The document provides information about the nervous system, including its anatomy and physiology. It discusses the central nervous system (brain and spinal cord) and peripheral nervous system (cranial and peripheral nerves). It then covers performing a neurological examination, including obtaining a patient history, testing the cranial nerves, assessing the motor and sensory systems, and evaluating reflexes. The summary provides an overview of the key topics covered in the document.

1. The Nervous System
Dr Tsion D.

2. ANATOMY AND PHYSIOLOGY
• The central nervous system
– Brain
– Spinal cord
• The peripheral nervous system
– Cranial nerves (12 pairs)
– Peripheral nerves (motor and sensory fibers)
• Reflexes
• Motor and sensory pathways

7. History
• Taking the patient's history is traditionally the first step
in virtually every clinical encounter.
• A thorough neurologic history allows the clinician to
define the patient's problem.
• Solid knowledge of the basic principles of the various
disease processes is essential for obtaining a good
history.
• As Goethe stated, "The eyes see what the mind knows."

8. • Personal profile (Age, sex, address,occupation,
socio-economic status).
• Symptom onset (acute, sub-acute, chronic,
insidious)
• Duration of symptoms
• Course of the condition (static, progressive, or
exacerbating and remitting)
• Associated symptoms such as seizures,
headache, nausea, vomiting, and pain

9. • Pain should be further defined in terms of the
following:
– Location (Ask the patient to point with one finger, if
possible.)
– Radiation (Pay attention to any dermatomal
relationship.)
– Quality (stabbing, stinging, lightninglike, pounding,
etc)
– Severity or quantity (Estimate functional limitation.)
– Precipitating factors (stress, periods, allergens, sleep
deprivation, etc)
– Relieving factors (sleep, stress management, etc)
– Diurnal or seasonal variation

10. • Important miscellaneous factors of the history include the
following:
– Results of previous attempts to diagnose the condition
– Any previous therapeutic intervention and the response to
those treatments
 A complete history often defines the clinical problem and
allows the examiner to proceed with a complete but
focused neurologic examination.

12. Neurological examination
• The neurologic examination is challenging and
complex.
• Neurologic examination is performed to localize a
lesion in the central nervous system (CNS) or peripheral
nervous system (PNS).
• "History tells you what it is, and the examination tells
you where it is."
• The history and examination allow the neurologist to
arrive at the etiology and pathology of the condition,
which are essential for treatment planning.

13. Tools
• Reflex hammer
• Penlight
• Tongue blade
• Safety pin
• Cotton swab
• A Snellen Eye Chart or pocket vision card
• 128 and 512 ( or 1024) HZ tuning forks
• Dermatome chart

14. Neurological examination
o – Mental status
o – Cranial nerves
o – Motor
o – Reflexes
o – Coordination and gait
o – Sensory
o – Special techniques

15. • Elements of the mental status
examination(MOST MENTAL STATUS)
o level of consciousness
o orientation
o speech and language
o memory
o fund of information
o insight and judgment
o abstract thought, and calculations

16. Level of consciousness
• The state of awareness of the self and the
environment.
• Awake and alert
• Lethargic - Speak to the patient in a loud voice
– drowsy but open their eyes and look at you, respond to
questions, and then fall asleep.
• Obtunded - Shake the patient gently
– open their eyes and look at you, but respond slowly and
are somewhat confused.
• Stupor- Apply a painful stimulus
– The pt arouses from sleep only after painful stimuli.
• Comatose - Apply repeated painful stimuli
– A comatose patient remains unarousable with eyes closed.

17. ORIENTATION
• Awareness of personal identity, place ,and time.
• Requires both memory and attention
• Time (e.g., the time of day, day of the week, month,
season, date and year, duration of hospitalization)
• Place (e.g., the patient’s residence, the names of
the hospital, city, and state)
• Person (e.g., the patient’s own name, and the
names of relatives and professional personnel)

18. LANGUAGE
• Assessed by observing the content of the
patient's verbal and written output, response to
spoken commands, and ability to read.
– Fluency
– Naming
– Repetition
– Reading
– Writing
– Comprehension
Aphasia(LAGUAGE DIFFICULTY)
vs. dysarthria(SPPECH DIFFICULTY )

19. MEMORY
• Should be analyzed according to three main time
scales:
• 1) Immediate memory :- assessed by saying a list of
three items and having the patient repeat the list
immediately.
• 2) Short-term memory :- tested by asking the patient
to recall the same three items 5 and 15 min later.
• 3) Long-term memory :- evaluated by determining how
well the patient is able to provide a coherent
chronologic history of his or her illness or personal
events.

20. Cranial Nerves

21. The Cranial Nerves
• I Smell
• II Visual acuity, visual fields, and ocular
fundi
• II, III Pupillary reactions
• III, IV, VI Extraocular movements
• V Corneal reflexes, facial sensation,
and jaw movements
• VII Facial movements
• VIII Hearing

22. • Cranial Nerve I—Olfactory ( usually omitted)
– Use familiar and nonirritating odors e.g. coffee,
lemon, soap etc...
– 1st check the patency of each nostrils
– With eyes closed check one nostril at a time
– Odor perception, identification
• Cranial Nerve II—Optic
– visual acuity
– visual fields ( by confrontation)
– Funduscopic examination

23. Visual Acuity
• To test the acuity of central vision use a
Snellen eye chart.
• Position the patient 6meter(20 feet) from the
chart.
• Patients who use glasses other than for
reading should put them on.
• Visual acuity is expressed as two numbers
(e.g., 6 /12):
– The first indicates the distance of the patient from
chart, and
– The second, the distance at which a normal eye

24. Visual Fields
• Screening.
• Usually sufficient to examine the visual fields
of both eyes simultaneously.
• Screening starts in the temporal fields because
most defects involve these areas.
• Face the patient at a distance of
approximately 0.6–1.0 m (2–3 ft) and place
your hands at the periphery of your visual

25. screening

26. • Further Testing
• If you find a defect, try to establish its
boundaries.
• Test one eye at a time.

27. • CN II & III—Optic and Oculomotor
– Inspect the size & shape of the pupils, and
compare one side with the other.
– Test the pupillary reactions to light
• The direct reaction (pupillary constriction in the same
eye)
• The consensual reaction (pupillary constriction in the
opposite eye)
– Always darken the room and use a bright light
before deciding that a light reaction is absent.
– Examine the near response (accommodation)

28. CN III, IV, & VI - Oculomotor, Trochlear&
Abducens
• Observe for Ptosis (PROLASE OF AN ORGAN)
• Test Extraocular Movements
– Stand or sit 3 to 6 feet in front of the patient.
– Ask the patient to follow your finger with their
eyes without moving their head.
– Check gaze in the six cardinal directions using a
cross or "H" pattern.
– Pause during upward and lateral gaze to check for
nystagmus.
– Check convergence by moving your finger toward
the bridge of the patient's nose

29. The six cardinal directions

30. Cranial Nerve V—Trigeminal
• Motor
– the temporal and masseter muscles in turn , ask
the patient to clench his or her teeth.
– Note the strength of muscle contraction.
• Sensory.
– Pain sensation.
– temperature sensation
– light touch
• The corneal reflex

32. Cranial Nerve VII—Facial
• Inspect the face, both at rest and during
conversation with the patient.
• Note any asymmetry and observe abnormal
movements.
• Ask the patient to:
o 1. Raise both eyebrows.
o 2. Frown
o 3. Close both eyes tightly so that you cannot
open them.

33. Supranuclear facial palsy (obove
primary motor neuron or UMI)

35. Cranial Nerve VIII—Acoustic

36. CN VIII
• Assess hearing.
• If hearing loss is present => try to distinguish
between conductive and sensorineural hearing
loss.
• Using a tuning fork, preferably of 512 Hz or
possibly 1024 Hz.
• 1) Rinne test
– compare air and bone conduction
• 2) Weber test

37. Rinne test
• In conductive hearing loss, sound is heard
through bone as long as or longer than it is
through air (BC = AC or BC > AC).
• In sensorineural hearing loss, sound is heard
longer through air (AC > BC).

38. Test for lateralization (Weber test)
• In unilateral conductive hearing loss, sound is
heard in (lateralized to) the impaired ear.
• In unilateral sensorineural hearing loss, sound
is heard in the good ear.

39. CN IX and X — Glossopharyngeal
& Vagus
• Listen to the patient's voice, is it hoarse or
nasal?
• Ask Patient to Swallow
• Ask Patient to Say "Ah"
– Watch the movements of the soft palate and the
pharynx.
• Test Gag Reflex (Unconscious/Uncooperative
Patient)
– Stimulate the back of the throat on each side.
– It is normal to gag after each stimulus.

40. Cranial Nerve XI—Spinal
Accessory
• From behind, look for atrophy or assymetry of
the trapezius muscles.
• Ask patient to shrug shoulders against
resistance.
• Ask patient to turn their head against
resistance. Watch and palpate the
sternomastoid muscle on the opposite side.

41. Cranial Nerve XII—Hypoglossal
• Listen to the articulation of the patient’s
words.
• Observe the tongue as it lies in the mouth.
• Look for any atrophy or fasciculations
• Ask patient to:
– Protrude tongue
– Move tongue from side to side

42. The motor system

43. The Motor system
• Observation
• Body position
• Involuntary Movements - tremors, tics, or
fasciculations
• Muscle Symmetry
– Left to Right
– Proximal vs. Distal
• Muscle Bulk
– Pay particular attention to the hands, shoulders,
and thighs.

44. • Muscle Tone
• Ask the patient to relax.
• Flex and extend the patient's fingers, wrist,
and elbow.
• Flex and extend patient's ankle and knee.
• There is normally a small, continuous
resistance to passive movement.
• Observe for decreased (flaccid) or increased
(rigid/spastic) tone.
• Muscle Strength

46. • Test the following:
– 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 two of your fingers as hard as possible
(test hand 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)

47. – Adduction at the hips (L2, L3, L4, adductors)
– Abduction at the hips (L4, L5, S1, gluteus 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)

48. Coordination
• Coordination of muscle mov’t requires that
four areas of the NS function in an integrated
way:
– The motor system, for muscle strength
– The cerebellar system, for rhythmic movement and
steady posture
– The vestibular system, for balance and for
coordinating eye, head, and body movements
– The sensory system, for position sense

49. • To assess coordination, observe the pt’s
performance in:
o Rapid alternating movements
o Point-to-point movements
o Gait and other related body movements
o Standing in specified ways.

50. Rapid Alternating Movements
– Ask the patient to strike one hand on the thigh,
raise the hand, turn it over, and then strike it back
down as fast as possible.
– Ask the patient to tap the distal thumb with the tip
of the index finger as fast as possible.
– Ask the patient to tap your hand with the ball of
each foot as fast as possible.

51. Point-to-Point Movements
– Ask the patient to touch your index finger and
their nose alternately several times. Move your
finger about as the patient performs this task.
– Hold your finger still so that the patient can touch
it with one arm and finger outstretched. Ask the
patient to move their arm and return to your
finger with their eyes closed.
– Ask the patient to place one heel on the opposite
knee and run it down the shin to the big toe.
Repeat with the patient's eyes closed.

52. Gait
• Walk across the room, then turn, and come
back.
• Walk heel-to-toe in a straight line (tandem
walking).
• Walk on the toes, then on the heels—
sensitive tests respectively for plantar flexion
and dorsiflexion of the ankles, as well as for
balance.
• Hop in place on each foot in turn.
• Do a shallow knee bend, first on one leg, then
on the other.

53. Stance
• THE ROMBERG TEST
– This is mainly a test of position sense.
– The patient should first stand with feet together and eyes
open.
– Then close both eyes for 20 to 30 seconds without support.
– Note the patient’s ability to maintain an upright posture.
• TEST FOR PRONATOR DRIFT
– The patient should stand for 20 to 30 seconds with both arms
straight forward, palms up, and with eyes closed.
– A person who cannot stand may be tested for a pronator
drift in the sitting position.

54. Reflexes

55. Deep Tendon Reflexes
• The patient must be relaxed and positioned
properly before starting.
• Reflex response depends on the force of your
stimulus. Use no more force than you need to
provoke a definite response.
• Reflexes can be reinforced by having the
patient perform isometric contraction of other
muscles (clenched teeth).

57. • Biceps (C5, C6)
• Triceps (C6, C7)
• Brachioradialis (C5, C6)
• Knee (L2, L3, L4)
• Ankle (S1, S2)
• Abdominal Reflex
– lightly but briskly stroking each side of the abdomen,
above (T8, T9, T10) and below (T10, T11, T12) the
umbilicus.
– Note the contraction of the abdominal muscles
and deviation of the umbilicus towards the
stimulus.

58. • The Plantar Response (L5, S1)
– Stroke the lateral aspect of the sole of each foot
with the end of a reflex hammer or key.
– Note movement of the toes, normally flexion
(withdrawal).
– Extension of the big toe with fanning of the other
toes is abnormal. This is referred to as a positive
Babinski.
• Clonus
• If the reflexes seem hyperactive, test for ankle
clonus:
– Support the knee in a partly flexed position.
– With the patient relaxed, quickly dorsiflex the foot.

59. The Sensory System

60. • To evaluate the sensory system, you will test
several kinds of sensation:
– Pain and temperature (spinothalamic tracts)
– Position and vibration (posterior columns)
– Light touch (both of these pathways)
– Discriminative sensations, which depend on some
of the above sensations but also involve the cortex

61. • General
– Explain each test before you do it.
– Unless otherwise specified, the patient's eyes
should be closed during the actual testing.
– Compare symmetrical areas on the two sides of
the body.
– Also compare distal and proximal areas of the
extremities.
– When you detect an area of sensory loss map out
its boundaries in detail.

62. • Vibration
• Use a low pitched tuning fork (128Hz).
– Test with a non-vibrating tuning fork first to
ensure that the patient is responding to the
correct stimulus.
– Place the stem of the fork over the distal
interphalangeal joint of the patient's index fingers
and big toes.
– Ask the patient to tell you if they feel the vibration.
• If vibration sense is impaired proceed
proximally:
– Wrists
– Elbows

63. • Subjective Light Touch
• Use your fingers to touch the skin lightly on
both sides simultaneously.
• Test several areas on both the upper and lower
extremities.
• Ask the patient to tell you if there is difference
from side to side or other "strange"
sensations.

64. Position Sense
• Grasp the patient's big toe and hold it away
from the other toes to avoid friction.
• Show the patient "up" and "down."
• With the patient's eyes closed ask the patient
to identify the direction you move the toe.
• If position sense is impaired move proximally
to test the ankle joint.
• Test the fingers in a similar fashion.
• If indicated move proximally to the
metacarpophalangeal joints, wrists, and

65. • Dermatomal Testing
• If vibration, position sense, and subjective
light touch are normal in the fingers and toes
you may assume the rest of this exam will be
normal.
• Pain
• Use a suitable sharp object to test "sharp" or
"dull" sensation.
• Test the following areas:
– Shoulders (C4)
– Inner and outer aspects of the forearms (C6 and
T1)

66. • Temperature
• Often omitted if pain sensation is normal.
• Use a tuning fork heated or cooled by water
and ask the patient to identify "hot" or "cold."
• Light Touch
• Use a fine whisp of cotton or your fingers to
touch the skin lightly.
• Ask the patient to respond whenever a touch
is felt.

67. Discrimination
• Since these tests are dependent on touch and
position sense, they cannot be performed
when the tests above are clearly abnormal.
• Graphesthesia
– With the blunt end of a pen or pencil, draw a large
number in the patient's palm.
– Ask the patient to identify the number.
• Stereognosis
– Use as an alternative to graphesthesia.
– Place a familiar object in the patient's hand (coin,
paper clip, pencil, etc.).
– Ask the patient to tell you what it is.

68. Two Point Discrimination
– Use in situations where more quantitative data
are needed, such as following the progression of a
cortical lesion.
– Use an opened paper clip to touch the patient's
finger pads in two places simultaneously.
– Alternate irregularly with one point touch.
– Ask the patient to identify "one" or "two."
– Find the minimal distance at which the patient can
discriminate.

69. Special Techniques
• Asterixis
• Meningeal signs
– Nuchal rigidity or neck stiffness
– Brudzinski sign(in meningitis, involuntary flexion of
the knees and hips following flexion of the neck
while supine)
– Kernig sign

70. Approach to Unconscious Patient
• Consciousness:Is a state of awareness of internal
and external stimuli coupled with the ability to react
to these stimuli either by thought or by direct physical
movement.
• It is dependent upon the integrity and interaction
between the cerebral cortices and arousal system
(ARAS)

71. • Four questions demand immediate answer?
1. Are the vital functions intact or compromised?
2. How deep is the coma?
2. Is there raised intracranial pressure with actual or
impending tentorial herniation?
4. What is the cause of coma and is the cause
remediable?

72. • Take a history from relatives or
friends
•Was there any preceding
illness?
• Fever and headaches before coma would
suggest malaria or meningitis
•Was the onset of coma sudden
or gradual?

73. Neurologic examination of
comatos patient
• The state of responsiveness
• Brain stem reflex
• Motor examination

74. Assessing the state of
responsiveness
THE GCS (glasgow coma scale)
This is a score that describes the depth of
coma
It should be carried out on every comatose
patient
It allows effective communication with

76. Investigations
• CBC
• Blood film
• Glucose measurements
• Arterial blood gas analysis
• Electrolytes
• BUN & creatinine
• Toxicologic analysis of blood & urine
• Blood and urine cultures
• CSF examination

77. MANAGMENT
• Important principles are
– Look after the Airway Breathing and
Circulation first
– stabilize the patient with cervical spine
injuries
– Draw blood for lab studies
– Rapidly diagnose and treat the treatable
causes, like malaria, meningitis,
hypoglycaemia and hypertension
– Monitor the patient closely for any
deterioration in their GCS, or change in

78. • The main objective of therapy is to find the
cause and remove.
• Others supportive management like
1. Maintain clear air way
2. Give O2
3. Keep patient in semi-prone position
4. Suspect hypoglycemia in every case
and give 1-2 ml of 25% dextrose water

79. 5. If the patient is in shock, start rapid
infusion of( blood plasma or normal
saline)
6.Control of temperature hypo or hyper
tremie
7.Cerebral edema should be corrected
giving IV mannitol & dexamethasone
8. Give adequate nutrition via NG tube
when the patient is stable

80. 9. Prevent bedsores
10.Care for oral hygiene
11.Catheterize the bladder
12.Care of bowel

81. Prognosis of coma
• Depends on the cause of the coma.
• Metabolic comas have a far better prognosis
than traumatic ones.
• factors such as age, underlying systemic
disease, and general medical condition

82. • GCS-. Patients scoring 3 or 4 have an
85% chance of dying or remaining
vegetative, while scores >11 indicate
only a 5–10% likelihood of death or
vegetative state and 85% chance of
moderate disability or good recovery
• For anoxic and metabolic coma, clinical
signs such as the pupillary and motor
responses after 1 day, 3 days, and 1
week have been shown to have

83. THANK YOU