This document provides information on performing a neurological history and physical examination. It discusses assessing the mental status, cranial nerves 1-12, motor system, reflexes, sensory system, and special examinations. For the mental status examination, it describes how to evaluate level of consciousness, orientation, attention, memory, perception, thought, mood, speech, and higher cognitive functions. It also provides details on specifically examining the cranial nerves, motor strength and coordination, reflexes, and sensory function.

1. HISTORY AND PHYSICAL EXAMINATION
IN
NEUROLOGY

2. NOTE
 Central Nervous System-Brain & Spinal
Cord
 Peripheral Nervous System-12 pairs of c
ranial nerves and the spinal and periphe
ral nerves.
 Most of the peripheral nerves contain bo
th motor and sensory fibers.

3. HISTORY
 Assess the cooperation of patient
 If not/ be it consciously or unconsciously,/ ta
ke history form attendants
 Try to get a clarification of the meaning of a
complaint
 Onset, evolution and course of the sympto
m
 Observe- speech, thought
 Some symptoms might not have sign—get
more information from history

4. PHYSICAL EXAMINATION
1. Mental status
2. Cranial nerve
3. Motor system
4. Reflexes
5. Sensory system
6. Special examination

5. I)MENTAL STATUS
 *LOC
 *Attention
 *Memory
 *Orientation
 Perception
 Thought process
 Thought content
 Insight
 Judgment
 Affect
 Mood
 *Language(speech)
 *Higher cognitive fun
ction

6. 1.Level of consciousness*
 understand and respond to questions
 apply stimuli/ verbal, physical or painful/ and see resp
onse
 Conscious patient aware of himself & his environme
nt and is able to respond both to internal and external
stimuli
 Abnormality
 lethargy—drowsy, responds to quest’n and fall asleep
 obtundation– opens eye, responds slowly, confused a
nd low interest and alertness
 stupor– arouse from sleep with painful stimuli slow or
absent verbal response
 coma– unarousable

7. 2. Orientation*
 Time
time of the day,date, month, year
 Place
residence, name of hospital, city, state
 Person
patients name, name of relative, name of colleagu
es

8. 3. Attention*
 Digit span:- repeat a number of digits after you / forward
and backward/ or start with two and continue till the length the p
atient can’t repeat, tell loudly and slowly/ one digit per second
Normal-five forward/ four backward
 Serial seven:- subtract seven out of hundred note efort ,
speed, accuracy
Normal – finish in 1.5 min
 Spell backward:- Ask patient to spell a five lette
r word backward
Replace serial seven,

9. 4. Memory*
 Remote /years/
birthdays, anniversaries, names of school attended
 Recent/minutes, hours to days/
ask events of the day
 New learning ability
tell three unrelated words and ask the patient to repeat
after three to five minutes

10. 5. Insight and judgment
 INSIGHT:- Awareness of abnormality of the symp
tom, ask the patient what brings him to the hospital
 JUDGMENT:- Process of comparing and evalu
ating alternatives, assess patients response to family
situation, job, use of money, interpersonal conflicts

11. 6. Perception/Thought
 Perception:- sensory awareness of objects & th
eir interrelationship in the environment
Abnormality-hallucination, illusion
 Thought content:- what people think about a
nd level of insight & judgment, Abnormality-delusion,
phobia, compulsion, depersonalization
 Thought process:- the logic, coherence, & re
levance of patients thinking as it leads to selected go
als
Abnormality– circumstancial, loosening of associatio
n, flights of ideas

12. 7. Mood
 A sustained emotion affecting personal
view of the world
 Assess it during hx taking or ask directly
 Assess risk of suicide if pt is depressed
 Abnormalities—mood disorder

13. 8. Higher cognitive function*
 information and vocabulary
ask about specific facts and assess the amount of informati
on he has Eg- the name of the president, prime minister etc
 Calculating ability
addition and multiplication
 Abstract thinking
interpretation of proverbs, similarities between objects
 Constructional ability
copy figures
Abnormalities in the above functions occur in patients with ment
al retardation, dementia, schizophrenia

14. 9. SPEECH*
 Assess it during the interview
 Speech is mediated by the dominant hemisphere,
 assess
- spoken and written language
- character of speech/ articulation, fluency/
-if you find abnormality test different functions/na
ming, repetition, comprehension, writing/
 parietal- writing
 Parieto-occipital--- reading
 Frontal ---articulation
 Temporal---fluency, comprehension, repetition, writ
ing

15. Con’t
 Aphasia- fluency, comprehension, na
ming, repetition, reading, writing
- Anterior(Broca’s) aphasia-
fluency, articulation affected
- Posterior(Wernike’s) aphasia-
neologism, jargon
 Dyslexia-reading
 Dysgraphia-writing

16. II)CRANIAL NERVES 1-12
 All except 1 and 2 arise from the brain s
tem
 CN 1 & 2 are continuation of CN tissue
 Supply the head and neck / motor, sens
ory and autonomic/

17.  CN 1(Olfactory)
project to uncus and parahippo
Examine nasal canal
Assess smell
 CN 2(Optic)
Retina---optic nerve—optic chiasm--optic tract---lateral g
eniculate----calcarian cortex
Assess- visual acuity
visual field
others/ colour vision, visual localization, visual recog
nition/ if necessary
Visual acuity :- by Snellechart,special hand held ca
rd, count finger or light perception

18. Visual field
 confrontation
 Test one eye/ right with left and left with right/
 Sit at one meter distance and extend arm at eq
ual distance
 Assess every direction/up, down,right,lef
 perimeter

19.  CN 3(Occulomotor),4 (Abduscence)& 6(Trochl
ear)
Test extraocular mov’t
right eye
All except SO and LR supplied by CN3
levator palpebra Iris and ciliary muscle-Edinger Westpha
l nucleus
SR
IO
SO
IR
LR MR

21.  Conjugate eye movement integrate
d at brainstem
 Infranuclear-unilateral eye mov’t
strabismus- diplopia,dizziness
 Supranuclear-conjugate eye mov’
Lateral unilat-pontine paramdial reticular for
mation
Lateral bialteral-central pontine
Upward-central midbrain,inferior thalamic
Downward-medulla
 Cerebellar-Nystagmus
 Extrapyramidal-low interrupted purs
uit

22.  Pupil
size, shape, reaction to light and accomodati
on
afferent CN 2/bilateral/ and efferent CN3
abnormalities- Argyll Robertson pupil-NRL,R
A
-Tonic/Adie pupil-
CN 5(trigeminal) /ophthalmic,maxillary,
mandibular/
 sensory- face, upper teeth,nose, pharynx, tongue
 motor- Mastication muscles
 Parasympathetic- salivary and lacrimal gland

23.  CN 7(Facial)
 sensory- somatic auricle, taste anterior 2/3 of th
e tongue
 motor- muscles of facial expression
 Test-smile, eye closure,whistle,furrow,
 CN 8(Vestibulocochlear)
 cochlear –hearing
vestibular-- balance
Test hearing

24.  CN9,10,11(glossopharyngeal,vagus,accessa
ry)
 9-motor- pharyngeal,stylopharyngeal
taste-posterio 1/3
 10-motor-palate,pharynx,larynx
-parasympathetic-heart, viscera
 11- pure motor-sternocm, trapezius
See position of palate
Assess gag reflex, muscle/sternocm,trape
zius/
Hx-dysphagia, hoarseness of voice,dysart
hria
 CN 12(hypoglossal
◦ Motor to the tongue

25. MOTOR
 Involuntary movement
 Bulk
 Power-graded according to the research council scale
 Tone
 Reflex
 Coordination

26.  Gait
 Spastic hemiparetic
 Scissor
 Sensory ataxia
 Cerebellar ataxia
 Parkinsonian

27.  Bulk
 atrophy-LMNL
 Pseudohypertrophy- Musc dystrophy
 Power- Grade o-5
 Tone
 Hypotonic-LMNL, cerebellar
 Hypertonic- spastic- Corticospinal
-rigidity- extra pyramidal
-Paratonic/mitgehen
- gegenhalten/-bihemispheric lesion

28. Coordination
 RAM- observe speed, rhythm,smoothness
- hand
- finger
- thumb
 Point to point- observe smoothness and a
ccuracy
-finger to nose,
-heel to shin
 Stance
- Romberg’s sn 20-30s
- pronator drift 20-30s
 Gait
- assess the patients gait, tandem walk,

29. Reflex
 Grade 0-absent
1-low normal
2-average normal
3-brisk
4-associated with clonus
Ankle S1,2
Knee L2,3,4
Brachioradialis C5,6
Biceps C5,6
TricepsC6,7

30. SENSORY
Principles
 Compare symmetrically, distal &proximal
 Do it fast
 No need to do vibration and position proximal if distal is no
rmal
 Change pace and rhythm of examination
 Map the abnormality
Land marks :- C-3 neck, C-6 thumb, T-4 nipple, T-10 umbili
cus,
L-1 inguinal, L-4 Knee, L-5 Ankle, S3-5 peria
nal
 Modalities -pain &T-spinothalamic
-position& vibration-posterior column
-light touch-both
-recognition of shape, size, weight, form
- above + cortical

31. Special examination
Asterixis non rhythmic, brief flexion of the hand and
finger 1-2s
# Metabolic encephalopathy
Meningeal signs
Neck stiffness
Kernig’s
brudniski’s
Autonomic function
orthostatic change in BP,PR
Pupil rxn, sweating,

32. Minimental status assessment
 score out of 30,
 lower than 21 is associated with cognitive abnormality
& has 12 variables
- orientation to time and place and serial 7 score 5
- short term memory, learning ability and three stage
command 3
- naming and construction -2
- other variables assess speech/repetition, reading,
writing/ and another construction score 1

33. STUPOROUS OR COMATOUS PA
TIENT
 Respiration - hyperpnea- midbrain/pontine
- bradypnea-increase ICP
- Cheyne-stokes-hemispheric/dienceph
alo
- ataxic-medullary
 Pupil - unilateral D, -ve LR— uncal herniation
- midposition,-ve LR — midbrain
- miosis, +ve LR-- pontine
- fixed dilation-- diencephalon
- Horner’s syndrome– hypothal, thal
- Small pupil, brisk LR--- metabolic
- Small pupil, slugish LR--- Drug

34.  Ocular movement
Spontaneous
- conjugate deviation--- ipsilat hemisphere, contra
BS
- depression --- midbrain, metabolic
- dysconjugate--- CN 3 or6 affection
- ocular bobing low pon, cerebellar hematoma, hydr
ocephalus
 Reflex
- Oculocephalic
- Oculovestibular
 Corneal reflex absent in deep coma and drug induced c
oma/ light/
 Posture and muscle tone- Decerebrate/ decorticate

35. Thank you