SLCM Class 2014
Physical Examination – H. Transcribed by
First Block Neuroscience I
CEREBRAL CORTEX
 Awareness – brainstem and cortices
o Reticular formation: excitatory-activating
system of the brain
 Has excitatory and inhibitory area
 Two lesions involved in coma:
o Brainstem lesion
o Lesion on both sides of cortex
 Functional areas of human cerebral cortex
o Determined by electrical stimulation of cortex
 Primary areas: direct connections with receptors
 Secondary areas: make sense of functions of primary
areas (motor patterns)
 Association areas: receive and analyze signals from
multiple regions
o Parieto-occipito-temporal
 Continuous analysis of coordinates
of body and surroundings
 Language comprehension
 Visual processing of words
 naming
o Prefrontal
 Plan complex patterns and
sequences of movements
o Limbic
 Behavior, motivation, emotions
 Special emphasis for Wernicke’s and Broca’s areas
for language comprehension and speech production,
95% of all persons are located in the left hemisphere
o Wernicke’s: organizationof somatic, auditory
and visual association areas into a general
mechanism for interpretation of sensory
experience
 Frontal: motor
o Inferior part: smell
o Left: speech problem
 Temporal: language
o Limbic lobe underneath  where emotions,
memory loss, behavior are controlled
 Occipital: mostly visual
 Frontal lobe diseases: Please refer to power point for
detailed explanation. I will only mention the important
ones.
o Tactile anosognosia/bimanual
astereognosis: inability to know certain
tactile stimuli
o Anosognosia: you don’t know anything
o Apraxia: you don’t know how (or you are
confused) to do a certain procedure
 Temporal lobe diseases: Again, refer to power point.
o Wernicke’s aphasia
o Hypermetamorphopsia
o Kluver-Bucy syndrome
 Occipital lobe: mostly visual defects
CRANIAL NERVES
 CN IV – only one coming from the back
 Midbrain: CN III
 Between midbrain and pons: CN IV
 Pons: CN V (sensory part goes down up to spinal
Page 1
cord), VI
 Between pons and medulla: CN VII, VIII
 Medulla: CN IX-XII
 Branchial motors: skeletal muscle of face and neck
 Visceral motor: autonomic
 Refer to table.
MOTOR FUNCTION
 Review homunculus.
o Shows degree of representation of different
muscles of the body in the motor cortex.
Neuroscience I – Neurologic History Taking and Physical Examination
Neurologic History Taking and
Ludwig D. POBLETE
(16.06.10)
Pyramidal tract: corona radiata posterior limb of
internal capsule  midbrain  pons  pyramid of
medulla  decussate  85% lateral white
columns/15% anterior white column anterior horn
cells  motor root  motor nerve  muscle
 Anterior corticospinal tract: 15%, mostly spinal
muscles
 Lateral corticospinal tract: mostly arms and legs
 Lesions of motor system:
o Weakness (-)
o Cramps (+)
o Fasciculations (+)
o Abnormal posture
 Lesions of pyramidal tract:
o Upper motor neuron signs (UMN)
 Increased tone (also seen in basal
ganglia lesion)
 Hyperreflexia
 Abnormal signs – Babinski,
Hoffman
 UMN weakness pattern
 Lesions above decussation: contralateral weakness
 Lesions below decussation: ipsilateral weakness
 Bilateral represented muscles may not appear weak
with unilateral lesions
o These muscles are innervated ipsilaterally
and contralaterally: muscles of mastication,
tongue, SCM/trapezius,
laryngeal/pharyngeal muscles, upper ½ of
face, diaphragm)
 More distal muscles tend to exhibit more weakness
SENSORY FUNCTION
 Dermatomes: only look for this when motor root is
affected
 Dorsal column lemniscal system: dorsal root ganglion
 fasciculus gracilis/cuneatus  nuclei gracilis and
cuneatus  internal arcuate fibers  decussate 
medial lemniscus  ventroposterolateral nucleus of
the thalamus  posterior limb of internal capsule 
corona radiata  post-central gyrus
o Touch requiring high localization and
transmission of fine gradations of intensity
o Phasic (vibratory) sensations
o Sensations that signal movement against the
skin
o Position
o Pressure requiring fine degrees of judgment
of intensity
 Anterolateral system: posterior root ganglion 
substantia gelatinosa  cross to opposite side 
ventroposterolateral nucleus of the thalamus 
posterior limb of internal capsule  corona radiata 
post-central gyrus
o Pain
o Thermal sensation (hot and cold)
o Crude touch and pressure discrimination
o Crossing: immediately at that level
 Lesions of the sensory system:
o Numbness (-): to different modalities
 Hypoesthesia: partial cut, some
sensation
 Anesthesia: total cut, no sensation
o Dysesthesias (+): general term for pain, pins
and needles
o Allodynia (+): when you touch something not
painful, you feel pain
o Hyperpathia (+): painful stimulus feels more
painful
MYOTACTIC REFLEX OR MUSCLE STRETCH REFLEX
 Neuronal circuit of stretch reflex: muscle spindle 
proprioceptor nerve  (interneurons)  motor nerve
 muscle
 SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

 Intrafusal fiber: contains muscle spindles which have Responsible for the associated movements that
sensory structures that are capable of sending signals support voluntary activity
to the proprioceptor nerve which then sends it to the  Role in proper tone and postural adjustment
motor nerve and tells the muscle to contract  Lesions of basal ganglia
 Extrafusal fiber: normal fiber o If there are lesions in the basal ganglia, there
CEREBELLUM are generally involuntary movements
 Found in posterior fossa, dorsal part of brainstem o Altered muscle tone – rigid/dystonic
 Contains 3 lobes: posterior, anterior, flocculonodular o Loss of associated movements
 Somatic sensory projection areas in cerebellar cortex: o Appearance of adventitial movement
body is in the middle (vermis area) and extremities  Tremors (as in parkinsonism)
are on the sides  Chorea: brief, irregular twitchi
 Cerebellar tracts cross the brain twice so if left side is  Athetosis: moves like a snake
affected, the other side is also affected (Michael Jackson)
 Alcoholics: atrophied vermis  Hemiballismus
 Spinocerebellar tracts o Masked expression
o Has connection with other areas o Paucity of movement
o Review main tracts. o Gait instability
 Ventral spinocerebellar tract HISTORY TAKING
 Dorsal spinocerebellar tract  Genereal data
 Lesions of the cerebellum  Chief complaint
o Nystagmus  History of present illness
o Action tremor o Diagnosis
o Dysmmetria: trouble localizing things  Anatomic localization
o Dysdiadokokinesia: inability to do rapid  Disease
alternating things  Put all relevant information
o Ataxia: inability to control gait and stance in chronological order
o Titubation: midline is affected (neck and (oldest to latest)
body)  Significant (+) and (-)
o Overshoot: if one extremity is pushed, the  By the end of the history of present
tendency is to overshoot illness, you should have diagnosis
 What happens if cerebellum is stimulated?  Past medical history
o Nothing happens!  Surgical history
o It only coordinates information from different  Family history
areas, not the primary ‘mover’.  Medications
BASAL GANGLIA  Social history
 Helpers of the pyramidal tract PHYSICAL EXAMINATION
 Globus pallidus + caudate nucleus = corpus striatum  Top to bottom
(due to striae) o Mental status
 Globus pallidus + putamen = lentiform nucleus o Cranial nerves
 Has relation to all parts of the brain o Motor system
 Exerts influence on lower motor neuron by way of the o Reflex
cortex o Sensory system
 Modulates motor activity of the cortical region o Cerebellar function
 Concerned with coarse stereotyped movements o Others
 Principal influence is over the proximal muscles  Irritating tests should be done last.
 See succeeding pages for detailed PE.
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Neuroscience I – Neurologic History Taking and Physical Examination

SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

Ne S B V V G S Function
rve omatic ranchial isceral isceral eneral pecial
Motor Motor Motor Sensory Sensory Sensory

Olf      ü Sense of smell

actory
Op      ü Vision
tic
Oc ü      Motor to all
ulomotor extraocular muscles except
superior oblique and lateral
rectus
  ü    Parasympathetic
supply to ciliary and pupillary
constrictor muscles
Tro ü      Motor to superior
chlear V oblique
Tri  ü     Motor to muscles of
geminal mastication, etc. (V3)
    ü  Sensory from surface
of head and neck, sinuses,
meninges, and tympanic
membrane (external surface)
Ab ü Motor to lateral
ducens I rectus muscle
Fa ü Motor to muscles of
cial II facial expression, etc.
ü Parasympathetic
supply to all glands of the
head except the parotid and
integumentary glands
ü General sensation
from a small area around the
external ear, tympanic
membrane (external surface)
ü Taste, anterior two-
thirds of the tongue
Ve ü Balance
stibulo- III
coc
ü Hearing
hlear

Glo ü Motor to
sso- X stylopharyngeaus muscle
ph ü Parasympathetic
aryngeal supply to parotid gland
Va ü Motor to pharynx and
gus larynx
ü Parasympathetic
supply to pharynx, larynx,
thoracic and abdominal
viscera
ü Visceral sensory from
pharynx, larynx and viscera
ü General sensation
from a small area around the
Page 3

external ear
Ac ü Motor to
cessory I sternomastoid and trapezius
muscle
Hy ü Motor to intrinsic and
poglossal II extrinsic muscles of the
tongue except palatoglossus

NEUROLOGICAL EXAMINATION Definition Procedure Normal Abnormal

Mental Status        
General Behavior & Appearance   Observation     
Stream of Talk Tests Wernicke and Conversation    
Broca’s Areas  Observation

Neuroscience I – Neurologic History Taking and Physical Examination

SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

Mood and Affective Responses   Conversation    

Observation
Content of Thought   Conversation    
Observation
Intellectual Capacity   Conversation    
Observation
Sensorium        
Consciousness   Observe  Alert Not conscious
Attention Span   Serial 7 Test Attentive  Can’t finish
serial 7 test

You flick two fingers Sensory

repeatedly but person Inattention
notices only one side
Orientation      
Time   Ask about awareness of   Not Aware 
present location, time
Place     Not Aware
and awareness of self
Person     Not Aware
Memory        
Recent   Remembering 3 words   Amnesia
you give after 5 minutes;
Ask about last night
Remote   Ask personal events   Amnesia
about 5-10 years ago
Fund of Information    Ask about TRIVIA  
Insight    Ask for opinion  
Judgment   Give situation, see what  
person will most likely do
Planning    Let person tell you the   Can’t plan
things he has to do to
complete a given task
Calculation    Give a simple   Can’t process
mathematical problem problem
Language        
Naming    Ask person to name the   Can’t name 
object you are pointing to
Comprehension    Ask person to do multi-   Can’t
step tasks understand
Fluency    Conversational How do   Can’t finish
you do’s sentence or
thought
Repetition    Ask patient to repeat   Can’t repeat 
what you say
Writing    Ask patient to write   Can’t write
legibly (for
literate people)
         
Higher Cerebral Function        
Sensory Agnosia Do not know things      
Graphesthesia Ability to determine what Trace a figure on the   Can’t identify
is written on palm/skin palm of patient who has figure
his eyes closed
Ask if he can identify
what you wrote 
Stereognosia Tests ability to identify     Can’t identify
3D shapes shape
Tactile Inattention Tests the ability to feel  Lightly touch limbs, etc   Can’t feel touch
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touch
Astatognosia Tests position sense   
Anosognosia Tests things a person      
suddenly don’t know
Atopognosia Tests ability to localize      
touch 
Apraxia  Cannot do things      
Ideomotor Apraxia        
Ideational Apraxia  More severe than      
ideomotor apraxia
Constructional Apraxia Ask person to copy block   Cannot copy
structures (Lego, etc) given block
Observe structure
Dressing Apraxia   Ask person to do   Cannot dress
movements associated 
Neuroscience I – Neurologic History Taking and Physical Examination
SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

with dressing up
         
Cranial Nerves        
CN I (Olfactory) Least checked Use smelling salts and Can detect odor Can’t detect or
ask patient to identify wrongly
scent identifies scent 
CN II (Optic)      
Visual Acuity Use Snellen/Jaeger Let person read the  
charts  smallest row of figures in
the chart
Visual Fields Tests for hemianopsia, Test vision in all visual Finger  Hemianopsia/
etc fields movements Quadrantanopia
seen in all fields
Pupillary Reflex      
Direct Shine light on one eye Ipsilateral Amedriasis (no
Observe same eye  dilation is a response) or
grade 2 or 3 over-dilation
Consensual   Shine light on one eye Symmetric Amedriasis in
Observe opposite eye dilation of contralateral
contralateral pupil
pupil
Fundoscopy        
CN III (Oculomotor) Tests extraocular Let patient follow your Smooth pursuit Can’t follow
CN IV (Trochlear) muscles, ability to finger in all the major    
accommodate, conjugate directions of eye
CN VI (Abducens)
eye movement movement  East,
West, NE, NW, SE & SW
CN V (Trigeminal)        
Sensory   Graze face, arms and Similar Feeling is
legs on both sides and greater on one
ask person to compare side
sensation
Motor Checks integrity of the Put one finger at the Both muscles No/abnormal
cranial nerve and masseter and another at will move movement
muscles of mastication the temporalis muscle
then open and close jaw 
Corneal Blink Reflex    Touch corneas with Blink present  Blink absent
clean, light fabric when
the patient is looking
away from you
Jaw Jerk    Hit mental symphysis Negative Jaw closes 
with hammer
CN VII (Facial)        
Motor    Let person say Symmetric Palsy in one
“mamama” movement of side
Check orbicularis oculi muscles of the
Ask person to smile face
Taste        
CN VIII (Auditory/Vestibular)        
Weber Tests lateralization of Place tuning fork at the Same duration Lateralization
sound skull’s midline noted (sound
(intersection of sagittal longer in one
and coronal suture) ear) 
Rinne Tests air-bone  Place tuning fork at the Bone Converse is
conduction mastoid process and just conduction is true
near ear shorter than air
conduction
Schwabach Tests air conduction Compare person’s air  Same duration Longer in
Page 5

conduction against yours patient/ can’t

(if he hears the sound hear sound 
longer or shorter than
you)
CN IX (Glossopharyngeal) Tests presence of gag Stimulate soft palate or  Gagging Areflexia (but
reflex posterior pharynx to elicit gag reflex is
gag reflex normally absent
in 10% of
people)
CN X (Vagus)  Tests palatal elevation Ask person to say “Ah” Symmetrical Asymmetrical
and partly gag reflex and look at the symmetry elevation of elevation (uvula
of the palate  palate  deviates toward
strong side)
CN XI (Accessory) Tests motor innervations Push SCM down while Maximum  Little or No
of sternocleidomastoid telling the person to resistance resistance

Neuroscience I – Neurologic History Taking and Physical Examination

SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

and trapezius resist you

Head rotation SCM bulging No bulging

CN XII (Hypoglossal) Tests tongue movement Ask person to say “lalala” Normal Can’t say lalala
movement properly

Ask person to protrude Midline Deviation of

tongue protrusion tongue to one
side 
         
Sensory Tests integrity of spinal      
lemniscus
Pain & Temperature Tests integrity of lateral Touch a part of skin (on Positive No sensation/
spinothalamic tract the left and right side) hypoesthesia/
with a pin or needle anesthesia
Vibration & Proprioception Tests position and Vibration: Positive Can’t feel
vibration sense (integrity Ask if the person feels vibration/
of dorsal lemniscal tract/ the vibrations of the Can’t tell
posterior white columns) tuning fork on his back, position of
etc finger correctly

Proprioception:
Ask patient to close his
eyes then move one
finger up and down

Ask person to identify

position of finger as you
move it
Light Touch Tests light touch sense Pass cotton swab lightly Positive  Can’t feel
(integrity of on both hands, arms,
spinothalamic tract)  feet and legs Ask if
equal degree of
sensation
         
Motor      
Bulk   Observe before Symmetric, Atrophied
inspection good bulk muscles 
Look then lightly squeeze
muscles
Tone   Get a relaxed limb and No tension, Presence of
lightly wiggle it around rigidity nor tension, rigidity
(repeatedly flex or extend spascticity and spasticity
arms and knees)
Strength   Ask person to oppose Grading 5   Grading 3
your strength as you Max resistance below
bear down on each of his
shoulders
0 - no movement        
1 - minimal twitch        
2 - without gravity        
3 - against gravity        
4 - minimal resistance        
5 - maximal resistance    
         
Reflexes        
Superficial        
Cremasteric Reflex   Lightly graze medial Brisk and brief areflexia
Page 6

surface of one thigh elevation of

ipsilateral testis 
Superficial Abdominal Reflex   Lightly stroke abdominal Abdominal  areflexia
area toward the muscles tighten
umbilicus
Deep Tendon   ++ normal 0 areflexia
+ hyporeflexia
+++ hyper-
++++ clonus
Most Commonly Tested        
Biceps tests musculocutaneous Tap corresponding  Flick of biceps  See above
nerve (C5-C6) tendon with neuro
hammer (but for knee
Triceps Tests radial nerve (C6- Flick of triceps  See above
jerk, ask person to cross
C7)
Neuroscience I – Neurologic History Taking and Physical Examination
SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

Brachioradialis Tests radial nerve (C5- Flick of  See above

C6) brachioradialis
Quadriceps/Knee Tests femoral nerve (L2- Flick of knee  See above
L3-L4)
one leg over the other
Achilles/Ankle Tests tibial nerve (S1) Flick of ankle  See above
before tapping)
(ask person to
kneel)
Observe reflex
Pathologic (Frontal Release Signs)        
Babinski   Stroke dorsal surface of Negative Big toe moves
feet in inverted J pattern upward and
(lateral to medial)  painful spread
of toes
Clonus   Plantar flex the person’s  Negative  Foot/arm
foot and see how it goes experiences
back to position clonus of feet
and arm
Palmar flex the person’s
hand and see how it
goes back to position
Hoffmans   Raise middle finger from  Negative Other fingers
hand and flick it will curl (but in
10% of people,
this may be
normal)
Palmomental   Lightly graze palm of  Negative Mental muscle
outstretched, pronated twitches 
arm
Grasp   Lightly graze palm  Negative Fingers curl or
close over
palm 
Snout/Rooting   Tap lips  Negative Lips pucker
Glabellar Tap   Continuously tap glabella Person blinks Person blinks
once or twice continuously 
         
Cerebellum        
Coordination        
Finger-to-nose test Tests for presence of Place your forefinger a Person’s finger Can’t touch
dysmetria and intention distance from the is always on your finger
tremors person’s nose point to yours directly

Ask person to touch his Smooth Saccadic

nose with his forefinger movements movements of
first before touching your (smooth pursuit) finger
finger

Repeat above but this

time, move your finger 
Heel-to-shin test Tests for fine motor Ask person to place the Smooth Can’t  smoothly
movement heel of one foot to the movement move his heel
shin of the opposite leg

Ask him to move his heel

parallel to the direction of
shin
Rapid alternating movements  Tests for fine motor Ask person to rapidly Can accomplish Cannot rapidly
movement alternate both his hands rapid, alternate
between pronation & alternating movements
supination movements
Page 7

Ask person to rapidly ann

repeatedly touch his
forefingers to thumbs in
both hands
Overshoots Tests for fine motor Ask person to close his Can raise his Overshoots
movement  eyes, raise his pronated arm back to original level 
arms forward original position 
Push one arm down and
ask the person to put his
arm back to its original
level
Nystagmus (optokinetic    Ask person to follow a Both eyes have One eye
movement) long sheet of paper with synchronized doesn’t move in
alternating columns of saccadic sync with the
two colors movement other

Neuroscience I – Neurologic History Taking and Physical Examination

 SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

         
Gait and Balance Tests for Basal Ganglia Do not forget to check  
function associated movements
such as swinging of the
arms and a nice stance 
Tandem Gait Ask person to walk back Takes only one Takes slowly
and forth following a step to turn and a lot of
straight line  back  steps to turn 

Shuffling gait
Heel and Toe Walk   Ask person to follow a Smooth Can’t walk
straight line but walk movement straight, loses
heel-to-toe balance
Romberg's Sign   Let person close Will not lean or Will lean toward
eyes and raise his arms fall or lose one side and/or
forward balance upon lose balance
opening eyes upon opening
Let him open his eyes eyes
  Pronator Dip   Let patient close his eyes Arms will not fall  One/Both arms
with his arms raised will fall
forward
Meningeal Signs Assesses condition of Let patient lie down     
the meninges (great for supine position
looking for inflammation,
etc)
Brudzinski   Bend person’s neck and Negative Knees will
observe knee reflexively bend
movements
Kernigs   Bend person’s knee Negative Reflexive
extension of leg
occurs
         
Special Examinations        
Straight-Leg Test (Lasegue's Test) Tests for presence of In supine position, Negative Pain/electricity
pinched nerve straighten leg and raise it shoots down
without bending the knee the leg
Reverse Straight Leg Raising Test        
Crossed Straight Leg Raising Test        
Tinel's Sign   Hit pronated midwrist Negative Numbness in
with hammer hand 
Phalen's Maneuver Tests for carpal tunnel Put wrists together Negative  Numbness 
syndrome
Page 8

Neuroscience I – Neurologic History Taking and Physical Examination

SLCM Class 2014 Neurologic History Taking and
Physical Examination – H. Transcribed by
First Block Neuroscience I Ludwig D. POBLETE
(16.06.10)

Page 9

Neuroscience I – Neurologic History Taking and Physical Examination