1. Nervous system
History & Examination

2. Cardinal symptoms
 Altered sensorium
 Seizures
 Weakness
 Paresthesias
 Loss of function
 Abnormal movements
 Headache
 Abnormal behaviour

3. Nervous system
 Brain
 Cerebrum
 Midbrain
 Pons/medulla
 Cerebellum
 Cranial nerves- I-XII
 Spinal cord
 Peripheral nerves

4. Nervous system examination
 Consciousness
 Higher mental function
 Cranial nerves
 Motor system
 Sensory system
 Coordination
 Gait
 Meningial irritation, Skull, Spine

5. Consciousness
 Includes level (wakefulness) & content (awareness)
 Controlled by cerebral hemispheres & RAS in
brainstem
 Levels-
 Drowsy- arousable with verbal stimuli
 Stupor- arousable with painful stimuli
 Coma- not arousable
 Content-
 Confusion- a state of inattention & lack of clarity in thinking
(incoherent)
 Glasgow Coma Scale (GCS)- Eye.Motor.Vocal

6. Released reflexes
 In demented & confused patient
 Grasping- stroking of radial surface of palm, asso.
with C/L frontal lobe lesion
 Avoiding- stroking of ulnar surface of palm, asso. with
C/L parietal lobe lesion
 Glabellar tap
 Snout
 Sucking

7. Higher mental functions
 Orientation- time, place, person
 Memory- immediate, recent, remote
 Attention
 Calculation
 Language

8. Language
 Components-
 Articulation- Dysarthria
 Fluency
 Naming
 Repetition }Dysphasia
 Comprehension
 Reading
 Writing

9. Apraxia, Agnosia, Aphasia
 Apraxia- loss of ability to carry out learned
purposeful movements
 Agnosia- loss of ability to recognise, with
intact sensations & memory
 Aphasia- impairment of structure &
organization of language
 Receptive (fluent)- Wernicke’s
 Expressive (nonfluent)- Broca’s
 Dysarthria- defect in articulation &
enunciation of speech

10. Cranial nerves
 I- olfactory- sensory, smell
 II- optic- visual acuity/field, color vision
 III- oculomotor- MR,SR,IR,IO muscles,
sphincter pupillae (accomodation), levator
palpebrae superioris
 IV- trochlear- motor, superior oblique (SO4)
 VI- abducent- motor, lateral rectus (LR6)
AbR.OAd- abducted recti, obliques adducted

11. III, IV, VI nerve defect
 Squint/strabismus (paralytic)- secondary
(normal eye) > primary (affected eye)
deviation
 Diplopia- double image- true distinct &
false indistinct/blurred
 Head tilt- in the direction of affected muscle
 Past pointing- to same side on looking with
the affected eye
 Loss of accomodation
 Ptosis

12. Cranial nerves
 V- trigeminal- sensory to face
(cornea), motor to muscles of
mastication, controls oral secretion
 VII- facial- motor to all scalp & facial
muscles of expression except LPS,
taste sensation in ant. 2/3rd
of tongue

13. Facial palsy
 Supranuclear
 Lower face affected
 Emotional response
may be affected
 Taste intact
 Facial reflexes
increased
 No atrophy
 Infranuclear
 Whole face affected
 Emotional response
& reflexes affected
 Taste affected
 Hyperacusis
 Corneal reflex -nt
 Atrophy

14. Cranial nerves
 VIII- vestibulocochlear- balance & hearing-
vertigo, nystagmus, tinnitus, impaired
hearing, caloric tests, Rinne/Weber test
 IX- glossopharyngeal- sensory to post. 1/3rd
of tongue & pharynx
 X- vagus- motor to palate & pharynx
 XI- accessory- motor to sternomastoid &
trapezius
 XII- hypoglossal- motor to tongue

15. Motor system
 Upper motor neurons-
Corticospinal fibers from Frontal motor cortex 
Internal capsule  Pyramids in medulla 
crossover  Lateral corticospinal tract
(UM,LL)  terminates in anterior horn
 Lower motor neurons-
Anterior horn cells  Anterior spinal nerve root
 Peripheral nerve

16. Lesion
 Upper motor neuron
 Weakness
 Disuse atrophy
 Spasticity
 Reflexes
 Extensor plantar
 NCV- normal
 No denervation
potentials in EMG
 Lower motor neuron
 Pronounced weakness
 Wasting
 Flaccidity
 Loss of reflexes
 Fasciculations
 NCV- abnormal
 Denervation potentials
in EMG

17. Motor system examination
 Bulk
 Tone
 Power
 Reflexes
 Coordination
 Gait
 Involuntary movement

18. Power- grading
 0- complete paralysis
 1- flicker (any slightest movement)
 2- movement with gravity excluded
 3- movement against gravity but
not against resistance
 4- mild weakness
 5- normal power

19. Deep tendon reflexes (DTR)
 Jaw jerk- lesion
above trigeminal
motor nucleus-pons
 Supinator- C 5/6
 Biceps- C 5/6
 Triceps- C 6/7
 Knee- L 2-4
 Ankle- S 1/2
 Grading
 0- absent
 1- present
 2- brisk
 3- very brisk
 4- clonus

20. Superficial reflexes
 Corneal- trigeminal or facial nerve
 Palatal- IX-X cranial nerves
 Scapular- C5-T1
 Abdominal- T7-12
 Cremasteric- L1/2
 Plantar- L5/S1- extensor always abnormal
except age <1 year & postictal
 Bulbocavernosus- S3/4
 Anal- S3/4

21. Plantar reflex
 L5/S1
 Normally flexion of toes
 Extensor plantar reflex- components
 Extension of big toe, fanning of other toes, dorsiflexion of ankle,
flexion of knee, flexion of hip
 How to elicit?
 Babinski- stroke plantar surface of foot laterally from heel to toe
 Chaddock- stroke dorsal surface of foot laterally
 Oppenheim- stroke shin downwards
 Gordon- pinch/squeeze calf muscles
 Shaeffer- pinch Achilles tendon
 Extensor response denotes UMN lesion

22. Spinal segment & vertebra
 Vertebral column is longer than spinal cord
 Vertebra & corresponding spinal cord
segment
 Cervical vertebrae- +1
 Thoracic 1-6- +2
 Thoracic 7-9- +3
 T10- L1 & L2
 T11- L3 & L4
 T12- L5
 L1- sacral segments

23. Coordination
 Needs sensory input (joint/position),
cerebellum (lobes) & muscle tone
 Tests-
 Finger-nose test
 Rapid finger movements (touching the thumb)
 Dysdiadochokinesia
 Heel-shin test
 Walking in straight line  Tandem walking
 Romberg’s sign

24. Gait
 Legs exposed, feet bare
 Abnormal gait-
 Spastic- narrow base, knees extended, feet drag, circumduction
 Sensory ataxic- stamping with heel first
 Cerebellar ataxic- broad base, ‘drunken’
 Festinant (parkinsonian)- rapid, short shuffling steps
 Waddling (myopathic)- body tilted backwards, feet wide apart,
body sways sideways with each step
 High-stepping (peripheral neuropathic)- high step, toes landing
first

25. Involuntary movements
 Mostly due to disease of basal ganglia &
extrapyramidal system
 Types-
 Myoclonus- rapid irregular jerks of a group of muscles
 Tremor- distal, oscillatory, resting (P)/intentional (C)
 Athetosis- distal writhing purposeless movement
 Chorea- arrythmic forcible, jerky, rapid, restless movements
 Dystonia- abnormally maintained posture, plastic rigidity
 Hemiballismus- involuntary rapid violent flailing of arm
 Tics- repetitive abnormal movements, embarassing

26. Sensory system
 Receptors in skin  Peripheral nerves 
Posterior roots  Spinal cord (post. horn)
 Pain/temp./crude touch fibers crossover & ascend
in anterolateral spinothalamic tracts (UM,LL)
 Fine touch/position/vibration fibers ascend
ipsilaterally in posterior columns (LM,UL) that
crossover in medulla & travel in medial lemniscus
 Both join in thalamus, from where sensory
fibers travel via internal capsule to Parietal
cortex

27. Testing sensations
 From abnormal to normal areas
 Mark boundaries/dermatomes
 Touch & 2-point discrimination
 Vibration- tested at bony prominences
 Position- <10 degree movement can be appreciated
at all joints
 Pain- superficial (pin prick) & deep (muscle squeeze)
 Temperature
 Recognition of size/shape/weight/form

28. Other tests
 Meningeal irritation- neck rigidity,
Kernig’s sign (extend knee with hip
flexed)
 Straight leg raising test
 Deformity of skull or spine

29. Abbreviated neuro. exam.
 Pupils & ocular movements & fundus
 Facial movements
 Speech
 Power in arms & legs
 DTR & plantar reflex
 Pain & vibration in hands & feet
 Gait

30. Supported by
LP, X-ray, EMG/NCV, CT & MRI