NEUROLOGICAL

EXAMINATION

Personal H:
Handness
Occupation (driver)

C/O:
Onset, course & duration

Family H:
Heredofamilial ataxia
Familial periodic paralysis
Peroneal mus. atrophy
Past H:
2 T Trauma, TB
2 S Syphilis, Similar attack
2 H HTN, Heart disease
2 D DM, Drugs
1 E ENT
1 F Fever

HPI:
12 items
History
HPI
Motor

Sensory

Trophic
Cranial n

ICT

Fits
Speech

Sphincter

Gait
Mental

Hypoth

Other
Motor
Involuntary: extra , fasiculation
State
Tone
Weakness
Ataxia (cerebellum)

Dist or prox
Stat or Kinetic
Disappear e sleep or Not
UL or LL
Rt or Lt
Dist or Prox
Flexor or Extensor
Abductor or Adductor
Drunken gait
Intension tremors
dysdidoko
+ve romberge
Improve on bed
Sensory
Superficial: Pain, Temp, Touch
Deep: Position, Mov., Vibr.
Cortical: Steriog, T. loc., T. discr.




Ulcers: (N.B. : painless)
If +ve : pattern
Sensory level
hemihypoth
Glove & stock
Jacket loss
Trophic changes or deformities
Cranial n
:
Anosmia

:
Acuity
Field

,,:
Diplopia
Ptosis
Squint
:
Sensory
Pain,Temp
Motor
Masticat.
:
Sensory
Tast ant
Motor
Eey clos.
Mouth clos.
:
Deaf
Tinitus
Vertigo

, :
Dysph (phar)
N. regur (palat)
N. tone (palat)
Hoarsn (lary)
:
Shoulder elev
neck side mov
:
Tounge mov
ICT
Papilledema
Headache
Vomiting


Aura
Post effect
Cons. Loss
Gener. Or local
March

Fits
Speech
Aphasia: (higher neurolo. center lesion):
Receptive(sensory):
Spoken(Auditory)(aud recogn area lesion)
Written(Visual)(visual recogn area lesion)
Expressive(motor):
Spoken (brocas area lesion)
Written(Agraphia)(exners area lesion)
Dysarthria: (articul system lesion):
: bilateral slurred (psudobulbar)
Extra slow monotonus
Cerebellar stacatto
Cr n slurred (true bulbar)

Sphincters





Consciousness
Hallucination
Memory

Gait
Mental
Hypothalamus

D.I.
Polyphagia
Hypogonadal
Hypersomnia
Hyperpyrexia

Other systems affection
Examination
Motor

Sensory

Trophic
Cranial n

ICT

Fits
Speech

Sphincter

Gait
Mental

Hypoth

Other
General examination

Neurological examination:
Mental
Consciousness
Memory
Mode
Orientation
Behavior
Intelligence


EXAMINATION LEVEL OF
CONSCIOUSNESS (AROUSAL)
Level of Consciousness (Arousal): Techniques and Patient Response
Level Technique Abnormal Response
Alertness Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you,
and responds fully and appropriately to stimuli
(arousal intact).
Lethargy Speak to the patient in a loud voice. For
example, call the patients name or ask, How
are you?
A lethargic patient appears drowsy but
opens the eyes and looks at you, responds
to questions, and then falls asleep.
Obtundation Shake the patient gently, as if awakening a
sleeper.
An obtunded patient opens the eyes and
looks at you, but responds slowly and is
somewhat confused. Alertness and interest
in the environment are decreased.
Stupor Apply a painful stimulus. For example, pinch a
tendon, rub the sternum, or roll a pencil across
a nail bed. (No stronger stimuli are needed.)
A stuporous patient arouses from sleep
only after painful stimuli. Verbal responses
are slow or even absent. The patient
lapses into an unresponsive state when
the stimulus ceases. There is minimal
awareness of self or the environment.
Coma Apply repeated painful stimuli. A comatose patient remains unarousable
with eyes closed. There is no evident
response to inner need or external stimuli.
Glasgow Coma Scale
Speech
Read Sorat El Fateha
Aphasia: (higher neurolo. center lesion):
Dysarthria: (articul system or Cr n. lesion):

Trophic changes or deformities
Motor
Involuntary: extra , fasiculation
State
Tone
Weakness
Ataxia (cerebellum)
Reflexes

Dist or prox
Stat or Kinetic
Disappear e sleep or Not
UL or LL
Rt or Lt
Dist or Prox
Flexor or Extensor
Abductor or Adductor
Drunken gait
Intension tremors
dysdidoko
+ve romberge
Improve on bed
Rapid alternating movem
Finger-to-Nose /Finger
Heel-to-Knee Test
Rombergs Test
Gait
Sensory or
Cerebellar ataxia:

-ve romberg
Intension tremors
Tone
6 joints + dont forget support before joint
Tone is the resistance appreciated when
moving a limb passively
Normal Tone
Hypotonia
Central Hypotonia:shock UMNL, cerebellar
Peripheral Hypotonia: LMNL, myopathy
Hypertonia
Spasticity (Corticospinal Tract = )
Rigidity (Basal Ganglia, Parkinsons = extra )
Flexion at the elbow (C5, C6, biceps)
Extension at the elbow (C6, C7, C8, triceps)
Extension at the wrist (C6, C7, C8, radial nerve)
Squeeze 2 fingers as hard as possible ("grip," C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Oppostion of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4, iliopsoas)
Adduction at the hips (L2, L3, L4, adductors)
Abduction at the hips (L4, L5, S1, G. medius and minimus)
Extension at the hips (S1, gluteus maximus)
Extension at the knee (L2, L3, L4, quadriceps)
Flexion at the knee (L4, L5, S1, S2, hamstrings)
Dorsiflexion at the ankle (L4, L5)
Plantar flexion (S1)
Weakness: examine the following









Muscle(s) Function
Primary Nerve
Origin
DELTOID Shoulder abduction Axillary C5-C6
BICEPS Elbow flexion Musculocutaneous C5, C6
TRICEPS Elbow extension Radial C6, C7, C8
WRIST EXTENSORS Radial C6, C7, C8
WRIST FLEXION
Median
C6, C7
HAND GRIP Grasp Fingers
Median
C7, C8, T1
FINGER ADDUCTION Median C7-T1
FINGER ABDUCTION Ulnar C8, T1
THUMB OPPOSITION Median C8, T1
HIP FLEXION Iliopsoas L2, L3, L4
HIP EXTENSION Gluteus maximus S1
Quadriceps Knee extension L2, L3, L4
Hamstrings Knee flexion L4, L5, S1, S2
Tibialis anterior Foot dorsiflexion Deep peroneal L4, L5
Gastrocnemius Ankle plantar flex mainly S1
Ext hallicus longus
Extens of great toe L5
Weakness: examine the following
Upper limb:
Shoulder:
Adduction
Abduction
Flexion
Extension
Lat rotation
Med rotation
serratus ant.
Elbow:
Flexion
Extension
Wrist:
Flexion
Extension

Weakness: examine the following
Hand
Thumb
Oppon pollicis
Abd pollicis
Add pollicis
Flexor pollicis
Exte pollicis
Other fingers:
Abductors
Adductors
Flexion
Extension
Lumbricalis

Abdom. mus:
Flexion

Lower limb:
Hip:
Flexion
Extension
Adduction
Abduction
Knee:
Flexion
Extension
Ankle:
Dorsiflexion
Planter flexion


Trunk mus:
extension

C4
C5
C5
C6
C7
C7
C8
C8
T1
T7-
T12
L1,2
L2,3,4
L4,5
L5, S1
S1,2
S1,2
Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength
Deep (tendon jerks)
UL
BICEPS
BRACHIORADIALIS
TRICEPS
LL
KNEE + clonus
ANKLE + clonus

Reflexes & clonus
Superficial reflexes
Corneal
Grasp
Gag (palatal)
Planter
Abdominal
Cremastric
Anal
C5,6
C6,7
L2,3,4
S1,2
S1,2
T6-12
L1
S3,4,5
Abnormal Deep reflexes
Jaw jerk
Wartenberg
Finger jerk
Hofman
Patelal jerk
Adductor jerk





Technique
Babiniski Scratsh From below up- lat to medial
Chaddock The skin under and around the lateral malleolus
is stroked in a circular fashion.
Gondas Flex 3
rd
& 4
th
toes 7 release suddenly
Oppenheim press to the anterior surface of the tibia,
stroking down to the ankle.
Gordon Compressing the calf muscles
Schaefer Pinching the Achilles tendon enough to cause
pain.
Sure
signs of
????
EXAMINATION REFLEXES: SCALE
FOR GRADING
Reflexes are usually graded on a 0 to 4+ scale
4+ Very brisk, hyperactive, with clonus
3+ Brisker than average; possibly but not
necessarily indicative of disease (no clonus)
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response
Sensory
Superficial: Pain, Temp, Touch (one 2, Rt & Lt, derm)
Deep: Position, Mov., Vibr., N & M
Cortical: Steriog, T. loc & discr., Graph.




If +ve : pattern
Sensory level
hemihypoth
Glove & stock
Jacket loss
Cranial n
- smell
- Acuity: ( Snellen chart, Counting finger, Hand
mov., Light perception)
- Fields ( confrontation)
- Fundus
- Colour vision
,,- Ocular mov.
- Ptosis, Myosis or Mydriasis
- Reflexes:
Light: (direct & consensual)
Accomodation
Ciliospinal
Partial ptosis+
Miosis+
Anhdrosis+
Enophthalm
=
??
Complete ptosis+
Mydriasis+
Diverg squint
=
??
Cranial n
- Sensory: (ophth., maxillary, mandibular)
- Motor: (massiter, temporalis, tregoid)
- Reflexes:
Corneal
Jaw : if +ve = bilateral lesion above pons (above nc.)
- Sensory: (Tast ant of tounge)
- Motor: (frontalis, orbic occul., buccinator,
retractor angulii, orbic oris)
- Reflexes:
glabellar
- Nystagmus
- Hearing



Rapid phase toward
H pendular occular
H fix i.e. (lesion) cerebel
H Away from (norm) vestib
V vertical stem
Cranial n
, -Say AHH = palatal movement

Move up = normal
deviate to healthy =
LMNL
Move
No movement
-Palat reflex
-Pharyn reflex


Exag bilat=
Bilateral UMNL
Lost bilateral=
Bilateral LMNL
Cranial n
- Shoulder elev (trapezius)
- Neck side mov (sternomastoid)

- Observation ( atrophy, fascic)
- Midline protrusion (Deviation, invol. movem )
- Power

Sphincters
ICT






Gait
Other systems affection
Classical Patterns of Abnormal Gait
Parkinsonism Gait
Hemiparetic Gait
Ataxia Gait
Waddling Gait (Hip Girdle Weakness)
High Stepping Gait