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
