2. • Personal H:
– Handness
– Occupation (driver)
• C/O:
– Onset, course & duration
• Family H:
– Heredofamilial ataxia
– Familial periodic paralysis
– Peroneal mus. atrophy
• Past H:
2 T Trauma, TB
2 S Syphilis, Similar attack
2 H HTN, Heart disease
2 D DM, Drugs
1 E ENT
1 F Fever
• HPI:
– 12 items
History
3. HPI
• Motor
• Sensory
• Trophic
• Cranial n
• ↑ ICT
• Fits
• Speech
• Sphincter
• Gait
• Mental
• Hypoth
• Other
4. Motor
• Involuntary: extra ∆ , fasiculation
• State
• Tone
• Weakness
• Ataxia (cerebellum)
•Dist or prox
•Stat or Kinetic
•Disappear e sleep or Not
•UL or LL
•Rt or Lt
•Dist or Prox
•Flexor or Extensor
•Abductor or Adductor
•Drunken gait
•Intension tremors
•dysdidoko
•+ve romberge
•Improve on bed
5. Sensory
• Superficial: Pain, Temp, Touch
• Deep: Position, Mov., Vibr.
• Cortical: Steriog, T. loc., T. discr.
• Ulcers: (N.B. : painless)
If +ve : pattern
•Sensory level
•hemihypoth
•Glove & stock
•Jacket loss
Trophic changes or deformities
6. Cranial n
• ①:
• Anosmia
• ②:
• Acuity
• Field
• ③,④,⑥:
• Diplopia
• Ptosis
• Squint
• ⑤:
• Sensory
• Pain,Temp
• Motor
• Masticat.
• ⑦:
• Sensory
• Tast ant ⅔
• Motor
• Eey clos.
• Mouth clos.
• ⑧:
• Deaf
• Tinitus
• Vertigo
• ⑨, ⑩:
• Dysph (phar)
• N. regur (palat)
• N. tone (palat)
• Hoarsn (lary)
• ⑪:
• Shoulder elev
• neck side mov
• ⑫:
• Tounge mov
7. ↑ ICT
• Papilledema
• Headache
• Vomiting
• Aura
• Post effect
• Cons. Loss
• Gener. Or local
• March
Fits
8. Speech
• Aphasia: (higher neurolo. center lesion):
– Receptive(sensory):
• Spoken(Auditory)(aud recogn area lesion)
• Written(Visual)(visual recogn area lesion)
– Expressive(motor):
• Spoken (broca’s area lesion)
• Written(Agraphia)(exner’s area lesion)
• Dysarthria: (articul system lesion):
– ∆: bilateral→ slurred (psudobulbar)
– Extra ∆ → slow monotonus
– Cerebellar → stacatto
– Cr n → slurred (true bulbar)
13. EXAMINATION – LEVEL OF
CONSCIOUSNESS (AROUSAL)
Level of Consciousness (Arousal): Techniques and Patient Response
Level Technique Abnormal Response
Alertness Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you,
and responds fully and appropriately to stimuli
(arousal intact).
Lethargy Speak to the patient in a loud voice. For
example, call the patient’s name or ask, “How
are you?”
A lethargic patient appears drowsy but
opens the eyes and looks at you, responds
to questions, and then falls asleep.
Obtundation Shake the patient gently, as if awakening a
sleeper.
An obtunded patient opens the eyes and
looks at you, but responds slowly and is
somewhat confused. Alertness and interest
in the environment are decreased.
Stupor Apply a painful stimulus. For example, pinch a
tendon, rub the sternum, or roll a pencil across
a nail bed. (No stronger stimuli are needed.)
A stuporous patient arouses from sleep
only after painful stimuli. Verbal responses
are slow or even absent. The patient
lapses into an unresponsive state when
the stimulus ceases. There is minimal
awareness of self or the environment.
Coma Apply repeated painful stimuli. A comatose patient remains unarousable
with eyes closed. There is no evident
response to inner need or external stimuli.
15. Speech
Read Sorat El Fateha
• Aphasia: (higher neurolo. center lesion):
• Dysarthria: (articul system or Cr n. lesion):
Trophic changes or deformities
16. Motor
• Involuntary: extra ∆ , fasiculation
• State
• Tone
• Weakness
• Ataxia (cerebellum)
• Reflexes
•Dist or prox
•Stat or Kinetic
•Disappear e sleep or Not
•UL or LL
•Rt or Lt
•Dist or Prox
•Flexor or Extensor
•Abductor or Adductor
•Drunken gait
•Intension tremors
•dysdidoko
•+ve romberge
•Improve on bed
•Rapid alternating movem
•Finger-to-Nose /Finger
•Heel-to-Knee Test
•Romberg’s Test
•Gait
Sensory or
Cerebellar ataxia:
•-ve romberg
•Intension tremors
17. Tone
• 6 joints + don’t forget support before joint
• Tone is the resistance appreciated when
moving a limb passively
• “Normal Tone”
• Hypotonia
– “Central Hypotonia”:shock UMNL, cerebellar
– “Peripheral Hypotonia”: LMNL, myopathy
• Hypertonia
– Spasticity (Corticospinal Tract = ∆ )
– Rigidity (Basal Ganglia, Parkinson’s = extra ∆ )
18. Flexion at the elbow (C5, C6, biceps)
Extension at the elbow (C6, C7, C8, triceps)
Extension at the wrist (C6, C7, C8, radial nerve)
Squeeze 2 fingers as hard as possible ("grip," C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Oppostion of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4, iliopsoas)
Adduction at the hips (L2, L3, L4, adductors)
Abduction at the hips (L4, L5, S1, G. medius and minimus)
Extension at the hips (S1, gluteus maximus)
Extension at the knee (L2, L3, L4, quadriceps)
Flexion at the knee (L4, L5, S1, S2, hamstrings)
Dorsiflexion at the ankle (L4, L5)
Plantar flexion (S1)
Weakness: examine the following
19. Muscle(s) Function Primary Nerve Origin
DELTOID Shoulder abduction Axillary C5-C6
BICEPS Elbow flexion Musculocutaneous C5, C6
TRICEPS Elbow extension Radial C6, C7, C8
WRIST EXTENSORS Radial C6, C7, C8
WRIST FLEXION Median C6, C7
HAND GRIP Grasp Fingers Median C7, C8, T1
FINGER ADDUCTION Median C7-T1
FINGER ABDUCTION Ulnar C8, T1
THUMB OPPOSITION Median C8, T1
HIP FLEXION Iliopsoas L2, L3, L4
HIP EXTENSION Gluteus maximus S1
Quadriceps Knee extension L2, L3, L4
Hamstrings Knee flexion L4, L5, S1, S2
Tibialis anterior Foot dorsiflexion Deep peroneal L4, L5
Gastrocnemius Ankle plantar flex mainly S1
Ext hallicus longus Extens of great toe L5
Weakness: examine the following
21. Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength
22. Deep (tendon jerks)
UL
• BICEPS
• BRACHIORADIALIS
• TRICEPS
LL
• KNEE + clonus
• ANKLE + clonus
Reflexes & clonus
Superficial reflexes
• Corneal
• Grasp
• Gag (palatal)
• Planter
• Abdominal
• Cremastric
• Anal
C5,6
C6,7
L2,3,4
S1,2
S1,2
T6-12
L1
S3,4,5
Abnormal Deep reflexes
• Jaw jerk
• Wartenberg
• Finger jerk
• Hofman
• Patelal jerk
• Adductor jerk
Technique
Babiniski Scratsh From below up- lat to medial
Chaddock The skin under and around the lateral malleolus
is stroked in a circular fashion.
Gonda’s Flex 3
rd
& 4
th
toes 7 release suddenly
Oppenheim press to the anterior surface of the tibia,
stroking down to the ankle.
Gordon Compressing the calf muscles
Schaefer Pinching the Achilles tendon enough to cause
pain.
Sure
signs of
∆????
23. EXAMINATION – REFLEXES: SCALE
FOR GRADING
Reflexes are usually graded on a 0 to 4+ scale
4+ Very brisk, hyperactive, with clonus
3+ Brisker than average; possibly but not
necessarily indicative of disease (no clonus)
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response
24. Sensory
• Superficial: Pain, Temp, Touch (one ⅟2, Rt & Lt, derm)
• Deep: Position, Mov., Vibr., N & M
• Cortical: Steriog, T. loc & discr., Graph.
If +ve : pattern
•Sensory level
•hemihypoth
•Glove & stock
•Jacket loss
26. Cranial n
• ⑤ - Sensory: (ophth., maxillary, mandibular)
- Motor: (massiter, temporalis, tregoid)
- Reflexes:
• Corneal
• Jaw : if +ve = bilateral ∆ lesion above pons (above ⑤ nc.)
• ⑦ - Sensory: (Tast ant ⅔ of tounge)
- Motor: (frontalis, orbic occul., buccinator,
retractor angulii, orbic oris)
- Reflexes:
• glabellar
• ⑧ - Nystagmus
- Hearing
⑤→⑦
⑤→⑤
⑦→⑦
Rapid phase toward
H
pendular
occular
H
fix i.e. (lesion)
cerebel
H
Away from (norm)
vestib
V
vertical
stem
27. Cranial n
• ⑨,⑩ -Say AHH = palatal movement ⑩
Move up = normal
deviate to healthy =
LMNL
Move No movement
-Palat reflex
-Pharyn reflex
⑤→⑩
⑨→⑩
Exag bilat=
Bilateral UMNL
Lost bilateral=
Bilateral LMNL
