
her balance during this exam.

444
00:18:22,530 --> 00:18:24,370
You can open your eyes.

445
00:18:24,370 --> 00:18:27,860
And the last thing that
we will test is her gait.

446
00:18:27,860 --> 00:18:30,210
This can be assessed by
multiple different modalities,

447
00:18:30,210 --> 00:18:34,140
including a normal gait,
toe walking, heel walking,

448
00:18:34,140 --> 00:18:35,453
and then a tandem gait.

449
00:18:36,700 --> 00:18:37,970
Make sure that when you're assessing this,

450
00:18:37,970 --> 00:18:39,410
you walk by the side of your patient

451
00:18:39,410 --> 00:18:41,543
in case they do have a balance problem.

452
00:18:42,890 --> 00:18:45,150
All right, I'll just ask you
if you can take a few steps

453
00:18:45,150 --> 00:18:47,573
with your normal gait towards the door.

454
00:18:48,840 --> 00:18:49,673
Good.

455
00:18:49,673 --> 00:18:52,370
And then you can turn around
and walk back towards the wall

456
00:18:52,370 --> 00:18:54,240
on your toes.

457
00:18:54,240 --> 00:18:55,073
- My toes?

458
00:18:55,073 --> 00:18:55,906
- Yes, very good.

459
00:18:56,980 --> 00:18:57,813
Okay.

460
00:18:57,813 --> 00:19:00,693
And turn around and back
towards the door on your heels.

461
00:19:03,240 --> 00:19:06,240
And one last time, walk
back towards the wall

462
00:19:06,240 --> 00:19:08,083
with one foot in front of the other.

463
00:19:14,220 --> 00:19:15,053
Very good.

464
00:19:17,070 --> 00:19:19,470
All right, that's the end of the gait.

465
00:19:19,470 --> 00:19:20,303
So that concludes

466
00:19:20,303 --> 00:19:22,570
the end of the clinical
neurological examination.

467
00:19:22,570 --> 00:19:24,590
I thank you very much for joining us today

468
00:19:24,590 --> 00:19:26,740
and I wish you the very
best in your class.