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1. BY:
DR. EDITH KAYODE IYASERE
CONSULTANT PHYSICIAN/NEUROLOGIST
FORMER MEDICAL DIRECTOR,
CENTRAL HOSPITAL, BENIN CITY, EDO STATE
FORMER CHIEF CONSULTANT BOARD/ DIRECTOR
OF CLINICAL SERVICES
HOSPITAL MANAGEMENT BOARD,
BENIN CITY, EDO STATE
RETIRED PERMANENT SECRETARY MINISTRY OF
HEALTH

2.  Nervous System – CNS and the peripheral
nervous system (PNS)
 CNS - Brain and spinal cord
 PNS – contains all the nerves that lie outside the
CNS
 The primary role of the PNS is to connect the
CNS to the organs, limbs, skin and muscles.
 The PNS contains all the nerves that lie outside
the brain and spinal cord. It includes the cranial
nerves, spinal nerves, their roots and branches,
peripheral nerves and the neuromuscular joins.

3.  The PNS has two components:
 The Somatic Nervous System (SNS) and the
Autonomic Nervous System (ANS).
 SNS or voluntary nervous system: is
associated with the voluntary control of body
movements via skeletal muscles to perform our
daily functions.
 ANS: Regulates involuntary physiologic
processes including heart rate, blood pressure,
respiration, digestion and sexual arousal. It
contains three anatomically distinct divisions:
Sympathetic, parasympathetic, and enteric.

5.  Neurological disorders comprise those affecting the
brain, spinal cord, peripheral roots and nerves and
the muscles.
 They account for 20% of admissions to medical
wards and is the underlying cause of long term
disability in the community.
 Some CNS Disorders include:
 Headaches e.g. migraine.
 Cerebrovascular diseases (CVD) e.g. stroke.
 Epilepsy.
 Movement disorders e.g. Parkinson’s disease.
 Diseases of the spinal cord e.g. spinal cord
compression.

6.  Diseases of muscle e.g muscular dystrophies.
 Disorders of peripheral nerves.eg Guillan-Barre
Syndrome
 Disorder of neuromucular junction e.g
myasthenia gravis.
 Inflammatory disorders eg. Multiple sclerosis

7.  The spinal cord is a single structure, whereas: the
adult brain is described in terms of four major
regions: the cerebrum, the diencephalon, the brain
stem and the cerebellum.
 Cerebrum – Four lobes: frontal, parietal,
temporal, occipital
 Diencephalon - Hypothalamus, thalamus
 Brain stem – Midbrain, pons, medulla
 Cerebellum - Two cerebella hemispheres.
 Despite advances in diagnostic, neuroradiology and
electrophysiology, an accurate detailed case history
and neurological examination remains the
cornerstone of neurological diagnosis.

8. 1. History
 Identification
 Patient’s name
 Age, sex and race
 Handedness
 Marital status
 Occupation/ Religion
 Address
2. PRESENTING COMPLAIN
 E.g. Headache.
3. HISTORY OF PRESENTING COMPLAIN
 Symptom evaluation:
 Onset- acute, sub-acute, chronic, insidious
 Duration
 Course of the condition (e.g. static, progressive, relapsing, &
remitting)

9.  Severity of symptoms
 Precipitating and aggravating factors
 Ameliorating or relieving factors including
medications
 Presence or absence of related symptoms (Associated
symptoms)
 Previous diagnostic evaluations.
 History of Etiology
 History of Complications
4. PAST MEDICAL HISTORY
 Prenatal history and developmental mile stones if
applicable e.g. epilepsy
 Immunization

10.  Major illnesses e.g. Hypertension, diabetes mellitus
etc. surgeries, trauma
 Past and present medications including dosages and
indications.
 Allergies
5. FAMILY HISTORY
 Family tree
 Consanguinity
 Relatives with problems similar to patient’s problem.
 Age and state of health of living relatives.
 Age at death and cause of death of deceased
relatives

11. 6. SOCIAL HISTORY
 Education
 Employment- including occupational hazards and exposure
 Travel History
 Habits especially alcohol, tobacco and other hard drugs
 Sexual orientation.
7.DRUG HISTORY
 Recent and current medications. Many neurological symptoms
are caused by drugs given for other conditions e.g. tricyclic
antidepressants causing epilepsy or statins causing headache.
Any previous therapeutic interventions and the response to
those treatments.
8. REVIEW OF SYSTEMS
 Skin, eyes, ears, nose, throat, respiratory, cardiac, GIT, genito-
urinary, muscular, skeletal etc.

12.  Begins as the patient walks into the consulting room.
Note facial expressions, dress, posture, gait, speech
1. Mental state exams or higher cortical function:
 Orientation in time, place and person.
 Memory – Short and long term
 Attention & concentration – serial 3 and serial 7
tests Mood & Effect
 Sense of judgment.
 Abstract thinking
 Intelligence

13. 2.Language and Speech-
 Dysphasia
 Dysarthria
 Dysphonia
3. Cranial nerves:
3.1 Olfactory- Identification by smell of oil of
cloves, peppermint, coffee or tobacco.
3.2 Optic:
 Visual acquity in each eye
 Visual field in each eye
 Ophthalmoscope exam of Cornea, optic disk,
retina macula and blood vessels in each eye

14. 3.3.4.6 Oculomotor, trouchlear and Abducens
 Pupils - size, shape, direct and consensual reaction to
light, reaction to accommodation
 Appearance of eyes – ptosis, exophthalmos
 Eye movements
 Conjugate movements
 Nystagmus - series of repetitive or oscillatory
movement of the eye.
3.5. Trigeminal: Sensory, motor and
 Reflexes which include corneal, jaw jerk.
 Sensory - touch, pain and temperature sensation in
first (ophthalmic), second (maxillary) and third
(mandibular) divisions
 Motor: Mandibular branch innervates the temporalis,
masseter and lateral pterigoids (muscles of
mastication).
 Jaw opening & closing

15. 3.7. Facial nerve: Muscles of facial expression
 Motor function - inspect face for asymmetry, wrinkling of the
forehead, eye closure, buccinators, show your teeth.
 Taste anterior 2/3 of the tongue.
3.8. Vestibulocochlear: for hearing and balance
 For hearing – weber test (lateralization) and Rennie’s test
(tuning fork test – air conduction versus bone conduction)
 Vestibular – test for nystamus
3.9.10 Glossopharyngeal & vagus:
 They have an intimate anatomical relationship.
 Both contain sensory, motor and autonomic components.
 9th nerve - taste sensation posterior 1/3 .
 Gag reflex or swallowing
 Elevation of the palate midline or deviated.

16. 3.11. Accessory :
 Spinal part provides fibers to the trapezius and
sternocleidomastoids.
 Head turning
 Shoulder shrug
 Sternocledomastoid or trapezius atrophy
3.12.Hypoglossal : Supplies the muscles of the tongue
 Tongue atrophy or fasciculation
 Rapidity and strength of the tongue movements
4. Motor system:
 Assessed under the following
1. Inspection and palpation of muscles:
 Muscle atrophy or hypertrophy
 Fasciculation

17.  Abnormal or involuntary movements which include:
 Tremors
 Myoclonic Jerks
 Asterixis
 Dystonia
 Chorea
 Athetosis
 Ballismus
 Tics
2.Tone (in all limbs).
 Defined as resistance to passive movement.
 - Assessed as normal, hypotonia (decreased tone) or hypertonia
(increased tone). There are two principal types of hypertonia:
 Spasticity (clasp knife) and
 Rigidity (lead pipe) with or without cog wheel rigidity:-

18. 3.Power:-
 Strength of individual muscles.
 Grade muscle power according to Medical Research
Council scale.
 Grade 0-5
 0 = No movement
 1 = Flicker of movement
 2 = Movement from side to side
 3 = Movement against gravity
 4 = Movement against gravity and resistance
 5 = Normal power
4. Tendon reflexes:
 Normal
 Absent
 Decreased
 Hyperactive
 Hyperactive with clonus

19. 5. Co-ordination - cerebellar function
 - Finger nose test- dysmetria
 -Heel shin test – Dyssynegia
 -Rapid alternating movement – Dysdiadokokeinsia
 Also test for dysathria, nystaymus, stance & gait,
hypotonia
6. Sensory system:
A. Primary sensory modalities- pain (pin prick
sensation)
 Temperature
 Vibration sense. Tuning fork 128 hz.
 Joint position sense.
B. Cortical sensory modalities
 Stereognosis : Mental perception of depth, 3d
 Graphesthesia : ability to recognize shapes traced on
the palm
 Two point discrimination