COMPLETE NEUROLOGICAL EXAMINATION AND ITS APPLICATION IN PSYCHIATRY

1. Neurological examination in
psychiatry
Abid rizvi
Junior resident 3
Department of psychiatry

2. Major section of neurological
examination
• Mental status
• Cranial nerves
• Motor
• Sensory
• Reflexes
• Cerebellar functions and co-ordination
• Gait and station
• Abnormal movements

4. Mental Status Exam
1. level of consciousness
2. attention and concentration.
3. Orientation
4. Speech and language
5. Memory
6. Calculation skills
7. Logic and abstractions
8. test for agnosia and apraxia
9. judgement and insight

5. Level of consciousness
• “ability to relate to both self and surrounding”
• Quantitative lowering of consciousness
 fully alertness to coma
Clouding of consciousness to drowsiness to
coma

6. • Clouding of consciousness- deterioration in
thinking, attention, perception and memory.
• Drowsiness- patient is awake but drift into
sleep if not stimulated.
• Coma-unconscious (no verbal, motor or
response to painful stimuli.
• Glassgow coma scale

7. Eye opening Verbal response Motor response
Spomntaneous (4) Oriented (5) Obeys (6)
To speech (3) Confused (4) Localizes (5)
To pain (2) Inappropriate words (3) Withdraws (4)
Nil (1) incomprehensible (2) A flexiuon (decorticate) (3 )
Nil (1) A.Extension decerebrate
(2)
Nil (1)

8. • Quanlitative change in consciousness
Delirium
Fluctuation of consciousness
confusion

9. • Twilight state
Abrupt onset and end
Variable duration, few hrs to weeks.
Voilent emotional outburst and acts.
Disturbance in the continuity of consciouness
Epilepsy, brain tumor, alcohol intox,
neurosyphillis

10. • Dream like state (oneiroid state). –delirium
• Stupor
Doesn't fall on continuum from alertness to
coma
Mutism + akinesia
Patient may appear awake and alert.

11. Attention and concentration.
• Attention:” ability to attend to a specific
stimuli without being distracted by external or
internal stimuli”.
• Sustained attention is concentration.

12. Tests for attention
• Digit repetition tests
Digit span forward- 7 +_2
Digit span backwards 5 +_1
Difference between the two should not be
more than 2

13. Tests of concentration;
“A” random letter tests.
• 7 serial subtraction tests
• Counting WORLD BACKWARDS

14. ORIENTATION
• Orientation to time, place, person and their
situation

15. Speech and language
1. Patient is conscious but making no attempt to
speak – MUTISM
2. Patient is trying to speak but whispers –
APHONIA.
3. Volume of sound and the content of speech is
normal ,but the articulation and enunciation
of individual words distorted –
DYSARTHRIA.
4. Disorder of language - APHASIA

16. Examination of speech
1. Listen
2. British constitution, royal Devonshire
constabulary, triruvanathpuarm, Muzzafarpur,
chakravarthy rajgopalchary..(my baby ate a
cupcake on the train)
3. Read a paragraph
4. Count till 30.

17. Listen to the words for
• Slurring
• Rhythm (jerky, explosive, or monotonous)
• Loud or too soft.
• Particular letters presenting with difficulty.
• Nasal tone
• Disturbance constant or intermittent, increasing or
decreasing

18. • Correct co ordination of lips, tongue, palate,
larynx, and muscle of respiration.
• Upper motor neuron, lower motor neuron,
actual muscle, the coordinating system,
cerebellum and EPS.

19. Speech abnormal
language fn abn- aphasia
language function n
voice,volume,pitch,timbre
normal abnormal
dysphonia
hoarse,whispery,mute high pitched
adductor spasm
cough abnormal cough normal

20. voice,volume,pitch,timbre normal
Speech rhythm prosody abnormal speech rhythm prosody normal
hypernasal (Palatal
Weakness)
Speech slurred drunken speech flat monotonous ab labial (papa ma
Scanning no emotional tone facial weakness)
Cerebellar EP ,RIGHT FL
abn lingual(daddy
Abn velar (coke kuh ) palatal post tongue weak anterior tongue weak

22. Cerebellar dysarthria
• Speaks slowly, deliberately syllable by syllable
as if scanning.
• Flow of words is lost and each word is given
equal emphasis.

23. Pseudobulbar dysarthria
• Individual syllables are slurred and presision
of consonant production is lost.
• Brizh conshishushon

24. APHASIA
• DEF “defect in the power of expression or
comprehension by speech, writing, reading, or
gesture”.
• ? Any localizing value.
• Dr BROCA “ the diagram maker”
• Rt or left dominance natural; or enforced.

25. • Spontaneous speech
• Comprehension
• Naming object
• Repeatition
• Reading
• Writing
• Calculation

26. •Spontaneous speech: Note the patient's fluency, including phrase length, rate,
and abundance of spontaneous speech. Also note tonal modulation and
whether paraphasic errors (inappropriately substituted words or syllables),
neologisms (nonexistent words), or errors in grammar are present.
•Comprehension: Can the patient understand simple questions and commands?
Comprehension of grammatical structure should be tested as well
•Naming: Ask the patient to name some easy (pen, watch, tie, etc.) and some
more difficult (fingernail, belt buckle, stethoscope, etc.) objects
•Repetition: Can the patient repeat single words and sentences (a standard is
"no ifs ands or buts")?
•Reading: Ask the patient to read single words, a brief passage, and the front
page of the newspaper aloud and test for comprehension.
•Writing: Ask the patient to write their name and write a sentence.

28. BROCA’S APHASIA
• FLUENCY- impaired
• COMPREHENISON - normal
• REPEATITION - impaired
• NAMING - impaired
• WRITING - impaired (only small sentences)
• READING - impaired (only simple sentences).

30. Wernicke’s aphasia
• FLUENCY – normal (jagron or neologism)
• COMPREHENISON -impaired
• REPEATITION - impaired
• NAMING - impaired
• WRITING - impaired)
• READING - impaired

31. • Conduction aphasia – repetition impaired.
• Transcortical aphasia – repetition normal
• Anomic aphasia - naming impaired.

32. MEMORY
• Immediate recall (short term memory)
digit recall test.
• Recent memory.
orientation and ability to learn
new material.
• Remote memory.- tests patients fund of
knowledge

33. APRAXIA
“failure to carry out well organised voluntary
movement correctly despite intact motor,
sensory and co=ordinatory function.”

34. Method of testing
• Simple movements- put out your tongue,close
your eyes,(if impaired look for automatic mov)
• More complex- how to use comb,pen,scissors.
• 3 steps task – lightening a cigarette,
hammering a nail. (both with and without
object.)

35. Types
• Ideomotor apraxia
• Ideational apraxia
• Constructional apraxia
• Dressing apraxia

36. IDEOMOTOR APRAXIA
• Patient can perform automatic movements
(blowing nose, runing back hand in hair)
• Can describe and plan the action.
• Cannot carry out the motor movement.
• Most comman.

37. Ideational apraxia
• Part of the whole movement can be carried
out but the whole act not,
• Can carry out each step correctly but not the
whole movement.

39. Constructional apraxia
• Drawing geometrical figures and clock face
and marking time on it.

40. • Dressing apraxia.

42. • Lesion in the parietal lobe.

43. AGNOSIA
• “failure to recognise familiar object by one or
more senses.”
• Agnosia for smell and taste unknown.

44. Calculation skills
Logic and abstractions

45. Cranial nerve examination
I – olfactory VII - facial
II – optic VIII - vestibulocochlear
III –occulomotor IX - glossopharyngeal
IV – trochlear X - vagus
V – trigeminal XI – spinal
accessory
VI – abducens XII – hypoglossal

46. CN I - Olfactory
• Ask for any changes in sense of smell
• bottles of smells
• Test each nostril separately
• Avoid noxious stimuli

47. CN II - optic
• Visual acuity
• Visual fields
• Fundoscopy
• Color vision

48. CN III, IV, & VI
• CN III (oculomotor)
– Most extraocular movements
– Pupillary reflex
– Eyelid opening
• CN IV (trochlear)
– Supplies superior oblique
– (SO4)
– Downward and inward eye movement
• CN VI (abducens)
– Supplies lateral rectus
– (LR6)
– Lateral eye movement
Test full range of
movement of extraocular
muscles
Check for double vision
(by asking patient)

49. CN V - trigeminal
• Three divisions
– CN V1 – ophthalmic (sensory)
– CN V2 – maxillary (sensory)
– CN V3 – mandibular (sensory and motor)
• Motor to muscles of mastication
• Sensation
– Fine touch (cotton wool tip)
– Pain (neurotip)
• Motor
– Clench teeth to assess mastication muscles
• Corneal and jaw jerk reflexes
– not done routinely

50. CN VII - facial
• Motor
– muscles of face, scalp
and ears
• Sensory
– Taste to anterior 2/3
tongue
– Ear
canal/postauricular
• (Autonomic)
Assessment:
• Look at face
• Elevate eyebrows
• Scrunch up eyes (try to
open)
• Show teeth/smile
• (sensation not
routinely assessed)

51. CN VIII - vetibulocochlear
• Hearing and balance
To test:
• Crude hearing test (whisper double digit number
in one ear)
• Rinne
• Weber (lateralisation)
• (Rombergs)

52. CN IX - glossopharyngeal
• Motor
– Pharyngeal
muscles
• Sensory
– Taste to posterior
1/3 tongues
– Pharynx, tonsils,
fauces, TM,
posterior ear canal
• (Autonomic)
To assess:
• Open mouth, look at
palate (lesion deviates
soft palate to opposite
side)
• Assess swallow
• (gag reflex, mucosal
anaesthesia)

53. CN X - vagus
• Motor, autonomic and sensory to:
– Palate, pharynx, larynx, neck, thorax, abdomen
• To assess:
– Listen to voice
– (gag reflex)

54. CN XI – spinal accessory
• Motor to
– Sternocleidomastoid
– Upper trapezius
• To assess:
– Shrug against resistance
– Head rotation and movement
against resistance

55. CN XII - hypoglossal
• Motor to tongue
• To assess:
– Look for muscle wasting,
fasciculations, deviation
– Assess strength
– (Lesion deviates tongue
towards affected side)

56. Motor system
• Bulk
• Tone
• Power

57. Sensory system
• Pain, touch and temperature
• Propioceptive sensation
• Graphaesthesia and two point discrimination.

58. REFLEXES
• Present or absent
• If present, is it normal or abnormal.
• If absent, defect at the sensory or motor level.
• Abnormality are unilateral or bilateral. Can
any level can be appreciated.

59. Prerequesites
1. Comforetable relaxed patient
2. A good hammer
3. Flexible wrist
4. Knowledge of the reflex arch

60. Classification of reflex
• Deep tendon reflex
• Superficial reflex
• Pathological reflexes

61. Deep tendon reflexes.
Bicep jerk:
• Midway between flexion and extension,
slightly pronated and arm resting on lap of the
patient.
• C5-C6

62. Tricep jerk:
midway between flexion and extension
and resting in the patients lap.
• C6-C7

63. Supinator jerk:
• forearm in semiflexion and semipronation
• Stike at the base of the styloid process
• Flexion of the forearm
• Muscle tested is brachioradialis.
• C5-C6

64. The patellar reflex:
Various ways to elicit the jerk.
L2-L4

65. THE ANKLE JERK :
• DIFFERENT POSITIONS
• SI – S2

66. SUPERFICIAL REFLEXES
• PALMAR REFLEXES
• SCAPULAR OR INTERSCAPULAR REFLEXES
• SUPERFICIAL ABDOMINAL REFLEXES
• THE CREMASTERIC REPLEX.
• ANAL REFLEX

67. THE PLANTAR REFLEX
• POSITION
supine – hips and knee in full extension and heel
resting on the bed.
sitting – knee extended and foot held either in
examiners hand or on knee.
• OBJECT
“blunt point”, applicator stick, handle of reflex
hammer, a broken tongue blade, thumbnail, key
HENRY MILLER – “bentley key”.
babisnski- “goose quill”.

68. • Technique
- a delibirate firm stimulus which is not too
painful nor too light.
- Lateral side of sole starting from heel towards
the little toe (as described by Babinski).
- Medial movement across the metatarsal pad
(not described by Babinski). All such
movement should stop short of great toe.

69. • Normal response- plantarflexion of great toe.
• Abnormal response- dorsiflexion of great toe.
• Warm foot more response
• Triple response
• See first movement at metatarsophalangeal
joint
• Absent in anxious individual.
• Babinski negative – no such term

70. Babinski sign
Chaddock sign
Oppenheim sign
Gordon sign
Schaefer sign
Some of the other methods to test extensor-planter
response :

71. Disorder Of Gait

72. Normal physiology of gait
• Brainstem and spinal cord- Central pattern
generator.
• Subthalamus and midbrain (pedunculopontine
nucleus).
• Gait cycle – heel strike heel stike
• Stance phase
To bear weight

73. • Swing phase
To advance the limb
• One limb support double limb support
• Stance phase (60%).-initial ct, loading, mid
stance and terminal stance.
• Swing phase(40%)-pre swing, initial
contact,mid swing,and terminal stance.
• Double limb support-10%

74. • 80m p/m,113 steps /m ,stride length of 1.41m
• Base of feet-2 inches(1st compensatory effort)
• C.G- ANTERIOR TO S 2
• “ An efficient gait minimizes the displacement of the
central of mass by roatating and tilting the pelvis and
felxing and extending the various joint involved”
• Abnormal gait-Increased energy expenditure ,and
falling.

75. Abnormal gait
Parkinsonism
• Stooped posture-(head and neck forward).
• Knee flexed
• Flexion - elbow shoulder & wrist but fingers
extented.
• “freezing”- as start hesitation, or threshold
akinesia (even during talking or eating)
• Small ,slow, flat footed shuffles.

76. • “festination” {latin-festinaire- to hurry}
• Difficulty in stopping and turning ‘en block’
• Impaired postural reflexes and tendency to fall
forward (propulsion) –countered by festination.
• Souques’ leg sign

77. • PSP (progressive supranuclear palsy)
• CBD (corticobasal degeneration)
• PPD (primary pallidial degeneration)
• Wilson’s disease
• Multisystem atophy

80. Frontal gait disorder
• Gait apraxia- “lack of ability to use the legs
without deficit in sensory, motor or
cordination”.
• Marche a petis pas(walk of little steps).
slow, short,shuffling gait.
• Magnetic gait and Lower body parkinsonism

81. • Greatest difficulty in initiation- gait ignition
failure and start hesitation.
• Small feeble stepping movement with minimal
forward progress.
• Unable to lift the feet(as if glued)
• After few shuffles- stride length increase-
slipping clutch gait.
• Turn hesitation

82. • Diffuse frontal lobe envolvement
• Normal pressure and other hydrocephalous.
• Vascular disease in frontal lobe ,(subcortical
small vessel disease)

84. Cerebellar ataxic gait
• Wide based, clumsy, unsteady, lurching &
irregular.
• Staggering and drunken gait.
• Tendency to sway, eratic and unpredictible
stride length.
• Romberg sign +/_

85. • Difficulty in walking tandem.
• Hemispheric lesion- deviates towards the side.
• Vermis-grossly unstable, reels ion both
direction, need 2 people support.
• Stroke, trauma, tumor, neurodegenerative
changes and cerebellar degeneration.

86. Gait of sensory ataxia
• Normal balance –
vestibular system
proprioception
vision

87. • looses the awareness of lower extremity or
whole body in space.
• Depend upon visual input.( incred on eye clos)
• Walks with eyes down.
• “steppage” or double tap gait.(heel first)
“to increase the proprioceptive
feedback”.

88. Foot drop gait.
• lift leg ,to clear the toe.
• unable to stand on heel
• Toe first touch
• Toe end of the shoe is worn out..

89. +
Gait of spastic hemiperesis.
• loss of normal arm swing and circumduction
of leg.

90. Scissoring gait.
• Tightness of hip adductors so that knees cross
one in front of other with each step.
• Seen in cronic myelopathies as in MS. And
cervical spondilosis,

91. Herperkinetic gait.
• synderham chorea,huntington’s disease,and
other athetosis, dystonia and other abnormal
movement – accentuate during.
• Walking accentuate not only movement but
also postural instability

93. Abnormal
movements

94. Answer these :
• Part of body affected,
• Constant or episodic,
• At rest or on movement or both,
• Voluntary movement suppress or increases it,
• Positional alteration,
• Altered by emotion,enviroment or temperature,
• Effect of eye closure

95. • Is the patient aware of it
• Effect of attention

96. Abnormal involuntary movement as a
spectrum
Regular /predictible Intermediate Fleeting /unpredictible
Tremor Dystonias Fasciculation
Hemibalism Athetosis Myoclonus
Partial myoclonus Tic Chorea
Myokymia Dyskinesia
Steriotypy

97. TREMOR:
• involuntary, relatively, rhythmic, purposeless, oscillatory
movement.
• Define its:
location, rate amplitude, rhythmicity, relationship to rest
and activity,
• Underlying pathology and etiology.

98. • Tremor-
slow- 3 to 5 hz
medium- 5 to 10 hz
fast – 10 to 20 hz
• Fine, coarse, and medium

99. tremor
action
postural kinetic
rest

100. • Rest tremor- decreases on use of part.(P.syn)
• Action tremor
Postural tremor – limbs maintained
in an antigravity position.(ET & enhanced
physiological tremor)
Kinetic tremor – intentional tremor.

101. Rest tremor
• Disappear or atleast decreases on activity.
• Most commanly- distal extremity but can also
affect leg arm, tongue jaw head , eyelids or
rarely entire body.

104. Parkinsonian tremor-
• resting, nonintentional, slow and coarse.
• 4 to 5 hz (slow).
• Repititive contraction of agonist and antagonists.
• Initially unilateral in one digit, eventually becoming
bilateral.
• Disappears on sleeping and exercebated by anxierty
and fatigue.
• Classically pill rolling.

107. action tremors

108. Postural tremors
Physiological tremors-
• 8 to 12 hz.(slower in children and young adult)
• hand in postural tension
• Anxiety,fright,fatigue,
• hyperthyroidism- enhanced physiological
tremor(fine,rapid at outstreached fingers)

109. Essential tremors,.
• Commanest of all
• Familial, appear in second decade t0 sixth
decade and worsons.
• Senile tremor is a form of ET.
• ETOLOGY OBSCURE.
• MADE WORSE BY ANXIETY

110. ESSENTIAL TREMOR PARKINSON’S TREMORS
MOST PROMINENT AT SUSTAINED PSTURE
HENCE PATIENT MAY SPILL WATER WHILE
DRINKING
AT REST
NO SPILLAGE
HEAD AND VOICE INVOLVED RARELY INVOLVED,(ONLY IN LATE STAGE
ALCHOHAL AND BETA BLOCKER IMPROVES NO EFFECT

111. INTENTIONAL TREMOR.
• Cerebellar disease.
• Appear when precision is required to touch a
object.
• Finger shaking perpendicular to the line of travel.
• Amplitude of oscillation increases towards the
end of the motion.
• Finger nose test.

114. “wing beating tremor” of:
wilson’s disease

115. chorea
• Involuntary, irregular, random nonrhythmic,
hyperkinetic movement which are abrupt,
brief, jerky and ill sustained.
• Individual movement discrete,but variable in
type and location.
• Chaotic, multiform constantly changing
movement
• seems to flow from one part of the body to
another.

117. • Movement seems voluntary but are
involuntary.
• Persists at rest ,are increased by activity and
tension and disappears in sleep.
• One extremity,trunk, face, tongue, lips.
• Piano playing movement and milkmaid grip.
• Parakinesia
• Snake darting and fly catching

118. • Huntingtons chorea and synderham’s chorea.
• Huntington’s- facial grimacing more marked,
chorea more slow and less jerky and more
bizzare
• Bizzare prancing gait due to chorea.

122. Athetosis(a –thetosis without fixed position.)
• Slow, somewhat sustained, involuntary,
irregular, coarse writhing movement.
• Face, neck, trunk, fingers, hand and toes.
• Any combination of flexion, extention,
abduction and adduction.
• Flow from one part of the body to another
their direction changes.

124. • Usually congenital- perinatal injury to basal
ganglia.
• Pseudoathetosis( sensory athetosis).

126. asterixis
A- not ; sterixis – fixed
• An irregular sharp brief loss of posture
especially evident in the outstreched hand.
• Occurs in decompensated hepatic failure and
uremia, poisoning with hypnotic drugs and
respiratory failure.

127. hemibalism

128. Hemibalismus
• Wild flinging continuous movement that occur
on one side of the body.
• Infarction or hemorrhage in contra lateral
subthalamic nucleus,
• Continuous throughout waking disappear only
in deep sleep
•

129. dyskinesia
• All hyperkinetic movement- technically
dyskinesia.
• Term reserved for dyskinesia duie to drug.
• Comman problem in patients of PD treated
with lecvodopa.

130. Orofacial dyskinesia.
• Involuntary movement of the mouth, face, jaw
or tongue consist of incessant chewing ,
pursing of the lips, tongue thrusting, licking
and incessant chewing movement
• Tardive dyskinesia – dopamine antagonists

131. • More common in old females
• Difficult to treat.
• Other tardive phenomenon can also occur-
tardive tremor, tardive dystonia, tardive tics,
tardive chorea./

132. `

133. dystonia
“spontaneuos, involuntary, sustained muscle
contraction forcing affected part of the body
in abnormal posture”
• Any part can be affected.
• Can be generalized, focal, intermittent,
segmented and hemidistribution.
• Writer’s cramp, blepharospasm, spasmodic
totticolis, belly dancer dystonia.

135. myoclonus
• “repetitive, abrupt, brief, rapid, lightening like
jerky movement of one muscle or a group of
muscle.”
• Usually occurs in paroxysms at irregular
intervals, during rest or active movement
.often precipritated by emotional, mental
state, tactile,visual or auditory stimuli.

136. • Can be physiological- hiccups, hypic jerks.
• Often the myoclonic jerks are quite voilent.
• Seen with epilepsy (JME, WEST SYNDROME)

138. • Myoclonus without prominent seizure seen in-
CZ disease, Hallervorden Spatz syndrome,WD,
SSPE, AD.

142. Tics
• Some degree of awareness of movement, but
make movement in response to some urge or
compelling inner force.
• Tension and restlessness
• Unvoluntary.
• Co-ordinated repititive seemingly purposeful
act involving a group of muscle in their normal
synergistic relationship.

143. • Tics are exagerated during emotional tension
and disappear during sleep.
• When under scrutiny patient may supress
their tics, but they reaapear when their
attention get divided.
• Giiles de la tourrete- multiple tics type, motor
as well as vocal.( including obscenities).

145. akathesia.
• Inner restlessness and urge to move.

147. • Type of seizure ?
• Region of the brain involved ?

148. thank you

149. • Questions ??????????????