GENERAL NEUROLOGICAL

ASSESSMENT

Demographic Data :

Name :
Age :
Gender :
Address :
Occupation :
Height :
Weight :
BMI :

Chief Complaint : In patients words.

Case History :

History indicates probable pathology:

 History of presenting condition: Chronological
occurrence of manifestation with the character, exact
date, duration and other treatment.
 Information about mode of onset:
Mode of onset Probable cause
Abrupt/instantaneous Vascular/trauma
Deterioration over period of Inflammatory/demyelinating
time disease
Deterioration over month Chronic
inflammation/malignancy
Relapsing and remitting Multiple sclerosis
symptoms
Recurrent headaches Migraine

 Information about negative symptoms:

- Hemiparesis
- Memory loss
- Muscle weakness
- Micturition control
- Numbness, loss of feeling, perception, anesthesia.

 Information about positive symptoms:

- Pill roling tremor of finger and thumb
- Flashing lights preceding headache
- Repetitive twitching of finger
- A hallucination of an odd smell
- Paresthesia, tingling, dysesthesia

 Information about vertigo: Subjective/objective

  Information about mental symptom: Delirium,
confusion, personality changes, tension, drug abuse
 Information about disturbance in sleep rhythm:
Drowsiness, hypersomnia, insomnia
 Information about trauma.

Past medical and surgical history

Drug history

Socio-economic history : According to Modified

Kuppuswamy Scale

Family history

 Screen carefully before declaring negative family

history

Personal history

Functional history

 Past and current functional status in self-care

 Growth and developmental history
 Dominance of hand and foot
 Occupational and employment history and other
activities

History of toxin exposure

Environmental history

Associated Problem

 Diabetes
 . Blood pressure
 Cardiac disease
 . Other orthopedic dysfunction

Vital Signs

. Four vital signs:

1. Body temperature
2. Pulse rate
3. Blood pressure
4. Respiratory rate
Pain is considered as fifth vital sign, as perceived by the
patient on a pain scale 0-10.

PAIN ASSESSMENT

 Onset
 Nature
 Duration
 Intensity
  Type of pain
 Radiating or nonaddicting
 Aggravating factors
 Relieving factors
 Intensity of pain
 Visual analogue scale

On Observation

 General appearance:
- Agitation
- Vomitus
- Urinary or fecal incontinence

 Body built:
- Ectomorphic (thin, prominence of structures from
ectoderm)
- Mesomorphic (muscular, prominence of structure
from mesoderm)
- Endomorphic (heavy, fat body built, prominence of
structure from endoderm).

 Posture evaluation (mention the position of patient):

- Anterior view: Both eyes, acromion process, iliac
crests, ASIS, greater trochanter of femur, patella and
 malleoli should be horizontally level, waist angles are
symmetrical. Patella and feet face anteriorly.
- Posterior view: Ear lobes, shoulders, inferior angle of
scapula, iliac crests, PSIS, greater trochanter,
buttocks and knee creases malleoli should be in level.
Spine should be straight with medial border of
scapula equidistance from spine bilaterally. Varus and
valgus deformity of knee and calcareous should be
noted.
- Lateral view: The line of gravity should be bisect the
external auditory meatus, acromion process, greater
trochanter, posterior to patella and approximately two
inches anterior to lateral malleolus. The cervical and
lumbar spine should exhibit moderate lordosis and
thoracic spine exhibit kyphotic curve.

 Attitude of the limbs/body part:

- To know stage and severity of disease
- Observe for synergy
- Observe ipsilateral pushing

 Alignment of trunk and extremity:

- Lateral flexion to convexity on affected side
- Upper quadrant is in excessive forward flexion
 - Excessive spinal flexion throughout the spine the
convexity on the weak side and spinal rotation
towards the affected side
- Lateral translation of thoracic spine from hyper mobile
point of T10.

 Presence of any inflammatory sign

 Presence of joint effusion/edema/swelling

- Indicates disease originating from lymphatic,
neurological, vascular or cardiac problems
- Proximal edema due to renal dysfunction
- Distal edema suggest cardiac involvement
- Focal due to loss of muscle tone.

 Bony deformities:
- Indicate stage of presenting condition
- Observe for deformity from head to toe.

 Trophic changes:
Wound/scar/skin
Skin: Color and texture indicate state of circulation.
- Cyanosis: Blue discoloration of skin and nail bed
indicates lack of O2 and excessive CO, in superficial
blood vessel.
 - Pallor: Noted with decrease in blood flow/blood
hemoglobin.
- Erythema: Localize redness indicate increase blood
flow and inflammation.
- Generalize redness: Fever, sunburn, CO poisoning.
- Yellow skin: Increase carotene intake or liver disease.
- Observe areas most vulnerable to pressure injury in
prolong recumbence:

Supine Prone Side lying

Occiput Ears Ears
Spine of scapula Anterior shoulders Lateral shoulder
Spinous process Iliac crest Greater trochanter
Olecranon Patella Head of fibula
process
Sacrum Dorsum of feet Medial aspect of
knee
Coccyx Lateral and medial
malleolus
Back of heels
  External aids:
To know patient’s functional status and extent of injury
functional aids, walking aids and catheter
- Protective aids: Orthotics and prosthetics
- Catheter: Suggest site of injury
- Calipers: Paralysis of concerned muscles
- Wheelchair: Patient with severe disability.

 Wasting of muscles:
- It suggests less chances of developing spasticity
- Seen in neuromuscular disorder
- Seen in UMN type of lesion.

 Attitude of the patient:

- Alert and mobile/attentive and pleasant
- Placid and cheerful/sulky/perplexed
- Distressed/fearful/mask like face.

 Gait:
- Observe stride length, step length, frequency, time of
swing, speed of walking and duration of the complete
walking cycle.
- Circumductory gait indicates hemiplegia, festinating
gait indicates parkinsonism, ataxic gait indicates
incomplete spinal cord injury or cerebellar problem,
scissoring gait indicates spastic cerebral palsy,
cautious gait, dystonic gait, antalgic gait, waddling
gait, foot drop gait, gluteus maximus gait.

 Breathing pattern:
- Observe shape of chest
- Use of accessory muscles
- Pattern of breathing

 Normal breathing pattern:

1. Thoracoabdominal seen in females
2. Abdominothoracic seen in males

- If patient is using accessory muscles of respiration

commonly because of weakness of diaphragm, it may
indicate problem with C4 root level.
- Cheyne-Stokes indicates bilateral cerebral
dysfunction.
- Hyperventilation indicates low midbrain or upper pons
dysfunction
- Apneusis indicates middle and caudal pons
dysfunction.
 Facial expression:
- It can indicate about what the presenting condition is,
e.g. parkinson patient has mask like face
- Patient with lack of frowning or dropping of angle of
mouth suggest Bell’s palsy.
- Frontal baldness, ptosis, jaw hanging, wasting of
muscle of mastication are the typical features of the
myotonic dystrophy.

 Eye movements and pupils:

- Fix uncreative pupils
- Anisocoria indicates transtentorial herniation,
pharmacological, Horner’s syndromne
- Absent eye movemnent indicates muscle paralysis,
pontine dysfunction
- Gaze preference indicates hemispheric infract,
seizures, pontine dysfunction.

 Involuntary movements:
- Tremor: Simple, resting, intentional, postural,
physiological, psychogenic
- Shivering/rigor
- Fasciculation
- Myoclonus
 - Chorea
- Hemiballismus
- Athetosis
- Dystonia
- Spasms
- Tics
- Cramp

 Cranial nerve observation:

- Ptosis (III)
- Facial drop/Asymmetry (VI)
- Hoarse voice (X)
- Articulation of words (V, VII, X, XII)
- Abnormal eye position (I, IV, VI)
- Abnormal or asymmetrical pupils (II, III)

 Shoulder observation:
- Drooping of shoulder/contour of shoulder
- Abnormal prominence of acromion
- Sulcus sign, abnormal swelling, atrophy
- Ecchymosis, venous distension, winging of scapula

On Palpation

 Warmth/variation in temperature:
- Warmth is one of the cardinal signs of inflammation.
The dorsum of hand which is more sensitive to heat
changes is use for comparing skin temperature
above, over and below an inflamed area.

 Texture of skin: Dryness or excessive moisture

 Tenderness:
- Grade I: Patient complains of pain
- Grade l: Patient complains of pain and winces
- Grade III: Patient winces and withdraws joint
- Grade IV: Patient will not allow palpation of the joint

 Tissue tension

 Edema: It is an abnormal accumulation of fluid in the

intracellular spaces.
- It is pitting/non-pitting
- Mild: < 1/4" depth of depression
- Moderate: 1/4" to 1/2" depth of depression
- Severe: 1/2" to 1" depression

 Swelling:
- Acute: Soft, fluctuating thickening
- Chronic Leathery thickening
 - Blood: Harder, tense or thick gel like feeling with
warmth and develops immediately or in 2-4 hours
after injury.
- Pus (Thick and less fluctuant with warmth and
elevated temperature)
- Synovial swelling of joints (boggy, spongy feeling and
develops evident after 8-24 hours)
- Inflammation (swelling evident after 8-42 hours)
- Bony/hard swelling (due to osteophytes/new bone
formation)
- Soft tissue swelling
- Skin callus.

 Bony irregularities
 Pulses
 Synovial membrane thickening
 Crepitus

On Examination

Higher Mental Functions

 Level of consciousness (GCS Scale)

- Awake and alert: Attentive to normal stimulation
- Obtunded: Reduce alertness, slow response
- Lethargic: Drowsy may fall asleep if not stimulated
- Stupor: Responsive only with vigorous and repeated
stimuli
 Arousable with voice, gentle stimulation,
painful/vigorous stimulation
- Commatose: Cannot be aroused

 Language
- Fluency
- Naming
- Repetition
- Reading
- Writing
- Comprehension
- Aphasia versus dysarthria

 Memory
- Immediate-recall a measure of attention rather than
memory
- Remote
- 3 objects at 0/3/5 minutes
- Historical events
- Personal events

 Orientation
- Person-not who they are but who you are
- Place
- Time
 Other cognitive functions
- Calculation
- Abstraction
- Similarities/differences
- Judgment
- Personality/behavior
- Attention: Divided, alternating, sustained.

 Perception
- Body scheme/Body image
- Spatial relation
- Agnosias
- Aprexia.

 Cranial Nerve Examination

I (olfactory)
- Do not use a noxious stimulus
- Coffee, lemon extract
II (optic)
- Visual acuity
- Visual fields
- Fundoscopic exam
III/IV/VI (oculomotor, trochlear, abducens)
- Pupillary response
- Eye movements
- 9 cardinal positions
 - Observe lids for ptosis
V (trigeminal)
- Motor-jaw strength
- Sens-all 3 divisions
VII (facial)
- Observe for facial asymmetry
- Forehead wrinkling, eyelid closure, whistle/pucker
VIII (vestibular)
- Acuity
- Rinne, weber
IX/X (glossopharyngeal, vagus)
- Gag
XI (spinal accessory)
- Sternocleidomastoid muscle
- Trapezius muscle
XII (hypoglossal)
- Tongue strength
- Right thrusts tongue to left.

Motor Examination

 Anthropometric Measurement
 Limb Length Measurement
 Girth Measurement
 Range of motion: Active and passive
 Capsular Pattern
 Joint Play Movement
 Manual Muscle Testing (MMT) - Graded 0-5
 0-no movement
 1-flicker
 2-movement with gravity removed
 3-movement against gravity
 4-movement against resistance
 5-normal strength

 Resisted Isometrics
 Muscle Length Testing
 Muscle tone
 Voluntary control assessment

 Tremor
- Rest
- With arms outstretched
- Intention
- Chorea
- Athetosis

 Abnormal posture reflexes

- Muscle stretch reflexes (deep tendon reflexes)
- Graded 0-5
 0-absent
 l-present with reinforcement
  2-normal
 3-enhanced
 4-unsustained clonus
 5-sustained clonus

 Deep tendon reflexes

- Biceps
- Brachioradialis
- Triceps
- Knee
- Ankle

 Other reflexes
- Upper motor neuron dysfunction
- Babinski
- Hofman’s
- Jaw jerk.

Sensory Examination
 Superficial sensation:
- Touch
- Pain
- Temperature
- Vibration
 Deep sensation
- 128 hz tuning fork
- Joint position sense
- Pin prick

 Higher cortical sensations

- Graphesthesia
- Stereognosis
- Double simultaneous stimulation
- Textures

 Gait evaluation
- Include walking and turning
- Examples of abnormal gait
- High steppage
- Waddling
- Hemiparetic
- Shuffling
- Turns en bloc

 Cerebellar function Rapid alternating movements

- Finger to finger to nose testing
- Heel to shin
- Gait
- Tandem
 - Romberg sign – Stand with feet together—assure
patient stable-have them close eyes – Romberg is
positive if they do worse with eyes closed.

Special Tests

Ober’s Test
Thomas Test etc…

Investigation

 Pre-op Investigation
 Post-op Investigation
Like X-ray, MRI, CT Scan, Ultrasound, NCV, EMG,
ECG etc..
 Operative investigation – any surgery performed.

Functional Testing

 Functional evaluation using functional activities or

test.
Example:
Starting Position Action Function Test
Standing 1. Walking Functional/Non-
Backward functional
2. Running (able or not able
Forward to perform 6-8m)
(20degree
flexion)

Functional Assessment

 Functional outcome measurement scales

Example : Knee Outcome Survey Sports Activities Scale
The Lower Extremity Functional Scale
The Upper Extremity Functional Index (UEFI) etc…

Goals

Short-term goals
Long-term goals
Physiotherapy Management

Prognosis : Using Functional Assessment Scales and

Functional Testing Measures.

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