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Neurological Examination (Nervous System Examination)

Neurological Examination (CNS Central Nervous System Examination & PNS Peripheral Nervous System Examination)

A. Higher Mental Function Examination

Consciousness

  • Level of consciousness (whether the patient is comatose, stupor or delirious) : Glasgow Coma Scale (GCS)

Orientation to time, place, & person

Memory

Intelligence

Handedness

Perceptions

  • Delusions
  • Hallucinations
  • Illusions
  • Obsessions

Apraxia

Agnosia

Sleep

Speech and Language

  • Spontaneous speech
  • Naming objects, concepts
  • Comprehension of spoken commands
  • Reading aloud
  • Handwriting

B. Cranial Nerve Examination

1st Cranial Nerve (Olfactory Nerve)

  • Sense of smell

2nd Cranial Nerve (Optic Nerve)

  • Visual acuity : Finger counting at 1 meter
  • Visual fields : Confrontation method
  • Colour vision
  • Pupillary responses

3rd, 4th, 6th Cranial Nerves (Oculomotor, Trochlear, Abducent respectively)

  • Inspection (Diplopia, squint, nystagmus, ptosis, pupil-size, symmetry)
  • Examination proper (eye ball movements)

5th Cranial Nerve (Trigeminal Nerve)

  • Motor : Masseter and Temporalis Muscles
  • Sensory : Pain, temperature, light touch on face except at angle of mandible, Corneal reflex, Conunctival reflex

7th Cranial Nerve (Facial Nerve)

  • Motor : Ask to – form forehead wrinkles, close eye, raise the eyebrows, show the teeth, blow out the cheeks against the closed mouth, whistle.
  • Sensory : Taste at anterior 2/3 of tongue
  • Secretory : Lacrimation

8th Cranial Nerve (Vestibulocochlear Nerve)

9th & 10th Cranial Nerves (Glossopharyngeal and Vagus Nerves)

  • Gag reflex (Touch cotton at posterior 2/3 of tongue & see contraction of post pharyngeal wall)

11th Cranial Nerve (Accessory Nerve)

  • Sternocleidomastoid : Turn the head against resistance
  • Trapezius : Shrug the shoulders against resistance

12th Cranial Nerve (Hypoglossal Nerve)

  • Protrusion of tongue → Deviation → Same side lesion
  • Appearance of tongue (any wasting, tremor or fibrillation)
  • Power of tongue muscles
  • Tone of tongue

C. Motor System Examination

Nutrition

  • Muscular mass (Muscle girth) : Small muscles of hand, Forearm (above styloid process), Upper arm (above medial medial epicondyle), Leg (above medial malleolus), Thigh (above adductor muscles)
  • Circumference of the limbs : Upper limbs (10 cm above the olecranon, 10 cm below the olecranon); Lower limbs (18 cm above the superior border of the patella, 10 cm below the tibial tuberosity)

Tone

  • Hypotonia
  • Hypertonia (Spasticity, Rigidity)

Check at wrist, elbow, knee, ankle.

Power 

  • Upper limbs
  • Lower limbs

Grading

  • Grade 0 No movement
  • Grade 1 Flicker of contraction
  • Grade 2 Movement with gravity eliminated
  • Grade 3 Movement against gravity
  • Grade 4 Movement against resistance
  • Grade 5 Normal power (As the examiner)

Coordination

  • Upper limb: Finger nose test, Finger-finger-nose test, Dysdiadochokinesis
  • Lower limb: Heel-knee test, Tandem walking

Involuntary (abnormal) movements

  • Tremors
  • Chorea
  • Athetosis
  • Hemiballismus
  • Dystonias
  • Myoclonus
  • Tics
  • Fasciculation
  • Fibrillation
  • Myokymia
  • Minipolymyoclonus
  • Titubation

Gait

Reflexes

  • Superficial : Plantar, abdominal, corneal, conjunctival
  • Deep : Biceps, triceps, supinator (brachioradialis), knee jerk, ankle, patellar clonus, ankle clonus, jaw jerk

D. Sensory System Examination

Touch

  • Crude touch
  • Pressure

Pain

  • Superficial
  • Deep

Temperature

  • Hot
  • Cold

Posterior column sensations

  • Vibration sense
  • Joint sense
  • Muscle sense
  • Fine touch (discriminative)
  • Position Sense (Romberg’s Test)

Cortical sensations

  • Point localisation (Tactile localisation)
  • Two-point discrimination
  • Stereognosis
  • Graphaesthesia

Cerebellar signs

  • Dyssynergia
  • Dysmetria
  • Dysdiadochokinesia
  • Rebound phenomenon
  • Hypotonia
  • Gait
  • Speech disturbances
  • Nystagmus
  • Pendular knee jerk
  • Intention tremor
  • Titubation etc.

E. Sign of meningeal irritation

  • Neck rigidity
  • Kernig’s sign
  • Brudzinski’s sign
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