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minutes-hour Acute vascular convulsive Subacute Chronic hours-days inflammatory tumor degenerative disorder Features of pain hypertension smoking

DM hyperlipidemia atrial fibrillation, MI bacterial endocarditis Hematological diseases family history of stroke risk factors Cluster headache

Onset of symptoms
meningitis, encephalitis head or spinal injuries epilepsy or convulsions anticonvulsants, contraceptive pills, anticoagulants drugs

Past history


unilateral & preceded by flashing lights and with photophobia over one eye last for minutes-hours lacrimation, rhinorrhea, flushing of forehead predominantly in males over occipit neck stiffness

cervical spondylosis

Speech & Mental status

during relaxation of muscle e.g. Parkinson's disease with deliberate movement more at end of action e.g. cerebellar disease with cold holding a posture slow movement with thyrotoxicosis Benign essential (familial) tremor involuntary jerky movements Chorea physiological tremor shivering intention tremor resting tremor

generalized high ICP worse in morning with drowsiness or vomiting persistent unilateral over temporal area temporal arteritis tenderness over temporal artery blurring of vision Acute sinusitis Subarachnoid hemorrhage headache & pain or fullness behind eyes or over cheeks or forehead severe headache rapid onset localized then generalized neck stiffness bilateral tension-type headache frontal, occipital or temporal described as tightness no associated symptoms headache with scalp tenderness involve superficial scalp arteries trigeminal neuralgia temporomandibular arthritis glaucoma

Headache Tremor & involuntary movements

interruption of neural pathway level of anterior horn cells

above giant cell arteritis

hypertonia hyperreflexia no muscle wasting pyramidal weakness (greatest effect on antigravity muscles) interruption of reflex arc between anterior horn cell & muscle hypotonia hyporeflexia prominent muscle wasting fasciculation

Upper motor neuron (UMN) weakness

Facial Pain
Lower motor neuron (LMN) weakness

cluster headache temporal arteritis aneurysm of internal carotid or pos. communicating artery sup. orbital fissure synd. transient loss of consciousness due to reduced cerebral blood flow localized or generalized? abrupt Tonic-Clonic Seizures (grand mal epilepsy) preceded by aura loss of consciousness incontinence of urine or feces bitten tongue

limb weakness

wasting tone reflex generalized weakness normal tone & reflexes hysteria non-organic weakness Diseases of neuromuscular junction Muscle diseases Syncope

nerve entrapment peripheral neuropathy median nerve entrapment pain in hand may extend to shoulder paraesthesia only in fingers foot plantar flexed leg swing in lateral arc scissors gait Carpal tunnel synd.

Disturbed Sensation (numbness/ paraesthesia)

Faints & fits


Partial seizures

simple complex

no loss of consciousness loss of consciousness occur in children brief loss of awareness with staring without motor movements affect brainstem cause blackouts

Absence seizures (petit mal)

Hemiplegia Transient ischemic attacks (TIA) Hypoglycemia Hysteria dizziness Parkinson's disease light-headedness sense of motion of surroundings with nausea or vomiting benign positioning vertigo

Spastic paraparesis

muscular rigidity of leg extensors & flexors difficulty initiating movement & turning quickly shuffling propulsion (stoop position) retropulsion festination (short rapid steps) drunken gait (wide base) more in affected side loss of proprioception of joints (posterior column lesion) high stepping broad-based Romberg's test waddling gait (exaggerated alternation of lateral trunk movement) failure of skilled movement of walking shuffling small steps ( marche a petits pas ) difficulty initiating walking (gait ignition failure) urinary incontinence & dementia apraxia of gait proximal myopathy sensory ataxia Blackouts cerebellar ataxia

Dizziness Gait disturbance

vertigo causes

acute labyrinthitis vestibular neuronitis ototoxic drugs (aminoglycosides) Meniere's dis. (vertigo+tinnitus+deafness) altered consciousness, visual disturbance or falling

diplopia (double vision)

Visual disturbance

amblyopia (blurred vision) photophobia visual loss tumor (acoustic neuroma) trauma (fracture of petrous temporal bone) environmental noise degeneration



toxicity (streptomycin) infection Meniere's dis.

written by: Mohammad Al-Marhoon Reference: Clinical Examination (Talley) Clinical medicine (Kumar)

Lower limbs Upper limbs Cranial Nerves

if pt. is disoriented or has dysphasia Acalculia Agraphia Left-right disorientation Finger agnosia sensory inattention visual field astereognosis (tactile agnosia) agraphaesthesia dressing & constructional apraxia spatial neglect short- & long-term memory severe memory disturbance & making up stories Korsakoff's psychosis (amnesic dementia) common in alcoholics retrograde amnesia change in emotion, memory, judgement, carelesness, disinhibition abnormal but maybe normal in elder Grasp reflex Palmomental reflex Pout & snout reflex concrete explanation of proverbs anosmia gait apraxia Foster Kennedy synd. (optic atrophy & contralateral papilledema) pt. cannot understand spoken or written word fluent speech lesion in Wernicke's area pt. understand but cannot answer appropriately non-fluent speech lesion in Broca's area objects cannot be named fluent speech lesion in dominant pos. temporoparietal area pt. repeat statements & name objects poorly but follow commands lesion in arcuate fasciculus or fibers linking Wernicke's & Broca's areas Conductive Nominal doll's eye test Dysphasia Expressive (ant.) position upward or downward deviation Receptive (pos.) Head & Face Eyes 1 dilated pupil primitive reflexes Frontal lobe function Level confabulation posture non-dominant lobe signs Parietal lobe function inspect decerebrate (extensor) circulation dominant lobe signs (Gerstmann's synd.) breathing causes of unconsciousness CO2 narcosis (respiratory failure) Overdose Metabolic (DKA, uremia, hypothyroidism) Apoplexy (head injury, CVA, epilepsy) Cheyne-Stokes (diencephalic injury) Biot's (brainstem lesion) "irregular" Kussmaul (DKA) "deep rapid" shock dehydration cyanosis severe midbrain dis. arms: extension & internal rotation legs extension lesion above brain stem decorticate (flexor) arms: flexion & internal rotation legs extension involuntary movements Glasgow coma scale (GCS) Coma Stupor unconsciousness with reduced response to external stimuli unconsciousness with response to external stimuli sleepiness but pt. can be aroused bruising behind ear >>fracture of base of skull pontine lesion narcotic overdose subdural hematoma ICP subarachnoid hemorrhage conjunctival hemorrhage widely dilated pupils skull fracture

Temporal lobe function

Cerebral hemispheres



Battle's sign

small pupils

2ry brainstem hemorrhage

papilledema, retinopathy deviation of both eyes to 1 side cerebral lesion at same side epileptic focus on other side brainstem lesion

lift eyelid & roll head from side to side fixed eye looking at object >>intact brainstem eyes move with head >>abnormal Ears & nostrils bleeding CSF (glucose test to confirm) urine (incontinence, glucose, ketones, proteins, blood) Dysarthria Body blood glucose temp. stomach contents resistance to passive neck flexion Dysphonia


difficulty with articulation UMNL causes extrapyramidal conditions cerebellar lesions alteration in sound of voice laryngeal disease recurrent laryngeal nerve palsy hysterical causes

Neck stiffness

meningism cervical spondylosis cervical fusion Parkinson's dis. increased ICP

person, place, time

Orientation Handedness

Kernig's sign

Rt or Lt handed Lt dominant hemisphere in Rt handed Lt dominant hemisphere in 50% of Lt handed

Written by: Mohammad Al-Marhoon Reference: Clinical Examination (Talley)

Glasgow Coma Scale (GCS)

Spontaneous To speech To pain No response Oriented Confused conversation Inappropriate words Incomprehensible sounds No response Obeys Localize Withdraw Flexion Extension No response 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Eye opening (E)

Verbal response (V)

Motor response (M)

GCS = E + V + M Minimum=3 , maximum=15

Reference: Clinical Medicine (Kumar)

motor for tongue inspect wasting & fasciculations of tongue after protruding, deviate toward affected side UMNL >>small immobile tongue LMNL >>fasciculation,wasting,weakness shrugging of shoulders against resistance turn head to the side against resistance feel bulk of trapezius feel bulk of sternomastoid -pharynx -middle & inner ear -pos. 1/3 of tongue parotid gland pharynx & larynx mus. of pharynx, larynx,palate say "Ah" in 10th nerve palsy, uvula move toward normal side palate & uvula

Hypoglossal (XII)

Accessory (XI)

sensory not tested routinely except in anosmia

Olfactory (I)
sensory secretory sensory X motor IX

don't use ammonia (stimulate 5th nerve) -URTI -smoking -ethmoid tumor -basal or frontal skull fracture -congenital -meningioma

causes of anosmia sensory

Glossopharyngeal (IX) & Vagus (X)

test with Snellen chart pt. is 6 meters away sudden bilateral blindness bilateral occipital lobe infarct or trauma bilateral optic nerve damage retinal vessel occlusion temporal arteritis optic neuritis migraine cataract gradual bilateral blindness glaucoma diabetic retinopathy optic nerve or chiasmal compression or damage Visual fields examined by confrontation move pen (or finger) from outer peripheral field to center, for the 4 directions +20 lens see cornea, iris, lens see fundus blurred margins >>papilledema optic disc Fundoscopy color normal >>yellow white >>optic atrophy retinitis pigmentosa

9th is sensory & 10th is motor touch back of pharynx reflex contraction of soft palate most common cause of reduced reflex is old age test ability to swallow assess voice for hoarseness sensory for hearing inspect external auditory canal use otoscope to see eardrum air or bone conduction? tuning fork in mastoid process then in line with external meatus audible nerve deafness AC>BC not audible conduction deafness BC>AC for lateralization tuning fork in center of forehead nerve deafness >>good sound in normal ear conduction deafness >>good sound in abnormal ear for balance Hallpike maneuver in vertigo (benign paroxysmal positioning vertigo) Vestibular part Weber's test Rinne's -ve Rinne's +ve Rinne's test cochlear part gag reflex Examination visual acuity sudden unilateral blindness

Optic (II)

0 lens

Acoustic (VIII)

retinal detachments

Cranial Nerves

central retinal a. occlusion >>milky white fundus central retinal v. thrombosis >>scattered hemorrhages Pupil size ptosis light reflex direct response >>same pupil constrict consensual response >>other pupil constrict far & near objects

accommodation Motor & sensory dropping of mouth corner smoothing of wrinkled forehead nasolabial fold wrinkle forehead against resistance shut eyes tightly & force open each one smile or show teeth puff out both cheeks taste in ant. 2/3 of tongue normal forehead wrinkling abnormal lower face absent forehead wrinkling abnormal lower face when pt. shut eye on side of LMNL, eyeball move upward & incomplete closure of eyelid sensory UMNL LMNL Eye movements facial asymmetry

put pen 30 cm away from pt. eye & move it in H-pattern Loss of conjugate movement in any direction Convergence Jerky horizontal Nystagmus Jerky vertical Pendular sign of ocular mus. weakness Diplopia 2 images side by side or one above other detect direction of greatest separation 3rd nerve lesion complete ptosis divergent strabismus (eye down & out) dilated pupil unreactive to direct light 6th nerve lesion failure lateral movement convergent strabismus diplopia supranuclear palsy loss vertical or horizontal or both gazes -both eyes affected -pupils fixed & unequal -no diplopia loss of vertical & later of horizontal gaze neck rigidity & dementia loss of vertical gaze with nystagmus on attempted to see below

Facial (VII) Oculomotor (III) Trochlear (IV) Abducent (VI)

Bell's phenomenon

sensory & motor Largest cranial nerve Opthalmic Maxillary Mandibular muscles of mastication trigeminal neuralgia severe shooting pain in a division Facial sensation in 3 divisions (forehead, cheek, jaw) clench teeth palpate masseter & temporal mus. open mouth against resistance (pterygoid mus.) touch by cotton reflex blinking of both eyes sensory >>opthalmic division motor >>facial nerve Jaw jerk (masseter reflex) Corneal reflex
Written by: Mohammad Al-Marhoon Reference: Clinical Examination (Talley)

sensory divisions motor division Tic douloureux

conjugate gaze

progressive supranuclear palsy

Trigeminal (V)

Parinaud's syndrome

Motor division Examinations

Posture Muscle bulk move down >>UMNL test drifting of arms move up >>cerebellar dis. fingers move to any direction >>loss of proprioception irregular contractions of small areas of mus. fine or coarse intention tremor past-pointing look for at rest Finger-nose test Fasciculations motor neuron dis. motor root compression peripheral neuropathy primary myopathy thyrotoxicosis

pt. pronate & supinate hand on dorsum of other hand rapidly cerebellar dis. >>dysdiadochokinesis

rapidly alternating movements


pt. lift arms rapidly from sides then stop hypotonia in cerebellar dis. >>delay in stopping

rotate wrist with supination & pronation of elbow joint Rebound hypertonic hypotonic UMNL LMNL in parkinson's dis.

0: absent +: reduced ++: normal +++: increased or normal ++++: increased with clonus UMNL Myopathy Neuropathy ant. spinal cord root ant. horn cell

cogwheel rigidity


Upper Limb Motor System

high tone after sudden movement Myotonia assess by percussion on muscle (thenar eminence) ask pt. to make tight fist then open it 0: complete paralysis 1: flicker of contraction 2: movement but not against gravity 3: movement but not against resistance 4: moderate movement against resistance 5: normal power peripheral nerve lesion asymmetrical weakness brachial plexus or root lesion UMNL Shoulder Elbow Wrist abduction C5,6 adduction C6,7,8 flexion C5,6 extension C7,8 flexion C6,7 extension C7,8 flexion & extension C7,8 abduction & adduction C8,T1


absent or hypo-reflexia

apply reinforcement if absent Brachioradialis C5,6 Biceps C5,6 Triceps C7,8


Written by: Mohammad Al-Marhoon Reference: Clinical Examination (Talley)


lesion >> wrist drop test pinprick sensation over anatomical snuff box lesion at wrist (carpal tunnel) >> pen-touching test lesion in cubital fossa >> Ochsener's clasping test test pinprick sensation lesion >> claw hand lesion >> wasting of small muscles of hand grasp paper between thumb & lateral aspect of index finger Froment's sign

Radial n. (C5-8)

Median n. (C6-T1)

Ulnar n. (C8-T1)

test pinprick sensation



Upper trunk


Sensory System Upper Limb

anatomy Pain (pinprick) feel sharp or dull? start proximally in each dermatome compare both arms use test tube filled with hot & cold water Temperature inability to feel heat is almost always associated with inability to feel cold tuning fork (128 Hz) Vibration distal interphalangeal joints if absent >>wrist, elbow, shoulder Brachial Plexus flex & extend distal phalanx with pt. eyes open then closed little finger affected before thumb some fibers cross midline & travel in anterior spinothalamic tract Light touch Lesions use cotton compare sides

tricceps & forearm

Middle trunk


hand & forearm

Lower trunk


Peripheral Nerves

dull not localized not related to movement worse at night LMN signs affecting whole arm sensory loss in whole limb Horner's synd. waiter's tip position sensory loss over lateral aspect of arm & forearm true claw hand sensory loss along ulnar side Horner's synd. causes lower brachial plexus lesion claw hand C8,T1 sensory loss unequal radial pulse subclavian bruits palpate cervical rib cancer usually causes lower plexus lesion inflammation & radiotherapy causes upper plexus lesion Cervical rib synd. Upper lesion (Erb Duchenne) C5,6 Complete (rare) neurological pain

Spinothalamic pathway

Posterior column


Lower lesion (Klumpke) C8,T1

Written by : Mohammad Al-Marhoon Reference : Clinical Examination (Talley)

walk normally then turn around & walk back Heel-to-toe walking (midline cerebellar lesion) walk on toes (S1 lesion) walk on heels (L4,L5 lesion footdrop) squat then stand up (proximal myopathy) stand erect with eyes open then closed test station (Romberg test ) quadriceps mus. calves ant. tibial mus. knees & ankle knee can be tested by hanging leg freely over edge of bed clonus knee bent & thigh externally rotated due to hypertonia from UMNL flexion L2,3 Hip extension L5, S1,2 abduction L4,5, S1 adduction L2,3,4 Knee ankle Babinski sign flexion L5,S1 extension L3,4 plantar flexion S1,2 dorsiflexion L4,5 inversion & eversion L5,S1

Heel-shin test Toe-finger test Foot-tapping test Knee jerk L3,4 ankle jerk S1,2 Plantar reflex L5, S1,2 abnormal extension of big toe in planter reflex test UMNL

Motor System Lower Limb

Tarsal joint
Written by: Mohammad Al-Marhoon Reference: Clinical Examination (Talley)

sensory loss on lateral aspect of thigh no motor loss painful >>meralgia paraesthetica weak knee extension slight weakness of hip flexion absent knee jerk sensory loss of inner thigh & leg foot drop weak knee flexion absent ankle jerk & plantar response sensory loss on posterior thigh & calf foot drop weak dorsiflexion & eversion intact reflexes stimulated by light touch or scratch epigastric T6-9 mid-abdominal T9-11 lower abdominal T11-L1 stroke wall toward umbilicus absent in UMNL absent + increased tendon reflex >>corticospinal tract abnormality L1,2 stroke inner thigh downward in suspected cauda equina lesion sensory loss around anus scratch perianal area straight leg raising test anal reflex spine Written by : Mohammad Al-Marhoon Reference : Clinical Examination (Talley) Saddle sensation Cremasteric reflex sites Abdominal Reflexes Common Peroneal n. (L4,5 S1) Sciatic n. (L4,5, S1,2) Femoral n. (L2,3,4) Lateral cutaneous n. of thigh

Peripheral Nerves


Sensory System Lower Limb

Superficial (Cutaneous) Reflexes

pinprick Vibration ankle, knee, ant sup iliac spine big toe


Proprioception Light touch