2. NOTE
Central Nervous System-Brain & Spinal
Cord
Peripheral Nervous System-12 pairs of c
ranial nerves and the spinal and periphe
ral nerves.
Most of the peripheral nerves contain bo
th motor and sensory fibers.
3. HISTORY
Assess the cooperation of patient
If not/ be it consciously or unconsciously,/ ta
ke history form attendants
Try to get a clarification of the meaning of a
complaint
Onset, evolution and course of the sympto
m
Observe- speech, thought
Some symptoms might not have sign—get
more information from history
4. PHYSICAL EXAMINATION
1. Mental status
2. Cranial nerve
3. Motor system
4. Reflexes
5. Sensory system
6. Special examination
5. I)MENTAL STATUS
*LOC
*Attention
*Memory
*Orientation
Perception
Thought process
Thought content
Insight
Judgment
Affect
Mood
*Language(speech)
*Higher cognitive fun
ction
6. 1.Level of consciousness*
understand and respond to questions
apply stimuli/ verbal, physical or painful/ and see resp
onse
Conscious patient aware of himself & his environme
nt and is able to respond both to internal and external
stimuli
Abnormality
lethargy—drowsy, responds to quest’n and fall asleep
obtundation– opens eye, responds slowly, confused a
nd low interest and alertness
stupor– arouse from sleep with painful stimuli slow or
absent verbal response
coma– unarousable
7. 2. Orientation*
Time
time of the day,date, month, year
Place
residence, name of hospital, city, state
Person
patients name, name of relative, name of colleagu
es
8. 3. Attention*
Digit span:- repeat a number of digits after you / forward
and backward/ or start with two and continue till the length the p
atient can’t repeat, tell loudly and slowly/ one digit per second
Normal-five forward/ four backward
Serial seven:- subtract seven out of hundred note efort ,
speed, accuracy
Normal – finish in 1.5 min
Spell backward:- Ask patient to spell a five lette
r word backward
Replace serial seven,
9. 4. Memory*
Remote /years/
birthdays, anniversaries, names of school attended
Recent/minutes, hours to days/
ask events of the day
New learning ability
tell three unrelated words and ask the patient to repeat
after three to five minutes
10. 5. Insight and judgment
INSIGHT:- Awareness of abnormality of the symp
tom, ask the patient what brings him to the hospital
JUDGMENT:- Process of comparing and evalu
ating alternatives, assess patients response to family
situation, job, use of money, interpersonal conflicts
11. 6. Perception/Thought
Perception:- sensory awareness of objects & th
eir interrelationship in the environment
Abnormality-hallucination, illusion
Thought content:- what people think about a
nd level of insight & judgment, Abnormality-delusion,
phobia, compulsion, depersonalization
Thought process:- the logic, coherence, & re
levance of patients thinking as it leads to selected go
als
Abnormality– circumstancial, loosening of associatio
n, flights of ideas
12. 7. Mood
A sustained emotion affecting personal
view of the world
Assess it during hx taking or ask directly
Assess risk of suicide if pt is depressed
Abnormalities—mood disorder
13. 8. Higher cognitive function*
information and vocabulary
ask about specific facts and assess the amount of informati
on he has Eg- the name of the president, prime minister etc
Calculating ability
addition and multiplication
Abstract thinking
interpretation of proverbs, similarities between objects
Constructional ability
copy figures
Abnormalities in the above functions occur in patients with ment
al retardation, dementia, schizophrenia
14. 9. SPEECH*
Assess it during the interview
Speech is mediated by the dominant hemisphere,
assess
- spoken and written language
- character of speech/ articulation, fluency/
-if you find abnormality test different functions/na
ming, repetition, comprehension, writing/
parietal- writing
Parieto-occipital--- reading
Frontal ---articulation
Temporal---fluency, comprehension, repetition, writ
ing
16. II)CRANIAL NERVES 1-12
All except 1 and 2 arise from the brain s
tem
CN 1 & 2 are continuation of CN tissue
Supply the head and neck / motor, sens
ory and autonomic/
17. CN 1(Olfactory)
project to uncus and parahippo
Examine nasal canal
Assess smell
CN 2(Optic)
Retina---optic nerve—optic chiasm--optic tract---lateral g
eniculate----calcarian cortex
Assess- visual acuity
visual field
others/ colour vision, visual localization, visual recog
nition/ if necessary
Visual acuity :- by Snellechart,special hand held ca
rd, count finger or light perception
18. Visual field
confrontation
Test one eye/ right with left and left with right/
Sit at one meter distance and extend arm at eq
ual distance
Assess every direction/up, down,right,lef
perimeter
19. CN 3(Occulomotor),4 (Abduscence)& 6(Trochl
ear)
Test extraocular mov’t
right eye
All except SO and LR supplied by CN3
levator palpebra Iris and ciliary muscle-Edinger Westpha
l nucleus
SR
IO
SO
IR
LR MR
20.
21. Conjugate eye movement integrate
d at brainstem
Infranuclear-unilateral eye mov’t
strabismus- diplopia,dizziness
Supranuclear-conjugate eye mov’
Lateral unilat-pontine paramdial reticular for
mation
Lateral bialteral-central pontine
Upward-central midbrain,inferior thalamic
Downward-medulla
Cerebellar-Nystagmus
Extrapyramidal-low interrupted purs
uit
22. Pupil
size, shape, reaction to light and accomodati
on
afferent CN 2/bilateral/ and efferent CN3
abnormalities- Argyll Robertson pupil-NRL,R
A
-Tonic/Adie pupil-
CN 5(trigeminal) /ophthalmic,maxillary,
mandibular/
sensory- face, upper teeth,nose, pharynx, tongue
motor- Mastication muscles
Parasympathetic- salivary and lacrimal gland
23. CN 7(Facial)
sensory- somatic auricle, taste anterior 2/3 of th
e tongue
motor- muscles of facial expression
Test-smile, eye closure,whistle,furrow,
CN 8(Vestibulocochlear)
cochlear –hearing
vestibular-- balance
Test hearing
24. CN9,10,11(glossopharyngeal,vagus,accessa
ry)
9-motor- pharyngeal,stylopharyngeal
taste-posterio 1/3
10-motor-palate,pharynx,larynx
-parasympathetic-heart, viscera
11- pure motor-sternocm, trapezius
See position of palate
Assess gag reflex, muscle/sternocm,trape
zius/
Hx-dysphagia, hoarseness of voice,dysart
hria
CN 12(hypoglossal
◦ Motor to the tongue
25. MOTOR
Involuntary movement
Bulk
Power-graded according to the research council scale
Tone
Reflex
Coordination
28. Coordination
RAM- observe speed, rhythm,smoothness
- hand
- finger
- thumb
Point to point- observe smoothness and a
ccuracy
-finger to nose,
-heel to shin
Stance
- Romberg’s sn 20-30s
- pronator drift 20-30s
Gait
- assess the patients gait, tandem walk,
29. Reflex
Grade 0-absent
1-low normal
2-average normal
3-brisk
4-associated with clonus
Ankle S1,2
Knee L2,3,4
Brachioradialis C5,6
Biceps C5,6
TricepsC6,7
30. SENSORY
Principles
Compare symmetrically, distal &proximal
Do it fast
No need to do vibration and position proximal if distal is no
rmal
Change pace and rhythm of examination
Map the abnormality
Land marks :- C-3 neck, C-6 thumb, T-4 nipple, T-10 umbili
cus,
L-1 inguinal, L-4 Knee, L-5 Ankle, S3-5 peria
nal
Modalities -pain &T-spinothalamic
-position& vibration-posterior column
-light touch-both
-recognition of shape, size, weight, form
- above + cortical
31. Special examination
Asterixis non rhythmic, brief flexion of the hand and
finger 1-2s
# Metabolic encephalopathy
Meningeal signs
Neck stiffness
Kernig’s
brudniski’s
Autonomic function
orthostatic change in BP,PR
Pupil rxn, sweating,
32. Minimental status assessment
score out of 30,
lower than 21 is associated with cognitive abnormality
& has 12 variables
- orientation to time and place and serial 7 score 5
- short term memory, learning ability and three stage
command 3
- naming and construction -2
- other variables assess speech/repetition, reading,
writing/ and another construction score 1
33. STUPOROUS OR COMATOUS PA
TIENT
Respiration - hyperpnea- midbrain/pontine
- bradypnea-increase ICP
- Cheyne-stokes-hemispheric/dienceph
alo
- ataxic-medullary
Pupil - unilateral D, -ve LR— uncal herniation
- midposition,-ve LR — midbrain
- miosis, +ve LR-- pontine
- fixed dilation-- diencephalon
- Horner’s syndrome– hypothal, thal
- Small pupil, brisk LR--- metabolic
- Small pupil, slugish LR--- Drug
34. Ocular movement
Spontaneous
- conjugate deviation--- ipsilat hemisphere, contra
BS
- depression --- midbrain, metabolic
- dysconjugate--- CN 3 or6 affection
- ocular bobing low pon, cerebellar hematoma, hydr
ocephalus
Reflex
- Oculocephalic
- Oculovestibular
Corneal reflex absent in deep coma and drug induced c
oma/ light/
Posture and muscle tone- Decerebrate/ decorticate