The

Nervous
System
 RELEVENT CLINICAL NEURO-ANATOMY
Clinical Notes

x
corte
rtex
tor co

sory Parietal
ry mo

tosen
lobe
Prima

Soma

Frontal
lobe

Central
sulcus
Occipital
Temporal lobe
lobe

Cerebellum
Pons
Medula
oblongata
Spinal cord

THE CEREBRAL CORTEX AND DIFFERENT LOBES

Frontal lobes are concerned with executive function, movement,
behaviour, planning & speech. The parietal lobes integrate sensory
perception. The non-dominant parietal lobe is concerned with spatial
awareness and orientation. The temporal lobes contain the primary
auditory cortex and primary vestibular cortex. The occipital lobes
are responsible for visual interpretation. Deep to the grey matterand
the white matter, lies basal ganglia (concerned with motor control)
the thalamus (controls level of attention to sensory perception)
the limbic system (concerned with emotion and memory); and the
hypothalamus (responsible for homeostasis)
142 Primer of Medicine

Clinical Notes

3rd 4th

Reticular system

Pyramidal
motor tract

Cerebellum
5th The Brainstem contains all
sensory and motor pathways
6th Pontine
nuclei which enter or leave the
7th
cerebral hemispheres.
Cranial nerves

8th
It also houses the cranial
9th neve nulei and reticular
system.
10th

11th

12th

Motor tracts Sensory

tracts

ANATOMY OF BRAIN STEM.

The brainstem (Latin: truncus encephali) lies in the posterior cranial
fossa and is the distal part of the brain. It is 6 -7.5 cm long and 3-
4 cm wide.
The medulla oblongata is the lower part of the brain that appears
as a swelling at the upper end of the spinal cord. Besides being a
conduit for fibres running between the spinal cord and higher brain
regions, it contains control centres for involuntary functions such
as blood pressure, breathing, swallowing, and vomiting.
The medulla oblongata is the end part of the brainstem. The
medulla oblongata lies in the posterior cranial fossa. The upper
part of the medulla oblongata continues as the pons, while the
lower part – as the spinal cord. The medulla oblongata has two
surfaces – ventricular (anterior) and dorsal (posterior) surface.
The pons is the middle segment of the brainstem located above
the medulla oblongata. The pons lies in the posterior cranial fossa.
The Nervous System 143
Clinical Notes
Olfactory nerve

Optic nerve

Oculomotor nerve

Trochlear nerve

Abducent nerve
Trigeminal nerve

Vestibulocochlear nerve
Facial nerve
Glossopharyngeal nerve
Vagus nerve
Hypoglossal nerve
Accessory nerve

THE ANATOMY OF BRAINSTEM AND ORIGIN OF CRANIAL

NERVES
Like medulla oblongata, also the pons houses nuclei and has tracts
passing through them. Tracts within the pons not only travel to the
medulla oblongata but also connect the cerebrum with the
cerebellum.
An angle between the medulla oblongata and pons is known as
the pontomedullary junction. Another angle between the pons,
cerebellum, and medulla oblongata is seen – the cerebellopontine
angle. The functions of the pons are different, like sleep,
swallowing, respiration, hearing, taste.
The midbrain or mesencephalon is the uppermost part of the
brainstem. The midbrain lies between the pons below and the
thalamus above. The midbrain takes part in regulating eye
movement, visual and auditory functions, temperature regulation.
The midbrain has two parts separated by the cerebral aqueduct.
These parts are the anterior part and the posterior part.
The reticular formation is made of neurons spread between the
spinal cord and the thalamus and branching connections also to
144 Primer of Medicine
the brainstem. The nuclei of the reticular formation can be found in Clinical Notes
the brainstem. These nuclei are divided into three groups: lateral,
medial, and median.

Function
The brainstem contains nerves and tracts (nerve pathways) that
provide motor and sensory functions throughout the body. Nerve
tracts are composed of a sequence of nerves that rapidly send
messages along a specific route.
Major nerve pathways in the brainstem include :
• Spinothalamic : This tract runs at the outer portion of the
brainstem, relaying messages of sensation that originate in
sensory nerves to the spinal cord, through the brainstem, and
to the thalamus in the cerebral cortex.
• Corticospinal : This tract runs medially, near the centre of the
brainstem, sending messages from the motor portion of the
cerebral cortex through the brainstem, to the spinal cord, and
eventually to the muscles to control movement.
• Spinocerebellar : This tract runs in the lateral portion of the
brainstem, relaying messages between the cerebellum and the
spinal cord to regulate the body's position.
Some of the structures located in the brainstem work by
coordinating with neurotransmitters (chemical messengers) and
structures in other parts of the brain and throughout the body to
control complex functions.
Examples of these functions include :
• Movement : The substantia nigra and red nucleus in the midbrain
interact with the basal ganglia in the cerebral hemispheres to
help control movement.
• Autonomic functions : The medulla contains nuclei that
maintain functions like breathing and regulation of cardiovascular
function.3
• Sleep and consciousness : The reticular formation, a group
of nerves that extends throughout the brainstem, interacts with
the cerebral cortex to mediate states of arousal.
The Nervous System 145

us
Head • Upper limb •
Clinical Notes

yr
lg Trunk • Lower limb
tra

ea
en

ar
ec

or Visual fibres
ot
Pr

Sensory fibres
Internal capsule
posterior limb
Fibres for head Fibres for lower
limb
Internal capsule
Fibres to motor
Midbrain nuclei of other
half of midbrain
Crus cerebri
Fibres for
Fibres for head
lower limb
Pons VI nerve nucleus
VII nerve nucleus
Basilar part of
Corticospinal pons
(pyramidal) tract
Medulla Fibres to motor
nuclei of other
Pyramid half of medulla

Decussation

Spinal cord
Lateral (indirect)
Anterior (direct) corticospinal tract
corticospinal
tract To anterior horn
CORTICO SPINAL TRACT (PYRAMIDAL TRACT)
After originating from motor & pre-motor cortex, cortico-spinal tract
(Upper Motor Neuron) passes through the posterior limb of the
internal capsule and then ventral brainstem. Finally at lower medulla
most of its fibres decussate and enters the lateral columns of
spinal cord & synapse with the anterior horn cells. From Anterior
horn cell, Lower Motor Neuron starts.
146 Primer of Medicine

Leg Post-central Clinical Notes

Trunk cortex

Thalamus Arm

Face

Internal
capsule
Ventral
posterolateral
nucleus of
thalamus
MIDBRAIN

Principal sensory PONS

nucleus of V
Medial lemniscus
Nucleus of
funiculus gracilis

Nucleus of MEDULLA
funiculus cuneatus
Spinothalamic tract
Nucleus of
spinal tract V
Posterior column fibers

SPINAL CORD

Spinothalamic tract

THE SOMATOSENSORY PATHWAYS I.E. SPINOTHALAMIC

TRACT AND POSTERIOR COLUMN
Pain and temperature carrying sensory fibres synapse with second
order neurons that cross the midline in the spinal cord before
ascending in the contralateral anterolateral spinothalamic tract to
the brainstem.
On the other hand, proprioceptive ,vibration & other specific sensory
fibres enter spinal cord and ascend through ipsilateral posterior
column without synapsing and The second-order neurons cross
the midline in the upper medulla to ascend through the brainstem.
The Nervous System 147
Clinical Notes
Internal Middle
carotid cerebral
artery artery

Circle of
Willis

Basilar
artery

Bottom view of brain

1. Arch of aorta
2. Brachiocephalic artery
3. Subclavian artery
4. Vertebral arteries
5. Basilar artery
6. Carotid arteries
7. Carotid arteries
8. Carotid arteries
9. Anterior cerebral arteries
10. Anterior communicating arteries
11. Middle cerebral arteries
12. Posterior cerebral arteries

CEREBRAL COLATERAL CIRCULATION

148 Primer of Medicine
The brain is supplied by the internal carotid arteries (anterior Clinical Notes
circulation) and the basilas artery (posterior circulation). The basilar
artery is formed by joining the vertebral arteries.
These three vessels feed the anastomotic ring (circle of Willis) at
the base of the brain.

INSTRUMENTS REQUIRED FOR

NEUROLOGICAL EXAMINATION
 HISTORY TAKING & DOCUMENTATION
Particulars of the patient Clinical Notes
Name ................................................................................... Common neurological

Age .................... Sex .................... Handedness .................... symptoms :

Address ............................................................................... • Weakness of limbs

• Difficulty in holding an
Bed No. ................................. Religion ................................. object
• Difficulty in walking
Occupation ............................ Date of Admission ..................
• Wasting of muscles
Chief Complaints • Unsteadiness of gait
1. .......................................... for ......................................... • Tremor, fasciculation
• Dimness/loss/double vision
2. .......................................... for ......................................... • Dribbling of saliva from
3. .......................................... for ......................................... angle of mouth
• Vertigo/tinnitus/deafness
History of Present Illness • Feeling of ground like
• Analysis of Chief Complaints cotton wool
• Mode of onset : • Tingling/ numbness
• Progress : • Pain along nerve
• Analysis of Associated Symptoms • Difficulty in passing urine
• General Symptoms • Difficulty in speech
• Effect of Treatment • Headache, vomiting,
convulsion
Past Medical History
• Loss of consciousness
• Birth trauma • Difficulty in swallowing
• Head injury • Nasal regurgitation
• Convulsion
• Dementia
• Meningitis
• Confusion
• Tuberculosis
• Myocardial infarction
• Cerebro vascular disease
• Transient ischemic attack
• Vaccination (measles / chicken pox)

Family History
Father – alive/died at the age of ..................... of ....................

Mother – alive/died at the age of ....................of ....................

Hypertension / Diabetes Mellitus / CVA / IHD / Epilepsy /

Hyperlipidemia
150 Primer of Medicine
Personal & Social History Clinical Notes
Single / Married ...................... Earning member ..................... Causes of Hedache :

Addiction ............................... No. of children ........................ 1. Primary headache

Dietary habit .......................... Smoking .......... per day .......... • Tension headache
• Migraine
Housing condition ................... Bowel habit ………………......... • Cluster headache
Alcohol .................................. per day .................................. • External
• Idiopathic stabbing
Drugs / Exposure to STD / AIDS headache
2. Secondary headache
Occupational History
• Systemic infection
• Head injury
Menstrual and Obstetric History (Female)
• Subarachnoid hemorrhage
• Menarche, regularity, duration • Brain tumor
• LMP • Temporal arteritis
• Last child birth
• Meningitis
• H/O abortions, if any
• Glaucoma
Treatment or Drug History
• Drug alergy
• NSAID (analgesic)
• Oral contraceptive

Review of Systems
 GENERAL EXAMINATION
• LOOK (Appearance) : Alert / Confused / Drowsy / Clinical Notes
Depressed / Anxious
• BUILT : Normal / Tall / Short
• NUTRITION : Normal / Well nourished / Poor
• HEAD
• EYES
HEENT
• EARS
• NOSE & THROAT
• DECUBITUS :
• FACE : Facies, Parotid swelling
• ANEMIA (PALLOR) : Mild / Moderate / Severe
• JAUNDICE : Mild / Moderate / Severe
• CYANOSIS : Central / Peripheral / Differential
• EDEMA :
– Ankle
– Sacral
• CLUBBING :
• NECK : JVP / Wave forms / Carotid pulsation / Swelling / Sinus
• THYROID GLAND :
• LYMPH NODES : Cervical / Supra Clavicular / Axillary /
Epitrochlear
• BREAST
• SKIN CHANGES : Pigmentation / Rash
• SKELETAL DEFORMITIES : Kypohosis / Lordosis / Scoliosis /
Pes cavus / Gibbus
• PULSE :
– Rate :
– Rhythm : regular / irregular
– Character
– Volume : large / normal / small
– Arterial wall : normal / thickened
– Radio-femoral-delay
– Other pulses : equal / unequal
152 Primer of Medicine
• BLOOD PRESSURE : Clinical Notes
– Lying
– Sitting
– Standing
• RESPIRATION
– Rate :
– Rhythm :
– Type : abdominal / thoracic / thoraco-abdominal
• TEMPERATURE
The Nervous System 153
EXAMINATION OF THE NERVOUS SYSTEM Clinical Notes
A. Higher Function Glashow Coma Scale
§ Level of consciousness (GCS) :
• Conscious / drowsy / stupor / coma [G.C.S.] Eye Opening
• Depressed / euphoric Spontaneous 4
• Normal / subnormal To speech 3
• Recent and past To pain 2
No response 1
• Time , place , person
§ Mood Best Verbal Response
§ Intelligence Oriented 5
Confused 4
§ Memory
Inappropriate 3
§ Orientation
incomprehensible sounds 2
§ Dillusion / illusion / hallucination No response 1
§ Sleep
Best Motor Response
B. Speech Obeys commands 6
§ Aphasia Localises pain 5
• Receptive / expressive / global (dysphasia) Withdrawal to pain 4
§ Dysarthria
Abnormal flexor response 3
(decorticate posture)
• Spastic / scanning / monotonous / other
Extensor response 2
§ Aphonia (decerebrate posture)
C. Examination of Cranial Nerves No response 1
§ Olfactory (CN I)
GCS score = E + V + M
• Smell in both nostrils (normal / anosmia / parosmia) (Max. 15, Min. 3)
§ Optic nerve (CN II)
• Acquity of vision
• Field of vision
• Color vision
• Fundus examination
154 Primer of Medicine
Visual field defects Visual fields Clinical Notes
L R L R
Monocular blindness 1

Bitemporal hemianopia 2
Retina
Right homonymous
hemianopia 3 Optic nerve

Right superior Optic chiasm

homonymous 4
Optic tract
quadrantanopia
Lateral geniculate body
Right inferior
Lower fibres in

Optic radiation
homonymous 5
quadrantanopia temporal lobe
Right homonymous Upper fibres in
hemianopia with 6 anterior parietal lobe
macular sparing
Occipital cortex

DIFFERENT LEVEL OF LESIONS IN THE VISUAL PATHWAY AND CORRESPONDING

VISUAL FIELD DEFECTS

§ Oculomotor, trochlear and abducents (CN III, IV & VI) Common causes of ptosis :
• Ptosis • 3rd CN(oculomotor) palsy
• Squint • Horner’s syndrome
• Ophthalmoplegia • Myasthenia Gravis
• Nystagmus • Myopathies
• Pupils (size , shape, symmetry) • Pseudoptosis due to eyelid
• Reflex tumors
• Congenital
– Light reflex (direct and consensual)
– Accommodation reaction Causes of dialated pupil :
• Mydriasis
• 3rd CN(oculomotor) palsy
• Head Injury (late stage)

Causes of pinpoint pupils :

• Pontine hemorrhage
• Organo-phosphorus
poisoning
• Morphine overdose
• Heat stroke
LEFT SIDED COMPLETE PTOSIS
• Barbiturate overdose
(OCULOMOTOR NERVE PALSY)
The Nervous System 155
§ Trigeminal (CN V) Clinical Notes
• Sensation of face
Argyl Robertson Pupil :
– Ophthalmic
– Maxillary Small, irregular, unequal pupil
– Mandibular with atrophy of iris with loss
of light reflex, accommodation
• Motor function
– Massetor muscles
preserved, fails to dialate to
– Pterygoid muscles (deviation of jaw to paralised side)
mydriation ; classically found
– Temporalis muscle in neurosyphilis especially in
tebes dorsalis & GPI
• Reflex
– Corneal reflex
– Jaw jerk

N. facialis and
intermedius (VII)
Nucleus
Rami temporales salivatorius
Facial Nerve nucleus is located
superior
Glandula N. petrosus at pons. Upper part of the
superficialis Nucleus
lacrimalis nervi nucleus is bilaterally
major
facialis
innervated by corticobulbar
Nuclei
fibres while the lower part is
tractus
Ganglion having contralateral supply
solitaril
pterygopalatinum Ganglion only.After making internal genu
Rami geniculi
zygomatici Rami around CN-VI nuclei, it exits
buccales Chorda from lower part of pons and
tympani enters Internal Auditory
Foramen Canal.Then it enters facial
stylomastoideum canal, relays geniculate
ganglion, traverses middle ear
Ganglion submandibulare cavity and exits through
Glandula submandibularis stylomastoid foramen to supply
facial muscle and divides into
Rami cervicalis
pes ansaricus within parotid
Rami marginalis gland.Sensory part carries
mandibularis Motor fibres
taste sensation from anterior 2/
Sensory fibres
Glandula Parasympathetic 3rd of tongue and sensation
sublingualis fibres from middle ear region.

§ Facial nerve (CN VII)

• Look for drooping of angle
• Look for naso-labial folds
• Closing of eyes (orbicularis oculi) – Test
• Raising the eye-brows (frontalis) – Test
• Bare teeth
156 Primer of Medicine
• Frowning Clinical Notes
• Blowing whistling
Vertigo :
• Platysma
Vertigo is an abnormal
perception of movement of the
environment or self. The
patient feels that either the
surrounding world is moving or
he has a sensation of moving
in the world.
Vertigo may be central and
peripheral in origin.
Left and middle image showing deviation of angle of mouth
Cause :
towards left and loss of nasolabial fold on the right i.e. right sided
facial nerve palsy. Right image demonstrating left sided Bell's Peripheral Vertigo
phenomenon diagnosing left sided LMN type Facial Nerve palsy. • Acute vestibular
neuronitis (viral
In UMN type of Facial NS Paralysis – upper face is escaped. labyrinthitis)
⇒ Taste sensation at ant 2/3rd of tongue ie chorda tympanii • Benign paroxysmal
• Sweet positional vertigo (BPPV)
• Salt • Ménière’s syndrome (with
deafness and tinitus)
• Sour
• Bitter Central Vertigo
§ Vestibulo-cochlear nerve (CN VIII) • Brain stem ischemia
• Deafness (test of hearing)
• Migraine
• Temporal lobe epilepsy
• Rinnie’s test
• Drug induced
• Weber’s test (Gentamicin, quinine)
• Positional nystagmus (for vestibular function)
Others
• Conductive / perceptive deafness
• Middle ear disease
§ Glosso-pharyngeal, vagus and accessory nerve (discharge from ear)
(CN IX, X & XI) • Carotid sinus
• Sensation of the posterior third of tongue & pharynx hypersensitivity
• Taste sensation of posterior third of tongue • Postural hypotension
• Palatal movements : ask patient to say ‘Ah’ • Panic attack
• Acoustic neuroma
• Uvula : central / deviated
• Gag / pharyngeal reflex
• Trapezius muscle : ask patient to shrug against
resistance
• Sternomastoid muscle : ask patient to rotate his chin
to opposite side against resistance
The Nervous System 157
§ Hypoglossal nerve (CN XII) : tongue Clinical Notes
• Wasting
Features of UMN lesion :
• Fasciculation
• Tremor 1. Weakness or paresis of
muscles
• Fibrillation
2. Increased tone (clasp-
• Movements of tongue
knife)
• Deviation : deviated to the paralysed side on protesion 3. Exaggerated jerks
(due to unopposed action of the contralateral 4. Loss of abdominal reflex
genioglossus muscle)
5. Extensor plantar response
• Protrusion 6. Pronator dripp of upper
D. Examination of motor system : limb
§ Bulk of muscle 7. Clonus may be present
• wasting / hypertrophy (measurement of girth of muscle) Features of LMN lesion :

1. Weakness or paralysis of
muscles
2. Wasting of muscles
3. Fasciculations may be
present
4. Decreased tone
(hypotonia)
5. Loss of jerks
6. Plantar no respone

Progressive muscle weakness and wasting as seen in a case of

myotonica dystrophica showing frontal baldness, Hatchet shaped
face, delayed relaxation of muscles of hand.
158 Primer of Medicine
§ Tone of muscle Clinical Notes
• Normal / hypotonia / hypertonia
• Spastic / cogwheel /leadpipe / hysterical
§ Power of muscle
• Normal / diminished (grade 0-V)
§ Involuntary movements :
• Fasciculation / tremor / chorea / others
E. Sensory system examination :
§ Spino-thalamic sensation
• Pain
• Touch
• Temperature
§ Posterior column sensation :
• Muscle sense
• Position sense
• Joint sensation
• Vibration
§ Cotical sensation :
• Tactile localisation
• Tactile discrimination
• Steriognosis
F. Reflexes :
Right Left
§ Deep reflex
• Radial jerk
• Biceps jerk
• Triceps jerk
• Hoffman’s reflex
• Knee jerk
• Ankle jerk
The Nervous System 159
Clinical Notes

Eliciting biceps jerk : slightly flex the elbow with hands lying
loosely (across abdomen), now place your finger gently over the
biceps tendon at the antecubital fossa and then strike the
hammer over your finger. Normally it results in contraction of the
biceps and flexon of the elbow .

Eliciting triceps jerk : Hold the patient's hand , draw the arm
across trunk and allow it to lie loosely ; Now strike the hammer
over the triceps tendon approx 5 cm above elbow. Usually it
results in contraction of triceps and extension of the elbow.
160 Primer of Medicine

Clinical Notes

Eliciting supinator jerk : slightly flex the elbow, semipronate

forearm with hands lying loosely, now strike the hammer at the
lower end of radius approx 5 cm above wrist. Normally it results
in contraction of brachioradialis (and often, biceps as well) and
there is flexon of elbow (and also slight flexon of fingers,
sometimes)

Hoffman's reflex : Hold the patient's wrist by your left hand and
now flick the terminal phalanx of the patient's middle finger by
your thumb and finger. In hyper reflex states, it results in flexon
and adduction of thumb as well as flexon of tip of other fingers.
The Nervous System 161
Clinical Notes

Eliciting knee jerk : patient lying supine, flex the knee at 45

degree angle, place the left hand below knee to support it and
now gently tap the patellar tendon with the hammer. Normally it
results in contraction of the quadriceps and extension of the
knee. Alternatively, ask the patient to seat on the edge of the
bed and allow the legs to hang freely, now tap on the patellar
tendon and look for response.

Ankle jerk : externally rotate the patients leg and slightly flex at
knee. Now dorsiflex the foot by your left hand and strike the hammer
over the achilles tendon. Normally it results in contraction of the
calf muscles (gastrocnemius) and planter-flexon of the foot.
162 Primer of Medicine
§ Superficial reflex Clinical Notes
• Abdominal reflex
Causes of absent ankle jerk
• Plantar response
but extensor plantar
• Cremesteric reflex : ask the patient to lie down (or response :
stand) and gently stroke the upper inner part of thigh
downwards & inwards . Normally there is contraction of • Subacute combined
cremasteric muscles resulting in pulling up of ipsilateral degeneration of spinal
testicle & scrotum. cord
• Anal reflex : gently scratch the perianal skin and it • Friedreich’s ataxia
results in contraction of the external sphincter. • Taboparesis
• Diabetes mellitus with
cervical myelopathy
• Multiple sclerosis

Causes of peripheral
neuropathy :
• Diabetes mellitus
• Vitamin deficiency (B1,
B6, B12)
Abdominal reflex : patient should lie flat and abdomen relaxed. • CKD
Now lightly stroke the abdomen from outside inwards in all four
• Alcohol
quadrants. Normally muscles of stimulated quadrant contracts and
• Drugs (1 Mt)
umbilicus moves in that direction.
• GB syndrome
• Leprosy

Eliciting plantar response : ask the patient to lie supine with

knee slightly flexed and thigh externally rotated. Now stroke the
outer aspect of the sole firmly with a blunt pointing object such as
key and move the stimulator forwards & then curve inwards the
The Nervous System 163
middle metatarsophalangeal joint. Normally there is flexon of the Clinical Notes
great toe at the metatarsophalangeal joint along with flexon of other
toes who also close together.babinsky response is when there is
extension of the great toe at metatarsophalangeal joint (& usually
also at interphalangeal joint) along with dorsiflexon of other toes
who opens out in a fanwise manner.

Upgrowing toe : positive plantar response.

TENDON REFLEXES AND ITS ROOT VALUE

Tendon reflex Root value Peripheral nerve

Biceps jerk C5 Musculo-cutaneous
Supinator / radial jerk C5, 6 Radial
Triceps jerk C6, 7 Median and ulner
Finger jerk C8 Anterior interosseous
Ankle jerk S1, 2 Sciatic
Knee jerk L2, 3, 4 Femoral
Plantar response S1, 2 Sciatic
Abdominal reflex T8-12
Cremasteric reflex L1, 2
164 Primer of Medicine

Clinical Notes
Signs of cerebellar lesion :
• Scanning dysarthria
• Intention tremor
• Jerking nystagmus
• Hypotonia
• Pendular knee jerk
• Ataxia of gait
• Dysdiadochokinesia

Common causes of tremor :

• Parkinsonism
• Cerebellar lesion
ELICITING ANKLE CLONUS • Hyperthyroidism
§ Clonus • Anxiety tremor
• Senile tremor
• Ankle
• Patellar Features of extra-
§ Organic reflex pyramidal lesion :
• Bladder / bowel / erection • Bradykinesia
G. Co-ordination : • Disturbance of tone
Right Left • Involuntary movements
§ Finger nose test
• Eye open
• Eye closed
§ Finger to finger test
§ Knee-heel test
§ Dysdiadochokinesia
§ Rebound phenomenon
H. Signs of meningeal irritation :
1. Neck rigidity
2. Kernig's sign
3. Brudzinski's sign
The Nervous System 165
Clinical Notes
Causes of wasting of small
muscles of hand :
• Motor Neuron Disease
• Syringomyelia
• Cervical Spondylosis
• Cervical Cord tumor
• Myotonia dystrophica
• Cervical rib
• Leprosy (tuberculoid)
• Syphilitic amyotrophy
• Patchy meningitis
cevicalis

HEEL-SHIN TEST OF CEREBELLAR TEST

KERNIG'S SIGN

I. Skull and spine :

J. Romberg's signs :
K. Stance & gait :
§ Hemiplegic gait : circumduction gait
§ Scissor gait : Spastic paraplegia
166 Primer of Medicine
§ High stepping gait : Clinical Notes
§ Staggering gait : Cerebellar lesion
Causes of spastic
§ Festinant gait : Parkinsonism
paraplegia :
§ Waddling gait : myopathy
1. Spinal cord compression
§ Stamping gait :
due to any cause (Pott’s
§ Bizarre gait :
vetebra)
L. Trophic changes : 2. Demyelinating disease
§ Perforating ulcers (MS)
§ Others 3. MND (Amyotrophic
Review of relevant other systems lateral sclerosis)
• CVS 4. Tranverse myelitis
– Heart sounds 5. Sub acute combined
– Added sounds degeneration (SCD)
– Murmur 6. Tropical spastic paraplegia
• Respiratory System 7. Traumatic
– Chest deformity / Expansion
Features of spinal cord
– Mediastinal position
compression :
– Breath sounds
• LMN sign at the level of
– Added sounds
compression
• Gastro-Intestinal System
• UMN sign (spasticites)
– Liver
below the level
– Ascitis
• Segmental sensory loss
– Kidneys
• Sphincter disturbance
– Bladder
(bladder)
SUMMARY OF THE CASE • Root pain.

PROVISIONAL DIAGNOSIS Non-compressive causes of

paraplegia :
DIFFERENTIAL DIAGNOSIS 1. Transverse myelitis
2. Multiple sclerosis
INVESTIGATIONS
3. Amyotrophic lateral
§ BLOOD
sclerosis (MND)
• Complete blood count
4. Syringomyelia
• Lipid profile
5. Friedreich’s ataxia.
• FBS / PPBS / HBA1C
The Nervous System 167
• LFT Clinical Notes
• Thyroid profile
Salient features of
§ CSF STUDY
Parkinson’s disease :
• Pressure
• Resting tremor (pill rolling)
• Color
• Mask facies with
• Protein
infrequent blinking
• Sugar • Bradykinesia
• Chloride • Cogwheel rigidity
• CSF Smear examination • Flexed posture
• Cell type / cell count • Festinant gait
• Culture sensitivity • Postural instability
• ADA (Adenosine Deaminase)
• CBNAAT for tuberculosis
• VDRL
§ X-ray of skull and spine
§ CT Scan of brain (plain / contrast)
§ EEG (electro encephalogram)
§ NCV (nerve conduction study)
§ EMG (electro myography)
§ MRI scan of brain & spine
§ Study of serum enzymes e.g. CPK (Creatinine
Phosphokinase)
§ MR Angiography
§ CT Angiography
§ Muscle biopsy

FINAL DIAGNOSIS

TREATMENT
168 Primer of Medicine
OSCE Clinical Notes
Neurological examination of upper limb
• Expose the upper limbs ensuring maintenance of dignity and
privacy, request a chaperone if appropriate.
• Inspect for wasting, fasciculations.
• As a screening test ask the patient to hold the arms out (palms
up) and close their eyes – watch for pronator drift.
• Assess tone.
• Test muscle power : shoulder abduction (axillary nerve C5),
elbow flexion (musculocutaneous nerve, C5, C6) and extension
(radial nerve, C7), finger extension (posterior interosseus nerve,
C7), index finger abduction (ulnar nerve, T1), little finger
abduction (ulnar nerve, T1), thumb abduction (median nerve,
T1).
• Assess reflexes at biceps (C5), triceps (C7) and supinator
(brachioradialis, C6).
• Test coordination with finger – nose test and look for
dysdiodokinesia.
• Test sensory modalities : pinprick, temperature, vibration sense,
joint position sense.

A 50 yrs. old female known diabetic is complaining of numbness

of right side of the face and deviation of the face to the left
side. How do you examine?
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Neurological examination of lower limb

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Examination of the cranial nerves

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Examination of tendon reflexes

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