History taking

And

Physical Examination

In neurology

Collected By:

Dr. Soran Mohamad Gharib

Reviewed By:

Dr.Hawar A. Mykhan

NeurologistF.I.B.M.S ( Neurology ) , , M.B.CH.B

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History Taking & Clinical Examination in neurology

During the history and clinical examination 2 points are important:

Where is the pathology?

What is the pathology?

History Taking

What is different in neurology is that the sequelae of events is

more important than the more details regarding some symptoms.

Ask the following questions or the patient will present with one of

the followings:

1) Weakness:

whether it is started from the proximal or distally i.e centrally

or peripherally.

2) Numbness and parasthesia:

numbness is the tingling sensation which is due to excitation

while the parasthesia is the loss of sensation and it is due to

inhibition.

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3) Headache:

ask about(site, bilateral or unilateral, aggravating and relieving

factors as increase during sleep as in ICP or relief by sleep in HTN

other factors as phototherapy, any associated features as N/V and

weakness and loss of consciousness and any epileptic attack, can

be relieve by taking certain medication, is it associated with

blurred vision and any lacrimation and any hearing problems , then

the onset of headache , is it intermittent or continuous , is there any

previous attack, is it severe or not i.e can interfere with daily

activity and make the patient to stay at home and remain in bed, is

it relive by vomiting, at which time is more during the day time or

night, is there any medical disease and HTN).

4)Visual disturbance:

as blurring vision and decrease visual acuity or any double

vision.

5) Hearing disturbance:

as fluctuating deafness which is more after 50 years of age

as the patient not hear well from short distance later it will be

changed and can be found in Mienerer's disease;

6) Vertigo:

the followings are the features of true vertigo:

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- Feeling of rotation.

-Sudden retro or propulsion

-Sinking and upward going of what is patient seeing.

7) Sphincteric disturbance:

ask about the followings:

* urinary incontinence( when the bladder is full dripping of urine

occur).

* urgent incontinence (whenever there is urine in bladder even it is

not full dripping of urine occur)

* frequency ( micturation daily more than 7 times)

* retention of urine.

8) Swallowing difficulties:

that associated with speech disturbance as nasal speech, aspiration,

nasal regurgitation.

Note :

if there is dysphagia for solid meal only mean the organic cause,

but for both solid and liquid mean neurological causes.

9) Loss of consciousness which is inhibitory.

10)Epilepsy which is excitation.

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11)Then any other disease as (DM, HTN , cardiac disease , drugs)

Notes:

*Center of consciousness is located in reticular activating system

that we have cerebral hemisphere, thalamus, midbrain-pons-

medulla

oblongata.

* When there is sudden loss of consciousness mean brainstem

lesion.

* Almost both thalamus should be affected in order loss of

consciousness to occur and usually it is not sudden loss.

Clinical Examination

Include 2 main parts :

A) General examination

1. Consciousness.

2. orientation

3. memory

4. speech

5. GAIT.

B) Specific examination:

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1. cranial nerve examination

2. meningeal signs

3. motor system examination

4. co-ordination

5. Sensory system examination.

Cranial nerve Examination

Remember we have 12 cranial nerves , and ( 1, 2,8 are sensory)

and (4,6,7,11,12 are motor) and (3,5,9,10 are mixed).

(1st is central and arise from the nasal mucosa, 2nd is central from

retina), (3rd and 4th from midbrain , 5th,6th,7th,8th are from pons ,

9th, 10th , 11st, 12nd are from medulla oblongata).. from 3rd to

12nd are peripheral.

Olfactory nerve

It can be examined by asking the patient to close the eyes then we

introduce certain but common and non irritable substance to each

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nostril that should be examined separately and then we ask the

patient to name that substance.

Smell receptors are in the nasal cavity, the olfactory nerve is going

under the frontal lobe through the cribriform plate under roof of

nasal cavity and it is from the anterior part of brain . its function is

smell.

The loss of smell is called ( anosmia) as may be due to head injury

or tumor, while the perversion of smell is called paronosmia.

Optic nerve

Its function is vision. The nerve start from globe and passes

through the optic canal of sphenoid bone then join with other nerve

that form optic chiasma then optic tract that pass to geniculate

body of thalamus then to area of 17 or visual cortex in occipital

lobe.

The pupillary light reflex had efferent part by 3rd CN and the

afferent part by 2nd CN.

The defect in this nerve can cause some abnormalities as blurring

vision, hemianopia especially the homonimus hemianopia( the

right eye-defect in nasal part of left and temporal part of right eye

occur) which is loss of half of visual field in one or both eyes and

this may be due to pituitary tumour that compress the optic tract or

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radiation or the bitemporal hemianopia due to defect in optic

chiasma.

Scotoma means the presence of blind spot that surrounded by the

normal visual field and the central scotoma is normal it is either

relative or absolute scotoma.

The component of examination are:

Visual acuity:

this can be examined by using the Snellen chart that is 6/6,6/9,

6/12, 6/18, 6/24,6/36,6/60. if this not done then counting fingers

from half meter that should be done for each eye separately by

asking the if this not response then hand movement, then light

perception as a last choice.

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Visual field:

this can be tested by confrontation test that you as an examiner

will sit in front of the patient but both of you should be at the same

level then you cover one of your eye and ask the patient to cover

the reverse eye , then you use a subject better with red head and

then move it to right, left, up, down infront of the patient but ask

the patient to look to it only by his opened eye without using the

head then repeat it to the other eye to see the field of vision.

Light reflex:

the light reflex is carried by optic nerve and then will be

return back by the 3rd CN that causing the constriction of pupil.

This reflex is 2 types which is direct (the eye that you put the light

on it) and the indirect (or called the consensual reflex) (mean the

other eye). This test is done by using the torch from the lateral but

should be as a brisk movement on the eye but avoid putting the

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light in 90 degree on the eye then look to the pupil whether

constricted or not.

Color vision: by using ishihara test.

Fundoscopy:

the patient and you should be at the same level and should be at 45

degree position and the patient should look to the prime

position or straight forward then putting one of your hand on the

head of patient and then using the scope laterally. The aim is to

look to the optic disc to know whether there is optic atrophy

(vessels are thin and margin is very white) or the papilledema

(which indicate the old lesion in which there is decrease or absent

margin, hyperemia and engorgement of vessels occur).

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Oculomotor ,trochlear and abducent nerves

The rule is that SO4, LR6 and MIIS3(medial rectus, inferior

oblique, inferior rectus , superior rectus).

Defect in 3rd make unable to look up,down,medially(dysconjugate

gaze), ptosis , dilated pupil and loss of accommodation reflex and

divergent squint occur.The cause maybe DM.

Defect in 4th CN the patient can not look downward,

and defect in 6th CN there is convergent squint.

The examination is as followings:

• Ask the patient to look straight forward then by inspection look

for 3Ps( pupil to know regular,round , and then look for ptosis-

lowset upper eye lid- then the proptosis by doing the Naffziger as 11

stand from behind the patient and then tilt the head inward and

look to the eye whether outside the imaginary anterior line or not).

* Then in first eye movement as putting one of your hand on the

head of patient and then by your finger or a subject better with red

head move it to the right, left, up, down and ask the patient to look

to it only using the eyes without moving the head, at that time look

for any nystagmus or squint or diplopia but this ask the patient do

u see that subject in one or two.

*Accommodation reflex: the reflex is positive and god only if the

followings occurred and this by sitting in front of the patient and

using the same above directly between the both eyes and move it

toward the patient by looking to it:

1. if both eyes are partially ptosed.

2. constriction of both pupils.

3. converging of both eye medially.

*Light reflex.

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Trigeminal nerve

The nerve has 2 branches motor and sensory. The motor will

supply the muscle of mastication which are (Masseter , Temporalis

muscle ,lateral and medial pterygoid muscles).

The sensory has 3 branches which are ophthalmic, maxillary and

mandibular branches and has the sensory function of pain and

temperature of scalp, face, lip, mouth, eyes and the ant.2/3rd of the

tongue.

The lesion of this nerve causing loss of sensation of the previous

areas and wasting of temporalis and masseter muscles and called

(trigeminal neuralgia- Tic Douloureux) that may be due to tumor,

vascular spasm, MS.

The examination is done as the followings:

Motor examination:(almost done before sensory branch):

- Look to the masseter and temporalis for any wasting and then ask

the patient to open the mouth for any jaw deviation.

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- Ask the patient to clinch the teeth then palpate the masseter and

temporalis muscles.

-Then put your hand under the chin and ask the patient to open it

against the ur hand resistant as much as he or she can then move

the chin to right and left against your hand beside that side.

- Reflex Examination: which is 2 reflexes

1. Corneal reflex:

use apiece of cotton then suddenly attached it to the lateral corner

of eye. This reflex has the sensory by ophthalmic branch of 5th CN

and the motor part of 7th CN.

2. Jaw jerk:

not found normally if +ve mean Bilateral UMNL, it is done by

slight opening the mouth then put your index at the angle of jaw

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then hit your finger by the hammer but in 45 degrees. This reflex is

supplied by C3

Sensory examination :

*Start up examination by using the special pin and move it as a

strip like line for each branch.

Facial nerve

The nerve has the function of ( expression, motor part of corneal

reflex, sensation of salivary and lacrimal gland, sensation of

anterior 2/3 of tongueand taste by chorda tympani branch).

The paralysis of the nerve called the Bell's palsy that occur as:

1-UMNL:

There is lesion above the nucleus and characterized by:

1. Hypertonia occur as Spasticity of the limb

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2. There is very mild or no wasting of muscle.

3. Reflexes are brisk or exaggerated.

4. The upper part of face not involved because the forehead has the

dual nerve supply but the lower part will be affected.

5. plantar reflex is upgoing mean +ve Babiniski sign.

The causes may be CVA, Pyramidal system lesion.

2-LMNL:

This indicates the lesion in the anterior horn cells and the lesion

occur inside the nucleus, it is characterized by:

1. Weakness and wasting of muscles.

2. Fasciculation

3. hypotonic

4. Loss of the reflexes.

Causes may be :

*Poliomyelitis

*Warding Hoffman syndrome

*Diabetic neuropathy

*Alcohol and trauma

*Drugs as INH and vincristine and metronidazole

* Infectios as diphtheria and Leprosy.

* Guillian-Barre syndrome.

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* Motor neuron dis.

•*Vitamin Bi and B12 deficiency.

* Amyloidosis.

The most common cause for Bell's palsy is idiopathic others may

be viral as mentioned above.

The effect of the UMNL is that the lower part of the face is more

obvious and deviation occur toward the healthy side.

The effect of the LMNL is that the upper and lower part will be

affected, there is loss of nasolabial fold on the affected side, and

deviation of mouth to the normal side occur, the patient can not

close the eyes properly, if the patient whistle there is leaking of the

air through the affected side , and there is increase the space

between the corner of mouth and the tongue of the affected side

when the patient open the mouth. Some time the patient will have

(Bell's Phenomena) in which the patient try to open the eyes but

the sclera is still appear and the eyeball go up and medially.

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Examination of this nerve is done as the followings:

1) Ask the patient to elevate the eye brows and then look to the

creases in the forehead if lesion occur there is absence of these

creases (Frowning test).

2) Ask the patient to close both eyes firmly and then try to open

them by your hand to know the ability of closing against the

resistance.

3) Look to the nasolabial fold whether present or flat.

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4) Ask the patient to show you his or her teeth as she or he

clinching.

5) Ask the patient to protrude the tongue then look to the angle

between the tongue and the corner of mouth whether increased or

not.

6) Ask to whistle.

7) Ask the patient to make the puffing of the mouth then touch the

cheeks for any air leaking or not.

8) Corneal reflex.

The Bell's palsy can be treated with

• prevent drying of the cornea by using artificial tear or

methylcellulose

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• corticosteroid as prednisolone

• massaging and electrical stimulation of the nerve

• surgery as tarsorrhaphy and the facial-hypoglossal anastomosis

Vestibulo cochlear nerve

Has function of hearing and balance by cochlear and vestibular

part respectively.

Defect in vestibular part causing the vertigo, the defect in the

cochlear part causing the deafness which is 2 types:

1) conductive Deafness: as due to ear wax , fluid and

otosclerosis. The Rinne's test result ( BC>AC) , and the

Weber test result is positive on the affected side only.

2) Sensorineural deafness: as due to acoustic neuroma ,

fracture of pterygotemporal bone and injury to the nerve,

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Rinne's test=AC>BC and Weber is +ve on the unaffected

side.

Not: Normally the AC ( Air conduction)>BC ( Bone conduction)

Examination is done as followings:

1) Roughly just by friction of the fingers near the ear bilaterally.

2) Rinne's test:

as we used the tuning fork and put it in front of the ear then put it

at the mastoid process ask the patient does it feel and hear same or

not.

3) Weber test:

as by using the tuning fork put it on the forehead ask the

patient hearing it normal and equal for both ear or not.

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4) Calorie test: For vestibular branch

5) Rotation test: for vestibular branch

Glosso Pharyngeal nerve

Its function is elevation of larynx and supply the posterior 1/3 rd of

the tongue and supply parotid gland. It is examined with vagal

nerve.

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Vagus nerve

It supplies the pharynx, larynx, heart, movement of palate and

viscera. The defect of these nerves make the patient to present

with:

*Nasal speech

*Nasal regurgitation

*Aspiration.

The causes may be unilateral as due to head injury and tumour or

bilateral as due to CVA ,MS, and bulbar and pseudobulbar palsy.

Examination is as followings:

1) Ask the patient to open the mouth and look whether the uvula is

deviated or not.

2) Ask the patient to say (Ahhh) then look to the soft palate

whether it is elevated or not.

3) Gag reflex: put tongue depressor on each side of tongue if

found mean it is good but may be absent in bulbar palsy.

4) Examination of posterior wall of pharynx by putting tongue

depressor on each side of tongue then pin prick of the wall ask

whether feeling is same or not.

5) Examination of posterior 1/3rd of toungue.

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Spinal accessory nerve

The nerve supply the SCM and the Trapezius muscle.

Examination is as followings:

*Ask the patient to look to one side and then by your hand palpate

the SCM of opposite side and same for other side.

*Ask the patient to shrug the shoulders and then put both hand at

the patient's shoulder against the resistance for trapezius mescle.

Hypoglossal nerve

The nerve supply the muscles of tongue. If there is palsy of the

nerve will causing the deviation of the tongue to the opposite site

of the lesion and there is atrophy of the affected side with some

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speech abnormalities as dysarthria and ataxia of tongue.

Examination is by asking the patient to open the mouth then look

for the symmetry, fasciculation , atrophy, abnormal movement as

ataxia or tremor.

Name of nerve Rank of the

nerve

Origin Motor or

sensory

Olfactory 1st Anterior part of

brain under

frontal bone

through

cribriform

plate( cerebral

hemisphere)

Sensory

Optic 2nd Retina Sensory

Oculomotor 3rd Midbrain Mixed

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Trochlear 4th Midbrain Motor

Trigeminal 5th Pons Mixed

Abucent 6th Pons Motor

Facial 7th Pons Motor

Vestibule cochlear 8th Pons Sensory

Glossopharyngeal 9th Medulla Mixed

Vagus 10th medulla Mixed

Accessory 11th medulla Motor

Hypoglossal 12th medulla Motor

Some Say Marry Money But My Brother Says Big Business

Makes Money

( S = Sensory , M= Motor , b =both )

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Examination of Meningeal signs

These signs are important to exclude whether meningitis is found

or not.

These signs are 3 :

Neck stiffness:

Patient is lying in supine and then flex the neck feel whether there

is rigidity or not, you can put the head of the patient just beside the

bed to make the flexion easier.

Kernig's sign:

this done by flexion of hip and then extension of knee that causing

painful sensation in the Hamstring muscles.

Brudizinski's sign:

this done by flexion of the hip only that causing

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involuntary flexion of neck or can be done by flexion of neck that

causing flexion of hip joint.

Motor system examination

Steps of the examination include the followings:

1-Inspection

Look for the followings:

1) Wasting of the muscles of both limbs:

In the upper limb especially look to the interossi muscles and

in the lower limb palpate the beside of the shaft of tibia and

then if the both sides between the tibial bone was same this

mean wasting of muscle so the bulging should be found

normally.

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2) Fasciculation :

( it is the fibrillatory or wavy movement of group of muscles)

almost look to the axillary and deltoid region or to the medial

aspect of thigh

3) Any abnormal movements:

include the followings:

Tremor : Examine for flapping tremor also by extending the both

upper limbs then extend both wrists, close the eyes , then push the

hand of patient toward the patient for flapping.

Chorea : it is the abnormal restless involuntary movement more

at the big proximal joints as around shoulder.

Athetosis : slow sinusoidal movement in the distal joints as in the

hand.

Hemiballismus : sudden violent movement due to sub thalamic

lesion.

4) Abnormal posture which is occurring as sustained movement

what is called Dystonia or the wrist drop....

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5) Look for any car of previous operation as for tendon

replacement.

2-Tone:

We have 3 degree of tone:

*Normal tone

*Hypotonia: as occur in cerebellar diseas and in peripheral

neuropathy.

*Hypertonia: As occur in 2 forms:

• Rigidity mean resistance will be continue through out the

movement and occur due to lesion in basal ganglia and occur due

to extra pyramidal lesion (Remember there is no special structure

or organ in body by this name only to differentiate it from the

pyramidal tract) and rigidity has 2 main forms:

A. cogwheel type-as occur at wrist joint and can be tested by

catching the hand of patient at the wrist joint then by other hand do

the circular movement of the hand it fond intermittent resistance.

Can be found in CVA.

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B. lead pipe Type -when you put the hand or forearm in a position

it will stay at that position as found in Dementia.

• Spasticity: mean there is resistance at the start of movement but

later become normal and no resistance, occur due to cortico spinal

tract lesion. Can be found in form of clasp-knife as in CVA.

Best way to examine the tone is by ( Sudden Fast Unexpected

movement) , as you handle the forearm at the elbow then by other

hand catch the hand of patient then move it to right and left then

suddenly move it toward the patient

and do the same movement at the lower limb.

To examine the clonus which is sustained continuous movement is

by catching the ankle and then move the foot toward the patient

many times then sudden move toward the patient.

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3-Power:

Remember the 5 degrees of the power:

G0 = there is no movement at all by asking the patient to move and

raise the hand can not do it.

G 1 = there is flicker movement, that the patient will only do some

fine movement at the fingers only

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G 2 = movement at bed side, as the patient wi1l move the hand at

the bed to right and left without elevating it.

G3= there is movement against the gravity as the patient will raise

the hand for a while.

G 4 = there is movement against the resistance for certain limit as

the patient will raise the hand and can raise it against your pressure

on the hand of patient.

G 5 = full normal movement.

The pyramidal weakness may occur in 2 forms:

* Central = here ther is paraplegia or hemiplegia and the grade of

power not equal around the affected joints.

*Peripheral weakness = there is bilateral symmetrical

involvement in UL or LL or both, and there is equal grades of

power around the joints.

CST play very important role and may be affected in case of

stroke, SOL, hematoma.

Functions include:

A- Anti gravity movements in the Upper limb:

1) Shoulder abduction

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2) Elbow extension

3) Wrist extention

4) Fingers extension

B- Anti gravity movements at the Lower limb:

1) Hip flexion

2) Knee flexion

3) Dorsiflexion of foot

4) Eversion of foot

So start the examination from proximal to distal because the

myopathy is almost proximal except in case of Myotonia

Dystrophica which is distal.

Upper Limb:

Tone Examination includes 6 muscle groups:

1) Deltoid= examine against the abduction of shoulder.

2) Latissimus dorsi = examine against the adduction of shoulder.

3) Biceps = examine against the flexion of the elbow joint.

4) Triceps = examine against the extension of elbow.

5) Forearm muscles = as examine against the supination and

pronation of forearm.

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6) Hand muscles = examined by ask the patient to grip your hand

strongly, and then against the extension ,flexion, abduction and

adduction of fingers.

Lower Limb:

Examination includes:

1) Examine against the abduction, adduction, extension( both of

your hands under the thigh of patient-glutei muscles) , flexion

(both of your hands on the patella of patient- iliopsoas muscle) of

hip joint.

2) Examine against the extension( quadriceps) and

flexion( Quadriceps Femoris) of knee joint.

3) Examine against the dorsi flexion, the plantar flexion, eversion

and inversion of the ankle joint.

4) Examine against the flexion and extension of toes.

Note :

•Monoplegia =paralysis of one limb as right hand

•Hemiplegia = paralysis of half of the body as right UL and LL •.

•Quadriplegia = paralysis of all limbs.

•Paraplegia = as paralysis of both LLs.

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4-Reflexes :

Before doing the reflex examination following points are

important:

*Remember the aim is to detect the mild asymmetry in reflexes

and not the gross obvious abnormalities.

*Almost start distally.

*Do complete relaxation of the patient before the examination

*Almost handle the hammer from the terminal part.

*Not hit the joint more than 2 times as the reflex will be

diminished by it self.

*Do the reflexes bilaterally and symmetrically as supinator on both

sides then the other reflexes.

*Elevate the hammer actively then let it hit the joint passively.

*Never say there is no reflex or diminished unless you do the re-

enforcement as by clinching the teeth or pulling the both hands

together.

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*L5 not share in any reflex.

*The most powerful reflex is knee reflex.

2 main groups of reflexes:

Deep Reflexes —Monosynaptic reflexes

A- UL ( Upeer Limb): include 3 reflexes:

Supinator Reflex:

By catching the fingers of the patient then hit about one finger or

one and half from the wrist joint by the hammer. Supply by C5, 6.

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Biceps Reflex:

Supply by C5,6 and done by flexing the elbow and put it on the

abdomen of patient then feel the biceps tendon and put your thumb

on it and hit your thumb with the hammer.

Triceps Reflex :

Supply by C7, done by flexing the elbow and put it on the

abdomen of patient then put one of your hand under the elbow

joint then hit by hammer about one finger or one and half from the

olecranon process. Muscle is triceps muscle and the nerve is radial

nerve.

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B-LL ( Lowe Limb): include 2 reflexes:

Knee reflex :

Supply by L3,4 and done by flexing the knee then put one of your

hand under the knee and by other hit the space between the head of

tibia and the lower part of patella. Muscle is quadriceps muscle,

nerve is femoral nerve.

Ankle reflex :

Supply by S1, muscle is Gastrocnemius muscle and the nerve is

posterior tibial nerve, is done by mild flexion of foot just do it on

the bed no need put that limb on the other one then hit the Achilles

tendon and watch the calf muscle.

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Superficial reflexes- Polysnaptict reflexes

2 main reflexes:

Abdominal reflex:

No specific supply some say it is T7,12, the muscles are rectus

abdominis muscles .

Abdominal reflex is absent in case of hemiplegia that the condition

will be confirmed by plantar up going, in case of obese and

multipara female.

Plantar Reflex :

Is done on the outer border of the foot and should be done

painfully and look to the big toe at first, the result is either:

*Big toe not move at all= pathological

*Big toe going up and down= called equivocal again is

pathological.

*Big toe is up going =severe pathological

*Big toe is down going = it is normal.

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Note : Remember the babiniski sign is +ve but normal in (neonate

and epilepticpatient).

In male also we have cremastric reflex (L1) by scratching the inner

aspect of the thigh in the creases for example.

And also the anal reflex that may be disappear in case of conus

medullaris lesion.

Note :

Hoffman sign is done by extending the wrist then scratch the tip of

middle finger then if +ve there is flexion of thumb and other

fingers.

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Co-ordination Examination

Also called cerebellar examination, and helpful for parkinsonism ,

include the following steps:

1) By inspection look to the eyes for the nystagmus (irregular

involuntary movements of eyes) , then test the speech of the

patient for the dysarthria, ask to protrude the tongue for the

ataxia, or intension tremor, hypotonia and decrease the

reflexes.

2) Finger-nose test :

as stand infront of the patient at first time explain for patient to put

the index finger on his or her nose and then on the examiner's

finger, then do it while the patient closed his or her eyes. The faster

touching your fingers the better the result, the result is either:

A.Intention tremor ( dysmetria) , if abnormal or irregular

touching of target found.

B.Dysnergia : total incoordination and clumsiness.

C.Post point: can not identify the target.

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3) Rapid-alternating test:

touching the other hand by palmar and dorsal surface of the other

hand, called Dysdiadochokinesia.

4) Heel-shin test:

ask the patient to make the friction of the heel of one foot on the

tibial shaft on the other limb.

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5) Romberg's sign:

ask the patient to stand and then do full abduction and move the

upper limb away from him self then close the eyes watch whether

falling occur or not.

6) Then examine for gait by asking the patient to move on the

straight line as if she or he measuring the distance by using the

feet.

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Sensory Examination

Superficial sensation: half of touch, pain and temperature.

Deep sensation: Half of touch, vibration.

Examination Steps:

1) Start from the both sides of face by pin prick or using a piece

of cotton wool, then proceed to the volar surface of the upper

and lower limb and all other areas, then ask the patient do

you feel it same on both side or not?

2) For vibration use the tuning fork: by asking to close the eyes

and whether feeling same or not put it on the following areas:

*Forehead

*Patella

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*Medial malleolus.

*Tuberosity of big toe.

3) Testing the Proprioception: this by asking to cloth eyes then

move the big toe 6 times upward and downward then ask the

patient to tell you the direction of the movement.

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Some Definition :

AGNOSIA: The inability to recognize the significance of sensory

stimuli, due to parietal lobe lesion. We have visual and olfactory

agnosia.

APRAXIA: inability to perform the purposeful movement in

absence of paralysis.

AGRAPHIA: inability to write.

ALEXIA : inability to read.

DYSCALGUL1A: inability to perform the mathematical

procedures.

Higher cerebral function Examination

The stepwise are:

1) Level of consciousness: either:

Fully conscious.

Coma : the complete loss of awareness to the environment even

when the patient is extremely stimulated.

Drowsy : inability to sustain the wakefulness without the external

stimuli.

Stupor : aroused only by vigorous and repeated stimuli only.

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The examination is as followings:

A- Do quick general examinations for any head trauma then say I

will take the vital signs as for high fever and type of respiration.

B- Do verbal command: ask the patient to show you 2

fingers( Hard command), or ask the patient to open eyes( easier

command).

C- Do the Localization of pain: as pinch to ear, cotton to nares,

shoulder pinch, calf pinch, pressure over the nail bed.

D- Then look to the response whether it is decerebrate (Extensor

posture), or Decorticate (Flexor posture). Treatment of focal lesion

causing coma need MRI and CT scan, while diffuse coma treated

by coma cocktail ( Thiamine 100 mg IV + Dextrose 50 ml IV+

Flumazenil 0.2-1 mg IV) also checking the ICP important.

2) Orientation:

do you know this person( Person), Do you know what is this place

(Place), do you know what time is it (Time).

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3) Memory:

we test 3 types of memory:

Immediate Memory : give him or her Phone number or 5

numbers but repeat it 3 times for him or her then after a few

minutes ask what that number was?

Recent Memory : ask the patient what you eat this morning?

Remote Memory: ask the patient about the some clear events that

occurred in that society to know whether can remember them or

not.

4) Speech:

include language, phonation and articulation.

The content include the followings:

* Comprehension: as ask the patient to close eyes, raise left leg,

put right hand on the head.

* Expression: during speaking you can note whether any

dysphasia or dysarthria.

* Reading: give the patient some paragraph to read it.

* Writing: ask the patient to write his or her name if not illiterate.

* Naming: show the patient a pen asking him or her to name it.

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* Repetition: give a sentence e ask the patient to repeat it after

you.

The abnormalities in speech occur as:

A)Dysphasia:

mean the disorder in using the language.

Include 4 types :

I. Expressive Dysphasia (Motor Dysphasia ): due to lesion in

Brocas area, her if ask the patient a question can understand you

but can not answer you.

II. Receptive Dysphasia (Sensory Dysphasia): occur due to

lesion in wernick's area here the answer will influent and use the

uncorrected word.

III. Conductive Dysphasia.: the patient have abnormality in

repetition.

IV. Global Dysphasia: include both receptive and expressive

Dysphasia due to lesion in arcuate fibers between that 2 areas.

B) Dysarthria :it is the disorder in articulation as due to disorder

in muscle of face , tongue pharynx or in BS or cerebellum , here all

features of speech is normal regarding the grammar and word. As

potato's speech.

C) Dysphonia: when impair air flow or damage to vocal cord.

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5- IQ of the patient: include the followings:

A- Difference and similarity: tell me what is the difference

between the apple and orange as regarding their color and taste.

B- Calculation: abstract the 30 from 2 then come down.

C-Attention: this can be noted during the history taking whether

the patient had attention for your questions or not.

D- Judgment: as give the patient a commonly used proverb ask

him or her to analyze it for you.

E- Insight: whether the patient feels he or she is sick or not if yes

means good insight.

F-mood and affect: mood is the patient's feeling, the affect is

what

you observe in the patient whether depressed euphoric...

6) Gait:

many types are abnormal as stamping gait, shuffling gait,

parkinsonian gait, circumduction gait in CVA, or the scissor gait

again in CVA.

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Glasgow Coma Scale – GCS

Total score is = 15

Eye opening:

None =1

Opening to pain=2

Opening to speech=3

Spontaneous opening=4

Best motor response

None=I

Extension of limb at elbow=2

Abnormal flexion=3

Withdrawal=4

Localization of pain=5

Obey command=6

Best verbal response

None=I

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Incomprehensive sound =2

Inappropriate word=3

Confused=4

Oriented=5

References:1-Hutchisons Clinical Method Michael Swash , 21st Edition 20022-Macleods Clinical ExaminationGraham Douglas ,11th Ediction,20053-Mannual of Practical MedicineR.Alagappan, 1st Edition, 19984-Davidsons Principles and Practice of MedicineHaslet , Chilvers , Boon, Colledge,Hunter 19th Edition ,20025-The ECG Made Easy John R. , Hampton , 5th Edition,1998

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6-Essentials of Applied ElectrocardiographyAtul Luthra ,1st Edition ,19937- http://meded.ucsd.edu UC UC San Diego , Division Of Medical Education 8- www.osceskills.com9- Practical Lectures By Dr Taha Mahwy10- www.medicinenet.com

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Contents :

History Taking In Neurology ………………………………2Clinical Examination In Neurology…………………………5Cranial Nerve Examination …………………………………6Examination Of Meningeal Sign……………………………..27Motor System Examination ………………………………….28Co-ordination Examination …………………………………..43Sensory System Examination…………………………………..46Higher Cerebral Function Examination………………………48Glasgow Coma Scale GCS ………………………………….....53References……………………………………………………….54Contents ………………………………………………………...56

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In This series :

Preparing the following practical books :1-Clinical Orthopedic.2- Clinical Gynecology .3- Clinical ENT .4- Clinical psychiatry .5- Clinical Neurology ( History taking & Physical

Examination In neurology)6-25 Cases in Clinical pediatric .7- History taking and physical examination in

surgery .8- The most important subject for 4,5, 6th stages

that you have to know before the exam .9- OSCE exam for 6th stage .10- ECG Interpretation.11- Common abdominal signs and symptoms .12- Theory exam Of previous years for 6 th stage13- History taking and physical examination in

Medicine14- Collection Of Physiology exam of previous years

for second stage medical students.

Preparing the following practical books for newly graduated doctors (Rotator) : About how to learn the routine of treating patient in All department in hospital : 1-Medical emergency & Case Management in CCU. 2-Surgical emergency . 3- Pediatric emergency & Case Management in premature Unit . 4- Obstetrical & Gynecological emergency. 5-Assessing and Management of patients in Primary health

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care & the most important medications used daily 6-ECG Interpretation.

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