NERVOUS SYSTEM
History
Loss / reduced strength
Loss / altered sensation
Numbness
Loss of balance
Difficulty in walking
Speech difficulties
Memory loss
Pain
Stiffness
Heaviness
SCHEME
1. Higher mental functions
2. Cranial nerve examination
3. Motor system
4. Sensory system
HIGHER MENTAL
Consiousness level –
conscious
FUNCTION
altered
conscious
coma
dementia
delirium
Orientation – time, place
and person
Intelligence
Memory
remote – years ago
recent – from mins to hours
intermediate – months
Emotional state – mood { happiness/
distress}
WHAT ABOUT YOU????
Hallucinations – false impression referred to
special senses
Delusions – false belief that continue to be
held despite evidence to contrary
Handedness : right / left
Disturbance in speech : aphasia
dysphonia
dysarthria
CRANIAL NERVE
EXAMINATION
1,2 – FORE BRAIN
3,4 – MID BRAIN
5,6,7,8 – PONS
9,10,11,12 –
MEDULA
OBLONGATA
1st olfactory nerve
Test for smell : intact
decreased – hyposmia
loss – anosmia
altered - parasmia
2nd optic nerve
Visual acuity – snells chart
ishihara isochromatic
chart
Visual felid – “confrontation
tetst”
3rd occulomotor 4th
trochlear 6 abducent
th
Extraoccular movements –
nystagmus, ptosis, diplopia
Pupillary reflex
Accomodation reflex
5th trigeminal
Palpate temporal and
massater muscle while
asking the subject to
clench the teeth
Lateral movements of
the jaw
Loss/ decreased
sensation over half of
the face
Corneal reflex
7th facial nerve
Raise both eyebrow
Frown
Close both eyes and open
against resistence
Show upper and lower teeth
Smile
Puffing of cheecks
Check for Anterior two third of
the tongue for taste sensation
8th vestibulocochlear
nerve
Weber test : Method - viberate the tunning
fork and keep in between the the forehead
conductive loss :Sound localizes to the
worse ear with
Nerve deafness : sound is better heard in
the normal ear
Middle ear diseases: sound is better heard
in the affected ear
Rinne test :
method - The Rinne test is performed by
placing a 512 Hz vibrating tuning fork against
the patient's mastoid bone and asking the
patient to tell you when the sound is no longer
heard.
Once the patient signals they can't hear it, the
still vibrating tuning fork is then placed 1–2 cm
from the auditory canal. The patient is then
asked again to indicate when they are no longer
able to hear the tuning fork.
9th glossopharyngeal nerve 10th
vagus nerve
Taste sensation in
posterior one third of the
tongue
Position of uvula and
palate movement – ask
patient to say “ah”
Gag reflex
11 spinal
th
accesorry
Ask the patient to
raise the shoulder
against resistence
Turn the neck to
one side against the
resistence -
sternomastoid
12th Hypoglossal nerve
Ask the patient to move
the tongue from side to
side
Ask the patient to move
the tongue towards the
cheeck while giving
resistance from outside
MOTOR SYSTEM
Attitude of the limbs
Nutrition – measurement
of girth of limbs
10 cm below and above
colecranon
10cm above patella
10cm below the tibial
tuberosity
Muscle tone degree of tone is
assessed by handling the limbs and
moving them passively at various
joints
hypertonia – spasticity
rigidity
hypotonia –
Muscular and cerebellar
disease
Muscel power
1. Grade 0 - no movement
2. Grade 1 – flickering movement
3. Grade 2 – movement with gravity
eliminated
4. Grade 3 – movement against gravity
5. Grade 4 – movement against minimal
resiatence
6. Grade 5 – movement against full resistence
Coordination :
Coordination of muscle movements
requires that four areas of the nervous
system function in an intergrated way:
The motor system – muscle strength
The cerebellar system (part of motor
system) – for rhythemic movements and
steady posture
Vestibular system – for balance and
coordination of eye and body movements
The sensory system – position sense
Coordination :
1. Finger nose test
2. Dysdiadochokinesia
3. Heel shin test
4. Rombergs sign
5. Tandom walking
6. Hop in place
7. Rising froam a sitting position
8. Test for pronator drift
Involuntary movements
1. Flapping Tremors
2. Chorea
3. Athetosis
4. Tics
Gait :
1. Scissors gait
2. Circumduction gait
3. Ataxic gait
4. Parkinsonian gait
5. High stepping gait
6. Antalgic gait
Sensory system
Proprioception – touch,
vibration, joint position
sense
Tacticle localisation
Two point discrimination
test
Stereognosis
Graphesthesia
Reflexes
Superficial – corneal abdominal plantar
Deep - biceps triceps supinator knee ankle
jaw
Grading –
1. 0 – absent
2. + - sluggish
3. ++ - brisk (normal)
4. +++ - brisker than average/
exaggerated
5. ++++ - very brisky with clonus
features UMN LMN
Location Cerebral cortex Brain stem and
spinal cord
Type of paralysis Spastic flaccid
Muscle tone Hypertonia Hypotonia
Deep tendon exaggerated Absent
reflex
Superficial reflex Absent Absent
Fassiculation Absent Present
Muscle wasting Absent Muscle atrophy
Plantar reflex Positive Negative
Extent of Wide spread Few muscles
paralysis supplying lower
Features Spasticity rigidity
Lesion Pyramidal Extrapyramidal
Resistance Encountered at throughout
beginning or end
Deep tendon jerk Exaggerated Normal or
diminished
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