HIGHER MENTAL FUNCTIONS

Consciousness—if impaired document using Glasgow coma scale

Orientation to time/place/person

Memory:

Immediate (repetition—30 seconds)

Recent (up to 5 minutes—recall)

Remote (> 5 minutes)

Intelligence

Mood/emotion

Concentration and calculation (subtract seven from 100)

Speech:

Spontaneous speech—comprehension

Fluency

Repetition

Reading

Writing

Naming objects

Phonation

Aphasia

Dysarthria

Apraxias—present/absent

Hemineglect—present/absent

Hallucinations and delusions—present/absent

Cranial nerves R L

Olfactory—I nerve:

Sense of smell (peppermint, soap, coffee, lemon peel or vanilla)

*Both eyes shut, one nostril checked at a time

Appreciate smell ± identify it

Optic—II nerve:

Visual acuity (perception of light/hand movements and finger counting/Snellen’s chart at 6 meters/Jaeger’s chart at 14 inches)

Visual field (confrontation method/menace reflex)—mention defects, if any

Color vision (Ishihara’s test)

Fundus

Oculomotor, trochlear, abducens—III, IV, VI nerves:

Eyelids (any ptosis)

Position of eyeballs at rest (any deviation, exophthalmos, enophthalmos)

Extraocular movements:

Binocular movements

Saccadic:

Pursuit:

Reflex (doll’s eye, caloric stimulation)

Uniocular movements

(#Comment on ophthalmoplegia, if present—supranuclear, internuclear, individual nerves, or muscles)

Pupil

Size (in mm)

Shape

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Reaction

Direct light reflex

Consensual light reflex

Accommodation reflex

Nystagmus

(Describe whether spontaneous or provoked/type—horizontal, vertical, rotatory, pendular)

Trigeminal nerve—V nerve:

Sensory:

Touch

Pain

Temperature

(To be checked on all three divisions around the jawline, on the cheek, and on the forehead)

Motor:

Jaw deviation

Hollowing above and below zygoma

Clenching teeth (feel temporalis and masseter)

Open mouth against resistance

Side to side movement of jaw (pterygoid)

Reflexes:

Corneal—present/absent (superficial reflex, 5th nerve afferent, 7th nerve efferent)

Jaw jerk—present/absent/exaggerated (deep reflex, afferent and efferent, both 5th nerve, center mid-pons)

Facial nerve—VII nerve:

Facial asymmetry (look for absence of wrinkling, drooping of corner of mouth, obliteration of nasolabial

fold, widened palpebral fissures)

Motor:

Frontalis (raise the eyebrows)

Orbicularis oculi (shut the eyes tight)

Buccinator (show teeth, smile, blow check, whistle)

Orbicularis oris (close lips, pronounce labials “p”,”b”,’’m”)

Platysma (pull down the corners of mouth)

(## Look for Bell’s phenomenon)

Sensory:

Anterior 2/3rd tongue taste (sugar, lime, salt, quinine)

Lacrimation

Hyperacusis—present/absent

Emotional fibers checking—emotions preserved or not

Vestibulocochlear nerve—VIII nerve:

The ability to hear the sound produced by rubbing the thumb and forefinger together is then tested for

each ear at distances up to a few centimeters

Rinne’s test—air conduction/bone conduction (AC/BC)

Weber’s test—lateralized/centralized

Caloric test [Irrigates one external auditory canal with cool (about 30°C) or warm (40°C) water.

Normally, cool water in one ear produces nystagmus on the opposite side. Warm water produces it on

the same side]

Glossopharyngeal, vagus IX, X nerve:

Note the patient’s ability to drink water and eat solid food and also see the character, volume and sound

of the patient’s voice.

Position of uvula

Movement of uvula on saying “ah”—any deviation

Gag reflex—present/absent/exaggerated (taste over the posterior third of the tongue and can be

tested)

Spinal accessory—XI nerve:

Sternocleidomastoid (instruct the patient to rotate head against resistance applied to the side of the

chin to tests the function of the opposite sternocleidomastoid muscle. To test both

sternocleidomastoid muscles together, the patient flexes the head forward against resistance placed

under the chin)

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Trapezius (shrugging a shoulder against resistance)

Hypoglossal nerve—XII:

Inspection (inside the mouth):

Size of tongue

Symmetry/any wasting

Fasciculation (on protrusion)

Deviation—side

Tremors

Palpation:

Tone

Power

Speech

MOTOR SYSTEM

Attitude

Upper limb

Lower limb

Bulk

Inspection: Symmetry, generalized wasting comment on small muscle wasting, deformities, claw

hand, foot drop, if any.

Measurement in cm R L

Arm (10 cm above olecranon)

Forearm (10 cm below olecranon)

Thigh (18 cm above the superior border of patella)

Leg (10 cm below the tibial tuberosity)

Note: Bilateral similar distance from fixed bony points till the maximum bulk of muscle.

Tone

R L

Upper limb

Lower limb

Note: Comment whether normal, hypotonia or hypertonia (spasticity/rigidity).

Power

Checked both isometric (resistance against movement) and isotonic (resistance at end of

movement).

0 Complete paralysis

1 A flicker of contraction only

2 Power detectable only when gravity is excluded by postural adjustment

3 Limb can be held against gravity but not resistance

4 Limb can be held against gravity and some resistance

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5 Normal power

Muscle R L

Neck

Flexors (SCM, platysma, scalene, suprahyoid, infrahyoid, longus colli and capitis, rectus capitis)

Extensors (trapezius and paravertebral muscles—splenius, erector spinae, transversospinalis,

interspinal intertransverse)

Note: Avoid active movement checking if cervical cord injury suspected

Shoulder

Abduction (0–15°—supraspinatus, 15–90°—middle fibers of deltoid, above 90°—trapezius and

serratus anterior)

Adduction (pectoralis major, latissimus dorsi and teres major)

Flexion (biceps brachii (both heads), pectoralis major, anterior deltoid, and coracobrachialis)

Extension (posterior deltoid, latissimus dorsi, and teres major)

Elbow

Flexion (biceps brachii)

Extension (triceps brachii)

Wrist

Flexion (FCR, FCU)

Extension (ECRL, ECRB, ECU)

Hand grip (long flexors)

Small muscles of hand

Trunk (rectus abdominis, transversus abdominis, oblique, pyramidalis)

Elevation of head or leg in supine position

Beevor’s sign if present

Abdominal binding to check for intercostal muscle weakness

Intercostal binding to check for diaphragmatic weakness

Hip

Flexion (iliopsoas)

Extension (gluteus maximus)

Abduction (gluteus medius and minimus, tensor fascia lata)

Adduction (adductor longus, brevis, and magnus)

Knee

Flexion (hamstrings)

Extension (quadriceps)

Ankle

Plantar flexion (gastrocnemius, soleus)

Dorsiflexion (tibialis anterior)

Small muscles of foot, EHL if needed

REFLEXES

Superficial reflexes R L

Corneal (cranial nerve V and VII)

Abdominal:

Epigastric (T6–T9)

Mid-abdominal (T9–T11)

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Hypogastric (T11–L1)

Cremasteric (L1, L2)

Anal reflex (S2, S3)

Plantar:

Reflexogenic zone—S1

Afferent nerve—tibial nerve

SC segments—L4, L5, S1, S2

Chaddock’s (lateral aspect of foot from below up), Gordon’s (calf), Oppenheim’s (anterior tibia), Schaffer’s (Achilles tendon),

Gonda’s (press down 4th toe), Stransky’s (adduct little toe), Bing’s (pinprick on dorsolateral foot)

Deep tendon reflexes R L

Jaw jerk (afferent and efferent both 5th nerve and center mid pons)

Biceps (C5, C6)

Brachioradial/supinator/radial periosteal (C5, C6)

Triceps (C6, C7, C8)

Knee jerk/quadriceps/patellar reflex (L2, L3, L4)

Ankle jerk (L5, S1, S2)

Clonus—present/absent

Patellar

Ankle

Latent reflexes (suggest pyramidal lesion if present unilaterally)

Tromner’s/finger flexor reflex/Hoffmann’s sign

Wartenberg’s sign

By convention the deep tendon reflexes are graded as follows:

0 = no response; always abnormal

1+ = a slight but definitely present response; may or may not be normal

2+ = a brisk response; normal

3+ = a very brisk response; may or may not be normal

4+ = a tap elicits a repeating reflex (clonus); always abnormal

Please do reinforcement maneuvers before saying DTR’s are absent

Primitive reflexes

Glabellar tap

Palmomental (both sides)

Sucking

Rooting

Pout and snout

Grasp

Involuntary movements (describe in detail)

Coordination (described later under cerebellum)

SENSORY SYSTEM

Primary sensation R L

Touch

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Pain

Temperature

Vibration

Joint position sense

Any sensory level

Pattern of sensory loss (graded/dissociative/crossed/hemi)

Cortical sensation (to be tested only in the presence of primary sensation intact) R L

Tactile localization (topognosis)

Two point discrimination

Stereognosis

Graphesthesia (figure identification)

Sensory extinction

Romberg’s test:

CEREBELLAR SIGNS

Upper extremity R L

Limb ataxia:

Outstretched arm test

Finger nose test

Nose-finger-nose test

Finger-finger test

Rapid alternating movements:

Rapid hand tapping

Pronation-supination

Thigh slapping

Pointing and past pointing

Writing (macrographia)

Rebound phenomenon (arm)

Tremors (intention)

Lower limbs R L

Heel knee test

Pendular knee jerk

Finger toe test

Rapid alternating movements—foot tapping

General

Titubation

Nystagmus

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Tremors

Hypotonia

Truncal ataxia

Tandem walking

Gait

GAIT

Base—wide or narrow

Slow/rapid

Falling to sides

Look which part of foot touches ground first (toe/heel)

How high foot lifted above ground?

Hand swing

Turning around

Position of hip, sound produced while foot touches ground.

Signs of Involvement of Autonomic Nervous System

Dryness of skin/excessive sweating/spoon test

Postural hypotension

Heart rate—baseline, on respiration, on standing

Palpable bladder

Pupillary reactions

Valsalva maneuver.

Signs of Meningeal Irritation

Neck stiffness

Kernig’s sign

Brudzinski’s sign—neck, leg, and pubis.

Skull and Spine

Deformities

Tenderness

Short neck.

SOFT NEUROLOGICAL SIGNS

Pyramidal drift describes a tendency for the hand to move upward and supinate if the hands are

held outstretched in a pronated position (palms downward), or to pronate downward if the hands

are held in supination.

Cerebellar drift is generally upward with excessive rebound movements if the hand is suddenly

displaced downward by the examiner.

Parietal drift is an outward movement on displacing the ulnar border of the supinated hand.

OTHER SYSTEMS

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Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation:

Cardiovascular system:

Inspection:

Palpation:

Percussion:

Auscultation:

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation:

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B. DIAGNOSIS FORMAT

GENERAL FORMAT

Nature of Disease

Onset: Sudden/acute/subacute/chronic (sudden—vascular, acute—demyelinating, subacute—

infections/space occupying lesions, chronic—degenerative)

Deficit: Monoplegia/hemiplegia/quadriplegia/paraplegia/nerve palsies/ataxia/sensory

disturbance/movement disorders.

Site of Involvement of Nervous System

Upper motor neuron disease—intracranial (brain or cerebellum) or extracranial (spinal cord)

Lower motor neuron disease—anterior horn cell disease, radiculopathies, neuropathies,

neuromuscular junction diseases, and myopathies.

FOR CEREBROVASCULAR ACCIDENT

Sudden onset, right-sided dense hemiplegia with right upper motor neuron (UMN) facial palsy due

to cerebrovascular accident possible thrombotic in etiology with site of lesion being left internal

capsule, possible involving the lenticulostriate branch of middle cerebral artery (MCA). Patient is in

state of neuronal shock. Patient has following risk factors _____.

FOR NEUROPATHY

Acute onset of symmetrical flaccid quadriplegia (ascending) with no evidence of sensory, bowel,

bladder involvement with bilateral lower motor neuron (LMN) facial palsy, possible site of lesion in

the peripheral nerve, pathology being demyelination—acute inflammatory demyelinating

polyneuropathy (AIDP).

FOR SPINAL CORD DISEASE

Subacute onset of symmetrical spastic paraplegia with involvement of sensory, bladder, and bowel;

with no involvement of cranial nerves with vertebral tenderness at T4-5, possible site of lesion is

spinal cord, the disease being compressive myelopathy.

Horizontal level

Extradural extramedullary

Vertical level

Motor level: Above T10

Sensory level: At T8

Autonomic level: Above T12

Reflex level: Above T10

Spinal level: T8

Vertebral level: T5.

Possible etiology: Tuberculosis—Pott’s spine.

FOR EXTRAPYRAMIDAL (PARKINSON’S DISEASE)

Insidious onset, slowly progressive, degenerative disease involving the motor system (in the form of

rigidity and tremors) with no evidence of sensory, cranial nerves or bowel, bladder, we would

consider involvement of extrapyramidal system probably parkinsonism with no evidence of

secondary causes, no signs or symptoms of Parkinson’s plus syndromes, functional status—Stage

III (Hoehn and Yahr staging system).

FOR ATAXIA

Insidious onset, slowly progressive, symmetrical ataxia and cerebellar signs of trunk and limbs with

no evidence of sensory, cranial nerve or autonomic involvement. I would like to consider the

possibility of degenerative cerebellar ataxia possibly inherited (family history +ve).

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C. CENTRAL NERVOUS SYSTEM: DISCUSSION ON CARDINAL SYMPTOMS

DISCUSSION ON CARDINAL SYMPTOMS

Taking a Neurological History

The neurological history should be a focused, goal-directed exercise that seeks to answer the

following questions:

Which part of the nervous system is affected by “a pathological process” and is causing the

symptoms (where is the lesion)? Is it a single lesion or are there multiple diffuse lesions?

Alternatively, is there a diffuse problem affecting many neurological systems?

What is the underlying pathological process (e.g. vascular, inflammatory, degenerative)?

Is this a purely neurological problem or a neurological manifestation of a systemic disease?

Note:

Ask the patient to tell their story in their own words

Explore each symptom in detail, evaluating the evolution and the way the symptoms affect the

ability to function

Ask for an eyewitness account when cognition or consciousness is involved

If you cannot make a neurological diagnosis, take the history again before arranging

investigations.

Pathology of neurological diseases

Acute Subacute Chronic

Vascular—stroke

Demyelination

Metabolic

Infection

Space occupying lesions

Metabolic

Degeneration

HIGHER MENTAL FUNCTION

Altered State of Consciousness

Onset

Any seizures, blackouts

Any fall/injuries

Any ear or nose bleed

Fever

Any ear pain or discharge

Drug history

Any addictions.

Other Higher Mental Functions

Speech difficulty

Difficulty to recognize people or objects

Memory defects

Inappropriate crying or laughter

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Lack of interest

Social disinhibition

Delusions/hallucinations.

Mental State and Cognition

Changes in the memory

State of alertness and drowsiness

Changes in the mood and affect (loss of spontaneity)

Language changes

Loss of spatial orientation

Diminished ability to carry out routine activities of daily living.

CRANIAL NERVE DYSFUNCTION

Ask about:

CN Symptoms

1 Smell disturbance

2, 3, 4,

6

Diplopia, blurred vision, blindness, difficulty in opening eyelid (CN3)

5 Difficulty in chewing, loss of sensations over face

7 Deviation of angle of mouth, accumulation of food at one side of the mouth, dribbling of saliva, loss of taste

sensation, hyperacusis

8 Tinnitus, hearing loss, dizziness, loss of balance

9, 10 Nasal intonation, nasal regurgitation of food, dysphagia, difficulty in speech, hoarseness of voice

11 Difficulty in neck/shoulder movements

12 Difficulty in mixing food in the mouth, difficulty in speech

For example: Left LMN 7th nerve palsy—history of retroauricular pain followed by abrupt onset

deviation of angle of mouth to right with slurring of speech and difficulty in left eye closure with

history of hyperacusis.

MOTOR DYSFUNCTION

Weakness

Distribution of Weakness

Is it symmetrical/asymmetric?

Plegia—complete loss of power—0/5 vs paresis—incomplete loss of power

One limb: Monoparesis.

Two limbs, same side: Hemiparesis.

Both lower limbs: Paraparesis.

All four limbs: Quadriparesis (or tetraparesis).

Pentaplegia is a spinal cord injury at or above C4 level, resulting in complete loss of motor

functions below the injury level and paralysis of respiratory muscles.

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