The document provides guidance on performing a neurological examination. It emphasizes that obtaining a thorough clinical history is key to making an accurate diagnosis, as it is sometimes the only way to diagnose certain neurological disorders. A neurological examination requires skill and experience to evaluate things like motor function, sensation, cranial nerves, coordination, and the presence of abnormal movements or seizures. The examiner should make the patient comfortable and modify their approach based on the patient's characteristics.

1. Neurological
Examination

2. Amr Hasan, MD,FEBN
Associate Professor of Neurology -
Cairo University

3. I. A good clinical history holds the key
to diagnosis.
II. In some neurological disorders, it is
the ONLY avenue to diagnosis
(epilepsy, migraine)
III. Needs Skill & Experience

4.  Make pt at ease: introduce yourself,
exchange social pleasantries, secure privacy.
 Be friendly, attentive, courteous (Don’t haste,
interrogate or stereotype).
 Analyze & inquire about significant symptoms,
minimize irrelevancies.
 Modify your approach according to pt’s
personality, age, education, culture & sex.

5.  Personal History.
 Complaint.
 Past History.
 Family History.
 Present History

6.  Name
 Age
 Sex
 Occupation
 Marital Status (no.of children & age of youngest)
 Residency
 Habits
 Handedness
NB: ♀ Menstrual history (?reg/duration/flow/pain)
Obstetric history
♂ stress on Special Habits+ Drug abuse.

7.  Prenatal.
 Natal .
 Postnatal.
 Feeding and lactation
 Vaccinations
 Milestones ( motor, psychic).

8.  Patient’s own wordS.
 O. C. D.
 The most distressing complaint.
 If more than one event…?

9.  Diseases (chronic illness, allergies, admission to hospital(s)).
 Operations (type & time, anesthesia, ?blood trasfision, post-
op complications).
 Drugs (chronic drug intake/ preceding the onset).
 Trauma (mechanism, site, witness/ associated with : altered
consc. convulsions, amnesia, personality changes, mfs of ↟ ICT,
bleeding/CSF leak)

10.  Consanguinity
 Similar condition (or risk factors) in the
family⇒ please establish “Pedigree Chart”

12.  Motor
 Sensory
 Cranial nerves
 Sphincters & Autonomic
 Coordination
++(pain, abnormal movement , seizures)

13. Analysis of the complaint(s) :
O C D
Onset: acute / subacute/ gradual.
Course: progressive, regressive, stationary,
relapsing (duration of attack, frequency,
timing (diurnal/nocturnal/seasonal, ⇧⇩fs).
Duration: since(date)….for (duration)

14.  O C D
 Distirbution: Uni/Bilateral.
Symm/Asymmetrical
Simultaneous/ Sequential
Distal/ Proximal
Flexor/Extensor
 Discrimination: UMN/LMN (early wasting, fasciculation,
flail/stiff)
 Degree of severity (ambulation)

15.  Ambulant with out support.
 Ambulant with minimum support
 Ambulant with maximum support.
 Wheel chair.
 Bedridden.

16.  Identify presence of weakness/paralysis:
‫بضعف‬ ‫حاسس‬(‫ثقل‬)‫الحركة‬ ً‫ف‬/‫عضالتك؟‬ ً‫ف‬
 Distibution:
Uni/bilat ....Rt/Lt.....UL/LL:
‫ناحٌة‬ ‫أي‬ ً‫ف‬/‫االثنٌن؟‬ ‫وال‬ ‫الساق‬ ‫وال‬ ‫الذراع‬ ‫شمال؟‬ ‫وال‬ ‫ٌمٌن‬
Symm/Asymm:
‫الدرجة‬ ‫نفس‬...‫ناحٌة‬ ‫من‬ ‫أكثر‬ ‫ناحٌة‬ ً‫ف‬
Simultaneous/Seaquential:
‫الثانٌة‬ ‫سبقت‬ ‫واحدة‬ ‫وال‬ ‫الوقت‬ ‫نفس‬ ً‫ف‬ ‫الناحٌتٌن‬ ً‫ف‬ ‫ابتدا‬ ‫الضعف‬

17. Proximal/Distal....
UL
‫فتح‬ ً‫ف‬ ‫صعوبة‬ ً‫ف‬/‫مٌاه‬ ‫زجاجة‬ ‫أو‬ ‫برطمان‬ ‫قفل‬/‫لمونة‬ ‫عصر‬...‫الباب‬ ‫فتح‬ ‫او‬
‫بالمفتاح؟‬
‫الشعر‬ ‫تسرٌح‬ ً‫ف‬ ‫صعوبة‬ ً‫ف‬/‫االٌشارب‬ ‫ربط‬/‫ثقٌلة؟‬ ‫حاجة‬ ‫شٌل‬
LL
‫تسند‬ ‫ما‬ ‫غٌر‬ ‫من‬ ً‫الكرس‬ ‫على‬ ‫من‬ ‫تقوم‬ ‫لما‬ ‫أكثر‬ ‫الضعف‬/‫السلم؟‬ ‫تطلع‬ ‫لما‬
‫رجلك؟‬ ‫من‬ ‫ٌفلت‬ ‫الشبشب‬
 Dicrimination(UMNL/LMN):
‫بتشوفها‬ ‫أو‬ ‫بٌها‬ ‫بتحس‬ ‫العضالت‬ ً‫ف‬ ‫رفة‬ ‫فٌه‬ ‫خسٌت؟‬ ‫عضالتك‬ ‫ان‬ ‫الحظت‬
‫مخشب؟‬ ‫وال‬ ‫ساٌب‬ ‫جسمك‬ ‫ان‬ ‫حاسس‬
 Degree of severity (Ambulation):
‫السرٌر؟‬ ‫من‬ ‫تقوم‬ ‫مابتقدرش‬ ‫وال‬ ‫ٌساعدك‬ ‫الزم‬ ‫حد‬ ‫وال‬ ‫لوحدك‬ ً‫تمش‬ ‫تقدر‬

18.  The condition started 2w ago when the pt
experienced acute onset , regressive course of
weakness of RT UL and LL , such weakness was
D>P,the pt felt his limbs neither flail nor stiff ,
there were no fasiculations, no wasting, no
manifestations as regard the other limbs ,and at the
onset the pt was ambulant with maximum support
and now he is ambulant without support.

19.  O C D
 Distribution: Uni/Bilateral.
Symm/Asymmetrical
Simultaneous/ Sequential
Extent (glove&stock/ dermatomal
sensory level/ hemi).
 Descrimination:
Superficial :+ve⇒parathesia, hyperthesia,allodynia,
pricking, burning,electrical
-ve⇒hypo/anasthesia.
Deep: +Rhomberg, Lhermitt symptom, walk on
sponge, hesitancy.
Cortical (less common)

20. Identify presence of sensory affection?
‫االحساس‬ ً‫ف‬ ‫بتغٌٌر‬ ‫الحظت‬
 Hypothesia:
‫قل؟‬ ‫احساسك‬..
‫ضعٌف؟‬ ‫وال‬ ‫الساقع‬ ‫و‬ ‫بالسخن‬ ‫بتحس‬
 Hyperthesia:
‫باأللم؟‬ ‫زائد‬ ‫احساس‬ ‫فٌه‬
 Parathesia:
‫سبب؟‬ ‫اي‬ ‫غٌر‬ ‫من‬ ‫كهرباء‬ ‫او‬ ‫حرقان‬ ‫أو‬ ‫بشكشكة‬ ‫احساس‬

21.  Distribution:
Uni/Bilat:
‫الناحٌتٌن؟‬ ‫فٌن؟‬
Symm/Asymmetrical
‫؟‬ ‫بعض‬ ‫زي‬
Simmultaneous/sequential
‫بعض؟‬ ‫مع‬ ‫وال‬ ‫الثانٌة‬ ‫قبل‬ ‫ناحٌة‬ ‫فٌه‬
Extent
‫الجسم؟‬ ‫نصف‬ ‫واخد‬ ‫؟‬ ‫محزمك‬ ‫؟‬ ‫لفٌن‬ ‫واصل‬ ‫ده‬ ‫التأثر‬
Deep sensory affection:
‫تقع‬ ‫ممكن‬/‫عٌنٌك‬ ‫تغمض‬ ‫لمل‬ ‫تتطوح‬/‫الصبح؟‬ ‫شك‬ ‫و‬ ‫تغسل‬ ‫لما‬
‫اسفنج؟‬ ‫أو‬ ‫رمل‬ ‫على‬ ً‫ماش‬ ‫كأنك‬ ‫زي‬ ‫وال‬ ‫صلبة‬ ‫رجلك‬ ‫تحت‬ ‫االرض‬
‫فجأة؟‬ ‫رقبتك‬ ً‫تثن‬ ‫لمل‬ ‫ظهرك‬ ً‫ف‬ ‫تسرح‬ ‫بكهرباء‬ ‫بتحس‬
Cortical sensation:
‫الشنطة‬ ‫جوة‬ ‫المفتاح‬ ‫علع‬ ‫تتعرف‬ ‫بتقدر‬/‫جٌبك؟‬

22.  The condition was also associated with
diminution of sensation( tingling and
numbness) involving the RT side of the body.
 The pt loses his balance on closing his eyes or
on entering a dark room.
 The pt is feeling the ground underneath as if
spongy

23.  I : ⇩/ altered smell, olfactory hallucinations.
 II : -ve: ⇩vision(blindness), scotomas, field defect.
+ve: scintillations , flashes, unformed/formed hallucinations.
 III, IV & VI: ptosis, diplopia, osillopsia
 V : ⇩/ altered sesation/pain in face, weak mastication.
 VII : ⇩mov facial ms:eye closure/
 VIII : ⇩hearing, tinnitus/ vertigo , unstaediness.
 IX,X, XI, XII: dysphagia /dysarthria/ dysphonia.

24. Olfactory nerve:
 Diminished olfaction
 Altered smell:
‫غرٌبة؟‬ ‫روائح‬ ‫بتشم‬
 Olfactory hallucinations:
‫وحشة؟‬ ‫روائح‬ ‫بتشم‬....‫شممها؟‬ ‫غٌرك‬ ‫ماحدش‬......‫اٌه؟‬ ‫قد‬ ‫لفترة‬

25. Visual acquity:
‫قل‬ ‫نظرك‬ ‫حسٌت‬/‫ضعف؟‬
Field of vision:
‫ماشً؟‬ ‫انت‬ ‫و‬ ‫الحاجات‬ ً‫ف‬ ‫بتخبط‬ ‫ممكن‬
Retinal affection:
‫خطوط‬ ‫تشوف‬ ‫ممكن‬/‫انوار‬/‫؟‬ ‫األشٌاء‬ ‫حجم‬ ً‫ف‬ ‫تغٌٌر‬
Colored vision:
‫االخرٌن؟‬ ‫عن‬ ‫مختلفة‬ ‫للوان‬ ‫رؤٌتك‬ ‫ان‬ ‫الحظت‬

26.  O C D
 Distribution: Uni/Bilateral.
Symm/Asymmetrical
Simultaneous/ Sequential
 Severity
 Painful or not.
 Limitation of ocular motility( double vision)
 Ptosis
 Local eye manifestations: (photophobia,
lacrimation, exophthalmos, red eye)

27. Diplopia
‫الرؤية‬ ‫في‬ ‫ازدواجية‬ ‫فيه‬/‫اثنين؟‬ ‫الحاجة‬ ‫بتشوف‬

‫واحدة‬ ‫عين‬ ‫تغمض‬ ‫لما‬,‫صورتين؟‬ ‫بتشوف‬ ‫برضه‬
‫؟‬ ‫بعض‬ ‫فوق‬ ‫وال‬ ‫بعض‬ ‫جنب‬ ‫الصورتين‬
‫معينة‬ ‫ناحية‬ ‫في‬ ‫تبص‬ ‫لما‬ ‫بتزيد‬ ‫الرؤية‬ ‫ازدواجية‬
‫معين؟‬ ‫وضع‬ ‫في‬ ‫تتحسن‬ ‫أو‬

28.  O C D
 Monocular or binocular.
 Corrected with closure of one eye or not.
 2 images ( next to each other, above each
other).
 False and true image.
 Painful or not.
 Diminution of vision.
 Ptosis.
 Local eye manifestations: (photophobia,
lacrimation, exophthalmos, red eye).

29. Pupillary affection
‫الشمس؟‬ ً‫ف‬ ‫بتزغلل‬ ‫عٌنٌك‬
Oscilopsia
‫امامك؟‬ ‫بتهتز‬ ‫الصورة‬ ‫تحس‬ ‫ممكن‬
Ptosis:
‫؟‬ ‫سقط‬ ‫جفنك‬ ‫ان‬ ‫الحظت‬

30.  O C D
 Distribution: Uni/Bilateral.
Symm/Asymmetrical
Simultaneous/ Sequential
Partial / complete
 Painful or not.
 Limitation of ocular motility( double vision)
 Diminution of vision.
 Local eye manifestations: (photophobia,
lacrimation, exophthalmos, red eye)

31. ‫التانٌة؟‬ ‫عن‬ ‫فارقة‬ ‫ناحٌة‬ ‫فٌه‬ ‫منمل؟‬ ‫وشك‬ ‫ان‬ ‫حاسس‬
‫؟‬ ‫كوٌس‬ ‫االكل‬ ‫تمضغ‬ ‫بتعرف‬
‫فٌن؟‬ ‫منمل؟‬ ‫انه‬ ‫حاسس‬ ‫كمان‬ ‫لسانك‬

32. ‫انت‬ ‫و‬ ‫كوٌس‬ ‫بتقفل‬ ‫مش‬ ‫عٌنٌك‬ ‫ان‬ ‫الحظ‬ ‫حد‬ ‫كوٌس؟‬ ‫عٌنٌك‬ ‫تقفل‬ ‫بتعرف‬
‫العادة؟‬ ‫غٌر‬ ‫على‬ ‫ناٌم‬
‫اآلخر؟‬ ‫النص‬ ‫زي‬ ‫بٌتحرك‬ ‫مش‬ ‫وشك‬ ‫نص‬ ‫ان‬ ‫الحظت‬

33. ‫قل؟‬ ‫سمعك‬ ‫ان‬ ‫حسٌت‬
‫وش‬ ‫فٌه‬ ‫بتحس‬/‫زن‬/‫األذنٌن؟‬ ‫احدى‬ ً‫ف‬ ‫طنٌن‬
‫بالدوار‬ ‫احساس‬ ‫فٌه‬ ‫هل‬(‫حوالٌك‬ ً‫الل‬ ‫أو‬ ‫انت‬)‫؟‬
‫االتزان؟‬ ‫بعدم‬ ‫احساس‬ ً‫ف‬ ‫هل‬

34.  Dysathria (nasal tonation):
‫خنفان؟‬ ‫فٌه‬ ‫اتغٌر؟‬ ‫صوتك‬ ‫ان‬ ‫حسٌت‬
 Dysphagia to liquids:
‫المٌاه‬ ‫تشرب‬ ‫لما‬ ‫ٌتشرق‬(‫ئل‬ ‫سا‬ ‫اي‬)
 Nasal regurgitation:
‫ترد‬ ‫ممكن‬ ‫المٌاه‬(‫ترجع‬)‫منخٌرك؟‬ ‫من‬

35.  UL ⇒ intention tremors↟on reaching target
(keys to locker, spoon to mouth), difficult
buttoning.
 LL ⇒clumsiness, staggering, wide base gait.
 Dysathria ⇒ Staccato

36.  UL ataxia
‫فٌه‬‫رعشة‬ً‫ف‬‫اٌد‬‫أو‬‫أٌدٌن‬‫بتزٌد‬‫مثال‬‫لما‬ً‫تٌج‬‫تحط‬‫المفتاح‬ً‫ف‬‫الباب‬‫أو‬
‫تشرب‬‫شمورب‬‫بالمعلقة؟‬
 Dysarthria(staccato)
‫الحظت‬‫أو‬‫االخرٌن‬‫الحظوا‬‫ان‬‫طرٌقة‬‫كالمك‬‫اتغٌرت؟‬
 LL ataxia
ً‫بتمش‬‫تتطوح‬‫لناحٌة‬‫أو‬‫ناحٌتٌن؟‬

37.  UMNL: acute ⇒retention, gradual ⇒precipitancy
 Post col.: hesitancy
 Autonomic manifestations:
1. Altered taste/ satiety/vomiting
2. CVS: postural hypotension/palpations
3. Skin: altered sweating, flushing, trophic changes
4. GIT: delayed emptying, diarrhea/constipation
5. Genitalia: erectile dysfunction, ⇩libido & orgasm

38. ‫ألم؟‬ ‫فٌه‬ ‫كان‬ ‫اٌه؟‬ ‫قد‬ ‫لمدة‬ ‫فٌك؟‬ ‫اتحبس‬ ‫البول‬ ‫ان‬ ‫حصل‬
‫تفضٌه؟‬ ‫تقدرش‬ ‫ما‬ ‫لكن‬ ‫بالبول‬ ‫احساس‬ ‫عندك‬
‫الٌوم؟‬ ‫مدى‬ ‫على‬ ‫فترات‬ ‫على‬ ‫منك‬ ‫بٌسٌب‬ ‫البول‬ ‫هل‬
‫طول؟‬ ‫على‬ ‫مغرقك‬ ‫البوا‬ ‫هل‬
‫البول‬ ‫ممكن‬/‫نفسك؟‬ ‫تحكم‬ ‫ماتقدرش‬ ‫كله؟‬ ‫؟‬ ‫منك‬ ‫ٌفلت‬ ‫البراز‬
‫ٌنزل؟‬ ‫علشان‬ ‫البول‬ ‫على‬ ‫تتحاٌل‬ ‫ممكن‬
‫باستمرار‬ ‫الحمام‬ ‫تروح‬ ‫محتاج‬ ‫انك‬ ‫احساس‬ ‫عندك‬.

39.  Pain/Headache:
1. OCD.
2. Character, site, radiation.
3. ⇧, ⇩, assosciation
4. Relation (sleep/stress: mental, physical &
psychological/ posture).
5. Severity (interrupt sleep/interfere with DLA)
 Abnormal mov
(slow/fast, regular/irregular,
postural/twisting/pseudopuposeful/ ? coordinated&
stereotyped, hyper/hypotonic )

40.  History is the most important part of Neurological evaluation,
that guides to establish:
• Focal
• Systemic
• Dissiminated
Anatomical
diagnosis
• Heredofamilial
• Symtomatic
• Idiopathic
Aetiological
diagnosis

41. Anatomical diagnosis
Focal Systemic Dissiminated
Dissimination in time
Dissimination in place
Dissimination in time
and place

42. 12/24/2016 42
1. The anterior (ventral) horn cell (MND)
2. The radicle (root).
3. The peripheral nerve.
4. The neuromuscular junction.
5. The muscle.
5
4
2
1
2
2
3

43. Where is the lesion
•Cortical
•Sub-cortical
•Cerebellar
•Brainstem
•Spinalcord
•AHC
•Roots
•PN
•Neuromascular Junstion
•Muscle

44.  Cortical: loss of consc/ convulsions/
aphasia/cognition and behavioral dis/
incomplete motor/ cortical sensory loss.
 Subcortical: complete motor/ all 1ry
sensations/ visual field defect
 Cerebellar: staccato speech/ intension
tremors/ wide base gait.
 Brainstem: ipsilat. Cranial nv
lowemotor+contralat. Hemiparesis(hypothesia)


45.  Spinal cord: sensory level , below UMN,
sphinchteric troubles
 AHC: fasiculations, weakness of LMN nature ( +/-
UMNL)
 Roots: radicular pain, Asymm , dermatomal motor
& sensory loss, ↟ with stretch.
 PN: usually symm, motor (LMN), sensory(glove &
stock).
 N-M junction: motor only, fatigability, diurnal
 Muscle: motr only (>px) mild ⇩ tone and atrophy.

46.  Hereditary
 Symptomatic
Vascular
Infection
Trauma
Toxin/Drugs
Autoimmune
Metabolic
Endocrinal
Nutritional
Neoplastic-paraneoplastic
Congenital
Idiopathic

47. SCAN
FILTER
ARRANGE
STAMPS

49. Old classification :
Based on:
 Degree of disturbance of consciousness.
 Response to external stimuli.
Response to
Increased verbal
stimuli
impairedLethargy or
drwsiness
Response to
Vigorous and
continuous verbal
stimuli
ImpairedStupor
No response to
verbal stimuli only
reflex to painful
LostSemi coma

50. GLASGOW COMA SCALE:
Motor responseVerbal responseEye opening
Obeys orders
5
Oriented
5
Spontaneous
4
Localise to pain
4
Confused
4
In response to speech
3
Flex to pain
3
Words no sentences
3
In response to pain
2
Extend to pain
2
Sounds no words
2
None
1
None
1
None
1

51.  Watch the patient while taking history.
Q1:Are there signs of self neglect?
Dirty ,unkempt (depression, dementia, drug
abuse)
Q2:Does the patient appear anxious?
Restlessness
Q3:Does the patient behave appropriately?
Overfamiliarity ,disinhibited (frontal lobe)
Unresponsive ,little emotional response
(depression)

52. Mood: inner feeling. (history taking)
Affect: outword expression. (examination)
Q:How are your spirits at the moment?
Q:How can u describe your mood?
Abnormalities :
 Depression.
 Euphoria.
 Emotional labilty.
 Apathy or indifference.

53.  Orientation:
For time ,place and person .
 Q1:What date,day,month,season,year,time of
the day?
 Q2:What place,town?
 Q3:What your name,ask about
persons(familiar and nonfamiliar)
 Attension:
 Passive: external stimulus
 Active: digit span.

54. A:immediate memory:
◦ “I will tell u 3 word and u repeat them”
◦ Name and adress test.
◦ Digit span.
B: short term(recent) memory.
◦ 5 minutes later ,ask about the 3 words or name and
adress.
◦ Events in last 24 hrs “what did u have for breakfast”.
C: remote memory:
◦ Old events e.g. who was the first president of Egypt

55. Abnormalities: AMNESIA
◦ Anterograde : loss of immediate and recent events.
◦ Retrograde :loss of remote events
◦ Transient global amnesia:
Causes :
◦ Dementias: Alzheimer’s disease ,vascular dementia.
◦ Tempora lobe lesions,
◦ Post concussion.
◦ korsakow’s syndrome with chronic alcoholism.

56. Serial seven test :
 Ask the patient to take 7 fro 100 thentake 7
from what remains.

57.  Q1: Ask patient to explain well known proveb.
Abnormality:
 Concrete thinking.
Causes:
 Frontal lobe lesions
 Dementias.

59. Ask the patient about Illusions and
Hallucinations
Illusion: misinterpretation of external stimuli
Hallucinations: perception without external
stimuli
(olfactory,visual,auditory,gustatory,somatic)
Test for AGNOSIA e.g.
Facial recognition “prosopagnosia”
Body perception “asomatagnosia, finger
agnosia,lt/rt agnosia”

60. Thought flow:
 refers to the quantity, tempo (rate of flow)
and form (or logical coherence) of thought.
Thought content:
 content would describe a patient's delusion,
overvalued ideas, obsessions, phobias and
preoccupations.

61.  The person's understanding of his or her
mental illness is evaluated by exploring his or
her explanatory account of the problem, and
understanding of the treatment options.
 insight can be said to have three
components:
◦ recognition that one has a mental illness,
◦ Compliance with treatment, and
◦ the ability to re-label unusual mental events (such
as delusions and hallucinations) as pathological

62. Judgment refers to the patient's capacity to
make sound, reasoned and responsible
decisions.
Ask the patient "what would you do if you
found a stamped, addressed envelope lying in
the street?"

64. The patient is fully conscious,
well oriented for time place
and person,
with normal memory and
mood,
he is cooperative and avarege
intelligence.

67.  How to examine?
◦ Familiar substance
◦ Non irritant
◦ Each nostril alone

69. • Anosmia
• Unilateral :
• traumatic,
• Inflammatory
• neoplastic: Foster-Kennedy syndrome
• Bilateral :
•ENT,
•Hereditary,
•Hysterical
• Parasomia
•Olfactory hallucination is due to central olfactory dysfunction

71.  Visual acuity
 Colour vision
 Visual field
 Fundus examination

72. Snellen chart
 Counting fingers 6
meters to 30 cm.
 Hand movement.
 Perception of light.

73.  Ishihara colour plates

74.  NORMAL FUNDUS

75.  Normal

78.  Confrontation method

80. Automated perimetry Bjerrum screen.

83. Monocular blindness

84. Bitemporal hemianopia

85. Contralateral
homonymous
hemianopia

86. Loss of vision with optic atrophy
Bitemporal hemianopia
Contralateral homonymous
hemianopia
Hemianopic pupillary reaction
Contralateral homonymous
hemianopia with
Macular sparing
Contralateral homonymous
hemianopia
preserved pupillary reaction

88.  How to examine
◦ Ocular movements
 Individual
 Gaze
Ptosis
◦ Pupils

94.  External ophthalmoplegia
 Internal ophthalmoplegia
NB:
compression: early mydriasis
and lost light reflex
infarction: pupillary reflex
intact

96. Abducent nerve palsy Trochlear nerve palsy

97. Partial Complete

99. Block the action of frontalis to
differentiate between partial and
complete ptosis.

100.  Ask the patient to look at you finger placed:
laterally, upwards and downwards.
 Comment on:
◦ Is it sponteneous or fixational
◦ If it has slow and rapid phases
◦ Direction

101.  ......pallPATIENTSCLIPSeyeVideo024.3
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102.  Size, shape, symmetry
 Response to direct and indirect light reflex.
 Accomodation reaction.
 Cilio-spinal reflex

104. Miosis Mydriasis
 Horner syndrome
◦ Congenital
◦ acquired
 Pontine lesion
 Opiate toxicity
 Argyl-Robinson pupil
 Diminution of vision.
 Drugs
 Hemianopic pupillary
defect
 Compression of 3rd
nerve.
 Adie pupil

105. Argyl-Robinson pupil Adie pupil

112. Motor part Sensory part
 Temporalis
 Masseters
 Pterygoids
 Pain -------touch
 Both sides of the face
 Ophthalmic, maxillary,
mandibular branches.
 The inner----- outer
part of the face

113. Pons
Spinal cord
medulla
Sensory supply of the face

114. Motor
Sensory
D reflex
S reflex

115. Jaw reflex
Corneal and conjunctival
reflexes
Exaggerated jaw reflex
Blinking of both eyes
Absence of blinking on one side
Absence of blinking on both sides

116. Corneal
reflex
St.
Aff
C )MSN→MFN(
Eff
R
•Corneo-mandibular
(jaw winking)
•Corneo oculogyric
Reflexes

118. Jaw deviation
Herpes zoster
ophthalmicus

120.  How to examine
◦ Muscle power
 Frontalis…..orbicularis oculi
 Orbicularis oris, buccinator, retractor anguli
◦ Reflexes
 Glabellar reflex
 Corneal reflex
◦ Taste sensation

122. Stylohyoid
Post. Belly of
diagastric
Stapidus

124. Site of the lesion:
Nuclear
Cerebellopontine
Facial canal
Extracranial facial lesion

126. Paralysis of the muscles of the upper and lower parts of the
face
Affecting voluntary, emotional and associated movements.

128. It is not known which pathways mediate mimetic (involuntary) innervation of facial m

131. virus reactivation.
Sympathetic vasospasm

135. Marcus Gunn jaw
winking

137.  Cochlear part
 Vestibular part

142. Vestibular dysfunction Caloric test

143. Vertigo
Central
Brain stem
VBI
PICA
MS
encephalitis
Cerebral
TLE
VASCULAR
Peripheral
Labryinthine
PHYSIOLOGICAL
Labrynthitis,
Meniere
Peripheral nerve
CPA LESIONS
VESTIBULAR
NEURITIS

145.  Deviation of the
palate
 Palatal reflex
 Pharyngeal reflex
 Swallowing water

150.  Examination of
trapezius.
 Examination of
sternomastoid.

156. Inspect the tongue for:
Deviation.
Wasting.
Fasiculations.
Abnormal movement
Evidence of systemic
disease
Test for the power

160. The motor system evaluation is divided into the following:
 Inspection:
◦ Body positioning,
◦ Muscle state [ wasting or hypertrophy],
◦ Involuntary movements, fasciculations.
◦ Skeletal deformities
◦ Trophic changes
 Muscle tone.
 Muscle strength.

161. Inspection

162. hemiplegic posture Parkinson disease

164.  Distribution
◦ Focal in one area
◦ Generalized
 Proximal
 Distal
 Unilateral or
bilateral
 Symmetrical or
not

172. .
 Look for skeletal deformities e.g. pes
cavus,scoliosis .

174.  Distribution
 Rest , postural, action .
 Frequency.
 Amplitude.
 Rhythmic or not
 What increase or decrease them

175.  ....pallPATIENTSCLIPSexstatic
tremors.mp4

176. Tone

177.  A: upper limbs:
◦ Shoulder: Gower’s method
◦ Elbow: passive flexion and extension.
◦ Wrist: shaking ,passive flexion and extension.
 B:lower limbs:
◦ Hip: rolling
◦ Knee: hooking, passive flexion and extension.
◦ Ankle :shaking , passive flexion and extension.

178.  Hypotonia
 Hypertonia
◦ Spasticity [ clasp knife]
◦ Rigidity
 Cogwheel
 Lead pipe
 Dystonia
 Myotonia
 Catatonia
 Stiffness [ meningeal irritation, stiff person
syndrome]

179. REFLEXES

180. Upper limb Lower limb
 Biceps reflex
 Brachioradialis reflex
 Triceps reflex
 Supraspinatous reflex
 Finger reflex
 Knee reflex
 Ankle reflex
 Patellar reflex
 Adductor reflex
Reinforcement
Clonus
Ankle Patellar wrist
Organic ===hysterical

181.  Planter reflex
◦ Babiniski method
◦ Chaddok method
◦ Baradah method
◦ Oppenhime
method
◦ Gordon method
◦ Schaefer method
 Abdominal
reflexes
 Cremastric reflex
 Gluteal reflex
 Anal reflex

183. Rate the reflex with the following scale:
5+ Sustained clonus
4+ Very brisk, hyperreflexive, with clonus
3+ Brisker or more reflexive than normally.
2+ Normal
1+ Low normal, diminished
0.5+
A reflex that is only elicited with
reinforcement
0 No response

196. 0 : No muscle contraction is detected
1 : A trace contraction is noted in the muscle by
palpating the muscle while the patient attempts to
contract it.
2 : The patient is able to actively move the muscle when
gravity is eliminated.
3 :The patient may move the muscle against gravity but
not against resistance from the examiner.
4 :The patient may move the muscle group against some
resistance from the examiner.
5 :The patient moves the muscle group and overcomes
the resistance of the examiner. This is normal muscle
strength.

197. Power
Examination Technique:
•power or strength is tested by comparing the patient’s strength against your own.
•compare one side to the other.
•grade strength using the Medical Research Council (MRC) scale.

198. MRC Scale
Grade Description
0 no contraction
1 flicker or trace of contraction
2 active movement with gravity eliminated
3 active movement against gravity
4* active movement against gravity and resistance
5 normal power

199.  Shoulder
◦ Adduction
◦ Abduction
◦ Flexion
◦ Extension
◦ Lateral rotators
◦ Medial rotators
◦ Serratus anterior
 Elbow
◦ Flexion
◦ Extension
 Wrist
◦ Flexion
◦ Extension
 Hand
◦ Thumb
◦ Intreossei
◦ Lumbricals

213.  Hip
◦ Flexion
◦ Extention
◦ Adduction
◦ Abduction
 Knee
◦ Flexion
◦ Extention
 Ankle
◦ Dorsiflexion
◦ Planterflexion
◦ Inversion
◦ Eversion

226.  COORDINATION

227. In the upper limb Lower limb
 Finger to nose, to
finger, to doctor
finger. Assess
decomposition,intentio
n tremors and
dysmetria.
 Dysdiadokokinesia
 Rebound phenomena
 Buttoning and
unbuttoning
 Heel to knee test
 Walking straight
 Romberg test

237.  For pain use pin prick, for touch use a cotton
piece
 Comapre
◦ Both sides……….if you are suspecting for hemihypthesia
◦ Lower limbs trunk upper limbs…….if you are suspecting
a level or jacket sensory loss
◦ Distal to proximal if you are suspecting socks and glove
distribution.
◦ Each radicle ( dermatomal suply) if you are suspecting
radiculopathy.
◦ Sensory area of each nerve if your are suspecting nerve
injury
◦ Do not forget examining the saddle rea

238. Deep senstion Cortical sensation
 Vibration sense
 Joint sense
 Muscle sense
 Nerve sense
 Romberg test
 Tactile localization
 Two points
discrimination
 Stereognosis
 Graphosthesia
 Perceptual rivalry

242. Root Action Muscles
L2 Flexor of the hip Ileopsoas.
L3 Extensor of the knee Quadriceps
L4 Dorsiflexion of the ankle Anterior tibial group
L5 Dorsiflexion of the toes Anterior tibial group & glutei
S1 Plantar flexion of the ankle and toes Calf muscles & glutei
S2 Flexor of the knee Hamstrings
S3, 4, 5 Anal contraction Anal and perianal muscles

243. Root Sensory
L1 Upper third of the front of the thigh.
L2 Middle third of the front of the thigh
L3 Lower third of the front of the thigh.
L4 Antero-lateral aspect of the thigh, Front of the knee, of the knee , Antero - Medial
aspect of the leg, medial aspect of the dorsum of the foot and the foot and big toe.
L5 Lateral aspect of the thigh and leg, Middle third of the dorsum of the foot and
Middle three toes.
S1 Postero-lateral aspect of the thigh and leg, Lateral third and little toe .
S2 Posterior aspect of the thigh and leg and sole of the foot.
S 3,4, 5 Anal, perianal and gluteal region (saddle-shaped area).

256. Meningeal Irritation tests

261.  Circumduction
 Scissor
 High steppage
 Waddling
 Stamping
 Wide base
 Deviation or zigzag
 Short steppage
 Dancing

262. THANK YOU