1st check GCS

Measures conscious level

Range from 3-15

Note: dementia - fully alert but not orientated in time, place, person

ORIENTATION

5 ( ) What is the (year) (month) (date) (day) (month)?

5 ( ) Where are we: (state) (county) (town or city) (hospital) (floor)?

REGISTRATION

3 ( ) Name 3 common objects (eg., "apple, table, penny"):

Then repeat them until he/she learns all 3. Count trials and record. Trials:

ATTENTION AND CALCULATION

5 ( ) Serial 7’s backwards. Give 1 point for each correct answer. Stop after 5 answers (100,93,86,79,65). Alternatively, spell "WORLD" backwards. One point for each correct letter.

RECALL

3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer (Note: Recall cannot be tested if all 3 objects were not remembered during registration.)

LANGUAGE

2 ( ) Name a "pencil," and "watch."

1 ( ) Repeat the following: "No ifs, ands, or buts."

3 ( ) Follow a 3-stage command: "Take a paper in your right hand, fold it in half, and put it on the floor."

1 ( ) Read and obey the following: Close your eyes.

1 ( ) Write a sentence. Score if it is sensible and has a subject and a verb

1 ( ) Copy the following design: intersecting pentagons, button/unbutton clothes

Total Score

Pyramidal system

Starts in primary motor cortex in brain

Lesion that affects 1st order MN gives UMN lesion

Lesion that affects 2nd order MN gives LMN lesion

Corticobulbar tract: primary motor cortex to BS

LMN lesion:

1. Bells palsy (affects CN VII): lesion in nerve itself

2. Bulbar palsy (stroke or tumour) affecting BS motor nuclei

1. Anterior horn cell in SC equiv. to motor nuclei in BS
2. Cortical lesion: UMN lesion in H&N and limbs
3. Subcortical lesion: UMN lesion in H&N and limbs
4. Lesion in BS: LMN lesion in H&N; UMN lesion in limbs
5. Lesion at C6: no signs in H&N; LMN lesion for limbs

Aromatic: coffee, perfume, camphor, mint, soap

Not-irritants: ammonia (stimulate pain receptors)

One nostril closed while Pt sniffs with other

Visual Acuity

Sit directly opposite Pt. Observe face: ptosis? Constricted pupils? Facial muscle wasting?

Ask Pt if he/she can see.

If yes, test visual acuity (modified Snellen chart, 14 inches from Pt).

Numerator; distance from Pt to obj. Denominator: size of figure (20/20: 20 (top) is distance bet eye and obj, 20 (bottom) is size of figure)

Test each eye separately

Dr and Pt eyes at same level

Cover one of Pt's eyes - Pt fixate on examiner's pupil

Test: upper temporal, lower temporal, lower nasal, upper nasal, central

Central scotoma: central vision blurred

Pt fixate on distant obj away from bright light

Examiner (R) to Pt's (R)

Size

Shape

Equality

Fix pt's chin with Dr's hand: keep head in central plane

Do quite slowly

Look for nystagmus and conjugate gaze

At first keep in same horizontal plane as eyes

Don't take finger out too wide - causes physiological nystagmus

Do 'H' shape: up/down at extreme, extreme, centre

When eyes follow down, look for lid lag. Usually upper eyelid hits limbus of cornea.

Ptosis / exophthalmos = can see white of sclera above and below pupil

Disconjugate visual axis / eye movt: squint / strabismus

If prolonged (esp. children): adapt to disconjugate eye movt - therefore despite disconjugate eye movt, brain suppresses vision from one eye

Abnormal image: tends to be image that is further and more blurred

Can test (by covering one eye) which image is the one that disappears (which is the false image)

II: afferent

III: efferent (Edinger-Westphal)

Consensual and direct response

Pupil of neurosyphilis

Accommodation reflex intact but light reflex not normal (small irregular pupils)

Pt to look at obj far away in room, look at pen close to Pt's face. Pupils constrict

MOTOR

Muscles of mastication

2 x pterygoids: open + close. Never close mouth unopposed (support back of head)

Masseter: Pt bite

Temporalis: Pt to bite, feel at temples

Jaw reflex: hold patella hammer halfway; wrist action, loosen jaw, finger on mandible, hit it downwards, don't bounce back

Corneal reflex: touch on side of pupil, bilateral blink

SENSORY

Use toothpick

Opthalmic: to side of forehead

Maxillary

Mandibular: keep away from line of jaw

Upper part of face: bilaterally innervated

Lower part: unilaterally innervated only

Look up (follow finger up): Frontalis

Screw up eyes: obicularis oculi

Facial n palsy (LMN): can only close affected part partially

Stroke: UMN facial palsy; can screw up eyes and raise frontalis (controlled by opposite hemisphere)

Back of head: C2

There is NO C1 dermatone

Don't ask to open mouth: this tests V

Show me your teeth: VII

Blow out cheeks

Taste: anterior 2/3 tongue

Stapedius: fixes eardrum (at loud noise, contracts immediately to protect eardrum). If VII palsy, LMN palsy, hyperacusis (noise sounds louder)

128 Hz: too low

Rinnes

Hit tuning fork, put on mastoid process, when can't hear buzzing anymore tell me, put by ear.

Air conduction should be better than bone

Repeat other side

Webers

Hit fork, put in centre of forehead

Bone conduction to both sides (should hear sound in centre)

Conductive deafness: sounds louder on that side (lateralised to that eye)

Use clean spatula (kept in envelope)

Push down on tongue: 'aaah' - uvula moves up. If moves to left, right-side is paralysed (vice versa)

Gag reflex: touch gently on pharynx (not blindly)

Ask Pt to speak: listen for dysarthria (baby hippopotamus, British constitution)

Dysarthria: articulation of speech

Dysphagia: higher mental function

Dysphonia: hoarse; larynx problem

Pt stick out tongue, move L/R, in/out (open mouth wide, keep tongue slightly in mouth, or else pt gets nervous and looks like fasciculations!)

Tongue power: stick tongue in cheek

XI: spinal accessory

Shrug shoulders (trazpezius)

SCM muscle

Ask Pt to walk

Arm swing, cadence (rhythm)

Walk heel-toe

Nystagmus

Horizontal: cerebellar hemisphere lesion

Vertical: BS (rarer)

Make sure that hands are in same horizontal plane as Pt's eyes (or else you will confuse horizontal and vertical nystagmus)

Ask Pt to talk

Slurring of speech?

Check for drift

Drift with eyes closed; non specific

Finger-nose test

Stand perpendicular to Pt's plane

Put finger at arms-length from Pt (not too close!)

Pt's eyes open

Look for intention tremor: as nearing target (coarse tremor)

Don't move hand too much. If you make more difficulty by moving hand, only move when Pt's hand is going back to nose

Close eyes

Carry on touching

Don't move hand

Test for past-pointing (cerebellar sign: ipsilateral to lesion)

Dysdiadokinesis

Rapid repetitive movt

Clap hands - bottom hand still

Alt dorsum and palm of top hand (only when Pt has mastered clapping hands)

Then fine movt: tap 3rd finger against thumb (one side at a time)

Lower limbs

Heel-shin test: make sure heel is on shin

Check as part of PNS

EPS - eg. PD

Inspect

Symmetrical? Wasting (nerve > EPS)

Look for wasting at

1. 1st dorsal interosseous (bet thumb and index finger)

2. Hypothenar + thenar muscles

3. Deltoids

Fasciculation: tap forearm muscle, any fasciculation? Compare with other side? Don't make it too deliberate

Tone: hold wrist, can test across several jts (vs. power, which is tested only across one jt). Rotate wrist. Both sides

Power: Pt clasp hands in front of chest: test deltoids. Bicep curl, Dr try to extend elbow. Give position of adv. to Pt (triceps very weak in bicep curl position, therefore do not test tricep from this position). Test rest of muscles of upper limb

Reflex

Make sure it is the reflex of the muscle of the tendon you are hitting, not due to the impact of the hammer causing movt

Bicep

Brachioradialis tendon: 2 fingers on radial edge

- Primary movt is upward movt of forearm

- Also some flexion of phalanges

- Afferent: C6, Efferent C6 but also a little C7/8, thereby causing finger flexion

- Sometimes present in younger Pts, not usually in elderly

- Cervical myelopathy

Tricep tendon: just above olecranon

Sensation of upper limbs

Ask

Distribution of sensory loss?

Which modality?

Pain: test symmetrically with pin prick (toothpick)

Temp:

Vibration: if can feel distally, no need to test proximally

Proprioception: hold on sides of fingers (otherwise, up and down movt stimulates deep pressure sensors). Show Pt with eyes open what 'up' and 'down' are - then ask with eyes closed. Little movts. Don't move up and down and then stop up/down - no need.

Rhomberg's test (proprioception - not cerebellar test!)

Lower limbs

Never test power across 2 joints - eg. Testing bicep, hold forearm, not hand

Babinski response: don't confuse with withdrawal response. If no response, come back to it later. If still no response: LMN. If toes curl upward: UMN lesion

Soft signs: sensory

Hard signs: reflexes - eg. Babinski, nystagmus

Pathonemonic: sign only in a specific disorder (very few)

If student is comfortable doing examination, examiner knows that student has been practising.