Nervous examination

Ø  Higher cerebral function

Ø  Cranial nerve examination

Ø  Motor system examination of upper and lower limb

Ø  Sensory system examination

Ø  Cerebellar function

Ø  Meningeal irritation

Ø  Gait

Higher cerebral function(ABCDE)

 

           Appearance-Ill/well looking

           Behavior-Normal/violent

           Consciousness-(Glasgow coma scale)

o   Eye opening(E)—Spontaneous/to speech/to pain/nil

o   Motor response(M)—Obeys/localises/withdrawn/flexion/extension/nil

o   Verbal response(V)—Oriented/confused/inappropiate word/incomprehensible sound/nil

 

            Delusion , delirium ,dementia ,illusion ,hallucination

o   Delusion is false perception of something  which is not a fact

o   Illusion is false perception of an object

o   Hallucination is false perception of special sense(Visual/auditory)

o   Loss of orientation of time and place

            Emotion—Laughs/cries always/euphoria

 

            Intelligence

 

            Memory

            Orientation of time ,place and person

            Speech

Cranial nerve examination

Olfactory nerve

Nasal mucosa>Cells>Nerves>Cibriform plate>Area 28

Ask 2  questions-

Ø  Ask if the pateint can smell of not or note if he is anosmic/hyposmic/parasmic

Ø  Ask if nasal congestion/not

Do the test-

Sitting position

Check nasal patency with

§  Torch

§  Hold cotton tip in front of 1 nasal opening

§  Ask the pt. shut the nostril with one finger and  to breath in and out and see if cotton  moves/not

§  Check opposite nasal opening also

§  Dip cotton tip with know products(Lux , আতর) and hold before patent nasal opening   with eye closed                      

Optic nerve

Must check 4 things-         Visual acuity

                                             Color vision

                                             Visual field

                                             Fundoscopy

1st ask if pt. use glass/not ,if do then tell him to put the glasses on

For visual acuity

Ø  Near vision-Ask the pt. to read if he can read or see close objects

Ø  Distant vision-Ideal by snellen’s chart ,if not available ask to see distant objects like counting bars of window or ফ্যানের কইটা পাখাetc.

For color vision-By asking the pateint to say red , green and blue colored objects

For visual field

Ø  I must sit 1 meter from pateint

Ø  Ask the pateint to close one eye with palm of hand and I will close opposite eye of mine  and tell him to look only to my nose

Ø  Then my index finger  should be wiggled  in  his  /mine upper temporal field ;tell him to notify me when he sees the wiggling and do same with lower temporal field. Then wiggle on opposite side to check upper and lower nasal field

Ø  Do same test for the other eye

For fundoscopy

We see the fundus of eyeball to detect-

                      Diabetic change

                      Papilloedema

                      HTN change 

Occulomotor ,trochlear and abducent nerves

Ask-If sees double(Diplopia)

Do test

Ø  Ocular movement by H shaped

Ø  Squint-Sit 1 meter away from pt ,close 1cover 1 eye and look at my torch; check for any movement of uncovered eye

Ø  Nystigmus-Sitting  position ,hold  finger  in arm length away ,move up down and left right and then look at pt. eye for nystigmus

Ø  Pupil-Size , shape ,symmetry

               

o   Light reflex; Look at distance ,torch from side and check for reflex(Direct and consensual)

o   Accommodation reflex;

§  Ask the pt. to fix eye at distant point and then suddenly present an object 15cm from eye and check for reflex

Ø  Oculocephalic reflex

·         Supine position ,hold pt’s head ,tell him to look at my eyes ,then  do NO-NO movement  and check for this reflex

Trigeminal nerve

Sensory test

       Fine touch by cotton twist

      

Ø  First make attention by touching anywhere    and ask if he can feel

Ø  Touch over 1 side of maxillary branch and ask—(Can you feel?)আপনি বুজতে পারেন

Ø  Then touch over opposite sided maxillary branch and ask the same

Ø  Finally when one branch of trigeminal is complete then ask-(Is your sensation equal on both side?)

o   দুই পাসে এক রকম নাকি আলাদা বুজলেন?

Ø  Do this procedure for all three branched area

        Crude touch/Pain-With pin

Ø  Repeat same procedures just like fine touch

        Corneal reflex-By cotton twist ,move just from limbus to laterally and see if eye blinks or not

Motor test

Ø  Ask to clench teeth and feel the temoralis and masseter muscle patency        

Ø  Open mouth against resistance

Ø  Jaw jerk-Open the mouth partially , and check jaw jerk; normally absent or very minimal

Facial nerve

Ask 5 questions

Ø  Does any food get stuck in your mouth

Ø  ( খাবার সময় মুখে খাবার আটকে?)

Ø  Have you noticed of water dribbling during drinking?

Ø  ( পানি মুখ থেকে গরিয়ে পড়ে?)

Ø  Do you get taste of foods?

Ø  ( খাবার স্বাদ পান?)

Ø  Do you have any hearing difference in any of the ears?

Ø  ( কানে কম বা বেশি শোনেন কিনা?)

Ø  Have anyone ever told you that your eyes are open during sleeping?

Ø  ( আপনাকে কি কেউ বলেসে যে ঘুমের সময় আপনার চোখ খোলা থাকে?)

Do test

Ø  Ask the pt to make wrinkle of forehead or by looking at my finger(Frontal belly)

Ø  Close your eyes ; I’ll try to open but u won't open, ok?(Orbicularis oculi)

Ø  Can you whistle?গাল ফোলান ,ফু দেন , শিশ দেন(Orbicularis oris)

Ø  Clench mouth(ই   করেন)(Levator anguli oris and risorius)

Ø  Rub something(Hair , fingers) behind both ear ask if he can hear or not(Stapedius)

Ø  Test sensation: Sweet>Salt>Sour>Bitter(Chocolate ,salts ,lemon ,metronidazole tablet); before and after every taste , wash mouth with water

Glossopharyngeal and vagus nerve

Ask—

Ø  Nasal regurgitation

Ø  ( খাবার সময় নাক দিয়ে আসে?)

Ø  To say something to asses nasal intonation

Ø  ( বলেন বাড়ি যাব)

Do test-

Ø  Open mouth and check with torch for uvular deviation(Deviates opposite to leison)

Ø  Say ‘AAH’ and check for uvular vibration/paralysis

Ø  To cough and hear it

Ø  Blow cheek by closing lips tightly

Ø  Give a glass of water to drink for gag reflex ,3 teaspoon water drink and check for cough/delayed cough/change in voice after each teaspoon

Accessory nerve(Only spinal part)

Ø  Check  for any muscle wasting/bulk of trapezius and sternocleidomastoid muscle

Ø  Shrug your shoulder(ঘাড় উঁচা করেন) and against resistance

Ø  Mover head to right and left( ডানে বামে তাকান) against resistance

Hypoglossal nerve

Ask

Ø  to open mouth and check with torch for any deviation /atrophy/hypertrophy/shape/size

Do test

Ø  Stick out tongue and move to right and left

Ø  Give pressure on both cheek with tongue against my fingers over cheek

Ø  Water swallow test

Motor system

Inspection

Ø  Visible wasting

Ø  If no visible wasting ,check fasciculation/fibrillation—Slight  tapping with forefingers over muscle bulk

Ø  Any lump ,ulcer ,scar ,gangrenous change ,deformity ,symmetry

Palpation

• Muscle bulk—Measure symmetry by tape if visible wasting(From knee/elbow)
• Tone—

          Palpate

          Fall on hand

          Passively move joints to check for tone

• Power grading—Grade 0; No movement

                                         Grade 1; Flickering movement

                                         Grade2; Side to side movement(No gravity)

                                         Grade 3; Movement against gravity(Ask pt. to raise leg)

                                         Grade 4: Movement against resistance

                                         Grade 5: Normal movement

• Reflexes and jerks—Knee and ankle jerk ,triceps ,biceps and supinator jerk

• Clonus(not in upper limb)

    

o   Knee clonus(Thumb and forefinger to push towards foot  with sustaining pr. above patella)

o   Ankle clonus(One hand on popliteal fossa with knee and ankle joint at 90 degree ;suddenly dorsiflex ankle

• Co-ordination—Heel shin test ,finger nose test

• Gait(not in upper limb)

Sensory system

Ø  Position—(First instruct the close eyes)

§  Toe (Ask the pt. to tell which direction his toe is directed towards after instructing him)

§  Thumb(Same); always check symmetry

Ø  Vibration—(First instruct and close eye)

§  By holding vibrating tuning fork at great toe/thumb and ask if pt. can feel or not(First control at forehead; always check symmetry)

Ø  Temperature—(First instruct and close eye)

§  With cold metallic object like tuning fork and ask if he can feel  cold or not but appropriate is to do this test by bottle of hot and cold water ;always check symmetry

Ø  Pain -(First instruct and close eye)

o   Superficial pain at dermatome

o   Deep pain at squeezing belly or calf or biceps muscle ;also symmetry

Ø  Two point discrimination—(Eye closed): also symmetry

Ø  Fine touch and crude touch-(First instruct and close eye)

                                             Over the area of dermatome; also symmetry

[Joint position and vibration are for dorsal column lesion]

Cerebellar sign

Ø  Head: Head nodding(Titubation)

·         Yes-yes or no-no movement

Ø  Eye: Nystigmus(When looking to the side of leison)

Ø  Nose: Finger nose test

Ø  Mouth: Scanning speech(Sudden stoppage of syllable; say lalmonirhat)

Ø  Hand:

§  Disdiadochokinesis(Repeated palm-dorsum clapping)

§  Rebound phenomenon

Ø  Leg:

·         Pendular knee jerk

·         Heel shin test

·         Disdiadochokinesis: Repeated clap by foot on my hand

Ø  Gait: Drunken gait

Gait

Two phases—

1.Stunce

2.Swing

(Bones , joints , muscle , frontal lobe , vision are responsible)

Types

Ø  1.Antalgic gait/limping gait

§  Found in any painful condition like injury

Ø  2.March de patepa gait

§  Found in frontal lobe leison

§  Tendency to walk on toes

Ø  3.Sensory ataxic gait/stumping gait

§  Found in posterior column leison

§  Very heavy heel drop step-walk

Ø  4.Drunken gait/cerebellar gait

§  Cerebellar  leison

Ø  5.Parkinsonian  gait

Ø  6.Hemiplegic gait

§  Stroke at internal capsule

Ø  7.High stepping gait

o   Common peroneal nerve leison

o   Flat foot heavy drop-walk just opposite to stumping gait

Ø  8.Seizzures gait

o   Bilateral stroke

o   Closed knee + distant footed walking

Ø  9.Waddling gait

o   Proximal muscle weakness

o   Normal in Pregnency

Ø  10.Vestibular gait

Signs of meningeal irritation

Ø  Neck stiffness

·         Supine position ,hold his head , ask to flex head until chin touch the chest which would be impossible in case of neck stiffness.Then try to do passive flex slowly and feel resistance

·         Causes—Meningitis ,encephalitis ,poliomyelitis ,hemorrhage ,raised ICP

Ø  Kernig’s sign

·         Supine position , passively flex at hip joint of one leg while extending knee. If resistant if found or other leg flex at hip the sign is +ve. Do same for other leg

Ø  Brudzinski’s sign

·         When neck is flexed ,drawn up of lower limb indicates +ve sign