SCHEME AND PROFORMA FOR NERVOUS SYSTEM EXAMINATION

Tell handedness of the patient in the history.

In general observation, mention about GCS

All vitals + PILCCOD

In head to toe examination, you may mention about abnormal body movements or it may be included in motor examination.

Higher mental functions: @ABCDE-MOS

Appearance: well dressed, groomed, hygiene, facial expression?

Behavior: cooperative/ irritable

Consciousness and communication: GCS/AVPU

Delusions/illusions/hallucinations: +/-

Emotions: excited or depressed, any change in mood

Memory: immediate(tell and ask), recent(last meal taken, ask to reverse number), past/remote(bday,             vacation)

Orientation: time, place and person(can recognize mother?)

Speech and language:

Articulation: say PASHUPATINATH

Fluency: assessed in spontaneous conversation

Comprehension: tell to do a task like show where is the door or close your eyes

Disturbance in naming:ask to name an object

Disturbance in repetition: ask to repeat something that you say

Disturbance in reading: write some command in a paper and tell to obey commands

Disturbance in writing: tell to write his name on a piece of paper

Content: whether its appropriate to scenario or not

Mental tests:

Intelligence : 100-7 test or 20-3 test

Abstract ability: ask like what will you do when house is in fire or you found letter on road

{content, articulation(cerebellar dysarthria: speaking in syllables i.e. scanning speech….bulbar and pseudobulbar dysarthria), comprehension(apasia: sensory/receptive and motor/expressive.)}

Signs of meningeal irritation: (remove pillow )

Neck rigidity

Kernig’s sign

Brudzinski’s sign (neck sign and leg sign)

Cranial nerves examination:

I: ask for history of rhinitis and examine nose for secretions and patency

   Check for smell sensation and don’t use strong odor

II:

visual acquity: near vision and far vision

field of vision: ‘H’-confrontation test

color vision: pin with colored heads/ ishihara chart

pupillary reflexes: direct, consensual, accommodation, RAPD

fundoscopy-not done unless ou have ophthalmoscope

pupils

III, IV and VI: first look for ptosis and squint

Eye movements

Nystagmus

Double vision

Pupil: shape, size, symmetry, margin

Reflexes(motor ): light reflex, accommodation reflex

V:

Sensory: touch with cotton wool, pain with sterile pain in B/L V1, V2 and V3.

Motor: clench teeth (masseter nd temporalis), move jaw sideways against resistance(pterygoids), open and close mouth against resistance(masseter)

Jaw jerk

Corneal reflex B/L

VII:

Inspection: width of palpebral fissure

Symmetry of frowning(while asking patient to look up)

Symmetry of blinking

Eye closure

Nasolabial folds

Angles of mouth

Drooling of saliva

Rashes on auricle

Tear (lacrimal glands)

Power of individual muscles:

Ask to close eyes and open against resistance(orbicularis oculi)

Ask patient to puff out the cheek and look for any escape of air, also ask to whistle(buccinators, orbicularis oris)

Ask patient to smile(orbicularis oris)

Ask patient to show teeth/clench teeth (platysma)

Taste sensation from ant 2/3^rd of tongue:

Ask to protrude tongue and then fix it with gauge piece without letting it go inside, put a drop of test solution and ask to point out the taste.

VIII:

Simple whispering test:

Occlude one ear and whisper into another @15cm distance, normal person should hear it.

Rinne test and weber test:

Vestibular function: caloric test (not done generally), Dix-Hallpike test, oculovestibular reflex

IX and X:

Speech: dysarthria

Soft palate: ask to open mouth and say ‘aah’, look soft palate and uvula

Gag relex (afferent is glossopharyngeal and efferent is vagus)

Taste sensation of posterior 1/3^rd of tongue

Ask to cough and assess the character of cough (glottis is closed by CN X)

Assess swallowing(give 3 teaspoon water, observe for absent swallowing, cough or delayed cough. If these are absent, ask to swallow a glass of water)

Air escape from nose while puffing out cheek

XI:

Power of SCM and trapezius. (cranial part of CN XI is assessed with vagus nerve)

XII:

Inspect tongue inside the oral cavity for atrophy and fasciculations

Ask patient to protrude the tongue and observe deviations and abnormal movements

Ask to move tongue side to side to assess the movement

Power of tongue muscle: ask patient to push the tongue against inside of cheek while pressing from outside

Assess speech for articulation

Motor system:

Bulk:

Inspection: symmetry, fasciculations, wasting, abnormal movements (if present describe: location, relation to rest/motion,  rate, rhythm, amplitude, relation to posture, relation to fatigue, emotion)
Palpation: confirm bulk by measuring circumference (upper limb-10cm from olecranon, thigh-18cm, leg-10cm)

            Feel the muscle

Tone: (left and right)

Upper limb: Across wrist elbow and shoulder

Lower limb: across knee, hip and ankle

Power: at sites mentioned for tone assessment

Reflexes:

Deep tendon reflexes: biceps, triceps, supinator, knee, ankle, knee and ankle clonus

Superficial reflexes: abdominal (upper, middle and lower), cremasteric, plantar

Hoffman’s reflex

Finger jerks

Sensory system: (in each dermatome B/L)

Superficial/exterioceptive/lateral spinothalamic tract: pain crude touch, temperature

Deep/proprioceptive: fine touch, joint position sense, vibration sense

Cortical sensory examination(done only if  above both are intact): 1 point localization, 2 point discrimination, stereognosis, graphaesthesia

Cerebellar examination: (power should be at least 4)

Finger to nose test

Heel to shin test

Dysdiadochokinesis

Rebound phenomenon

Pendular jerk

{intentional tremor, nystagmus, scanning speech, hypotonia, tandem gait}

Autonomic system:

Postural hypotension

Changes in salivation, lacrimation and absent sweating

{Wide fluctuation of vital signs}

Stance & Gait with rhomberg’s sign(heel to toe walking):

Well exposed legs, ask patient to walk across the room, turn back and come around and then to walk in a tandem gait

Note stride length, arm swing, steadiness, limping

Involuntary movements:

Tremors: stretch hands

Chorea: hands above head and protrude tongue

Athetosis: writhing movements

Dystonia

Hemiballismus

Myoclonus

Fasciculation and twitching: tongue

Tics: face and shoulder muscles

Carpopedal spasm: hand

Asterixis: outstretched hands

Peripheral nerves: (GBS, HZV, Leprosy)

Skull/Spine:

Trauma?

Size of head

Bulged frontanelle

Spinal deformity like kyphosis, scoliosis

Spina bifida, swelling or tuft of hair

SPECIAL THANKS : DR. SIDDHARTHA BHANDARI (IOM)