1. MEDICAL HISTORY
 Cardiovascular system(chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask
for a brief description for each of the positive symptoms.
 Respiratory system (cough, haemoptysis, wheezing, pain localized to the chest that might increase with inspiration or
expiration).
 Gastrointestinal system (change in weight, flatulence and heart burn, dysphagia, abdominal pain, vomiting, bowel habit).
 Genitourinary system (frequency in urination, pain with micturition, urine color, any urethral discharge, altered bladder
control like urgency in urination or incontinence, menstruation and sexual activity).
 Nervous system (Headache,loss of consciousness, dizziness and vertigo, speech and related functions like reading and
writing skills and memory).
 Cranial nerves symptoms (Vision, diplopia, facial numbness, deafness,oropharyngial dysphagia, limb motor or sensory
symptoms and loss of coordination).
 Endocrine system (weight loss, polydipsia, polyuria, increased appetite and irritability).
 Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness,aggravating and relieving
factors for the pain and any positive family history for joint disease).
 Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun).
NEURO
Category Tests
Example of
writeup
Mental status examination
 The assessment of consciousness, often using the Glasgow Coma
Scale (EMV)
 Mental status examination, often including the abbreviated mental
test score (AMTS) or mini mental state examination (MMSE)
 Global assessment of higher functions
 Intracranial pressure is roughly estimated by fundoscopy; this also
enables assessment for microvascular disease.
"A&O x 3,
short and
long-term
memory
intact"
Cranial nerve examination
Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye
movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic),
sensory function of face (V),strength of facial (VII) and shoulder girdle
muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement
and reflex (IX, X), tongue movements (XII). These are tested by their
individual purposes (e.g. the visual acuity can be tested by a Snellen chart).
"CNII-XII
grossly
intact"
Motor system
 Muscle strength, often graded on the MRC scale 0 to 5[4]
(i.e., 0 =
Complete Paralysis to 5 = Normal Power).
o grades 4−, 4 and 4+ maybe used to indicate movement
against slight, moderate and strong resistance respectively.
 Muscle tone and signs of rigidity.
 Examination of posture
o Decerebrate
o Decorticate
o Hemiparetic
 Resting tremors
 Abnormal movements
o Seizure
o Fasciculations
o Tone
 Spasticity
"strength 5/5
throughout,
tone WNL"

2.  Pronator drift
 Rigidity
 Cogwheeling (abnormal tone suggestive of
Parkinson's disease)
 Gegenhalten – is resistance to passive
change, where the strength of antagonist
muscles increases with increasing
examiner force. More common in
dementia.
Deep tendon reflexes
Reflexes: masseter,biceps and triceps tendon, knee tendon, ankle jerk and
plantar (i.e., Babinski sign). Globally, brisk reflexes suggest an abnormality
of the UMN or pyramidal tract, while decreased reflexes suggest
abnormality in the anterior horn, LMN, nerve or motor end plate. A reflex
hammer is used for this testing.
"2+
symmetric,
downgoing
plantar
reflex"
Sensation
Sensory system testing involves provoking sensations of fine touch, pain
and temperature. Fine touch can be evaluated with a monofilament test,
touching various dermatomes with a nylon monofilament to detect any
subjective absence of touch perception.
Sensory
o Light touch
o Pain
o Temperature
o Vibration
o Position sense
o Graphesthesia
o Stereognosis, and
o Two-point discrimination (for discriminative sense)
o Extinction
o Romberg test – 2 out of the following 3 must be intact to
maintain balance: i. vision ii. vestibulocochlear system iii.
epicritic sensation
"intact to
sharp and
dull
throughout"
Cerebellum
Cerebellar testing
o Dysmetria
 Finger-to-nose test
 Ankle-over-tibia test
o Dysdiadochokinesis
 Rapid pronation-supination
o Ataxia
 Assessment of gait
o Nystagmus
o Intention tremor
o Staccato speech
"intact
finger-to-
nose, gait
WNL"