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History takingAndPhysical ExaminationIn neurology Collected By:Dr. Soran Mohamad GharibReviewed By:Dr.Hawar A. MykhanNeurologistF.I.B.M.S ( Neurology ) , , M.B.CH.BHistory Taking & Clinical Examination in neurologyDuring the history and clinical examination 2 points are important: Where is the pathology?What is the pathology?History TakingWhat is different in neurology is that the sequelae of events is more important than the more details regarding some symptoms.Ask the following questions or the patient will present with one of the followings:Weakness: whether it is started from the proximal or distally i.e centrally or peripherally.Numbness and parasthesia: numbness is the tingling sensation which is due to excitation while the parasthesia is the loss of sensation and it is due to inhibition.3) Headache: ask about(site, bilateral or unilateral, aggravating and relieving factors as increase during sleep as in ICP or relief by sleep in HTN other factors as phototherapy, any associated features as N/V and weakness and loss of consciousness and any epileptic attack, can be relieve by taking certain medication, is it associated with blurred vision and any lacrimation and any hearing problems , then the onset of headache , is it intermittent or continuous , is there any previous attack, is it severe or not i.e can interfere with daily activity and make the patient to stay at home and remain in bed, is it relive by vomiting, at which time is more during the day time or night, is there any medical disease and HTN).4)Visual disturbance: as blurring vision and decrease visual acuity or any double vision.Hearing disturbance: as fluctuating deafness which is more after 50 years of age as the patient not hear well from short distance later it will be changed and can be found in Mienerer's disease;6) Vertigo: the followings are the features of true vertigo:- Feeling of rotation.-Sudden retro or propulsion-Sinking and upward going of what is patient seeing.7) Sphincteric disturbance:ask about the followings:* urinary incontinence( when the bladder is full dripping of urine occur).* urgent incontinence (whenever there is urine in bladder even it is not full dripping of urine occur)* frequency ( micturation daily more than 7 times)* retention of urine.8) Swallowing difficulties: that associated with speech disturbance as nasal speech, aspiration, nasal regurgitation.Note : if there is dysphagia for solid meal only mean the organic cause, but for both solid and liquid mean neurological causes.9) Loss of consciousness which is inhibitory.10)Epilepsy which is excitation.11)Then any other disease as (DM, HTN , cardiac disease , drugs)Notes:*Center of consciousness is located in reticular activating system that we have cerebral hemisphere, thalamus, midbrain-pons-medullaoblongata.* When there is sudden loss of consciousness mean brainstem lesion.* Almost both thalamus should be affected in order loss of consciousness to occur and usually it is not sudden loss. Clinical ExaminationInclude 2 main parts :A) General examination1. Consciousness.2. orientation3. memory4. speech5. GAIT.B) Specific examination:1. cranial nerve examination2. meningeal signs3. motor system examination4. co-ordination5. Sensory system examination.Cranial nerve ExaminationRemember we have 12 cranial nerves , and ( 1, 2,8 are sensory) and (4,6,7,11,12 are motor) and (3,5,9,10 are mixed).(1st is central and arise from the nasal mucosa, 2nd is central from retina), (3rd and 4th from midbrain , 5th,6th,7th,8th are from pons , 9th, 10th , 11st, 12nd are from medulla oblongata).. from 3rd to 12nd are peripheral.Olfactory nerveIt can be examined by asking the patient to close the eyes then we introduce certain but common and non irritable substance to each nostril that should be examined separately and then we ask the patient to name that substance.Smell receptors are in the nasal cavity, the olfactory nerve is going under the frontal lobe through the cribriform plate under roof of nasal cavity and it is from the anterior part of brain . its function is smell.The loss of smell is called ( anosmia) as may be due to head injury or tumor, while the perversion of smell is called paronosmia.Optic nerve Its function is vision. The nerve start from globe and passes through the optic canal of sphenoid bone then join with other nerve that form optic chiasma then optic tract that pass to geniculate body of thalamus then to area of 17 or visual cortex in occipital lobe. The pupillary light reflex had efferent part by 3rd CN and the afferent part by 2nd CN. The defect in this nerve can cause some abnormalities as blurring vision, hemianopia especially the homonimus hemianopia( the right eye-defect in nasal part of left and temporal part of right eye occur) which is loss of half of visual field in one or both eyes and this may be due to pituitary tumour that compress the optic tract or radiation or the bitemporal hemianopia due to defect in optic chiasma.Scotoma means the presence of blind spot that surrounded by the normal visual field and the central scotoma is normal it is either relative or absolute scotoma.The component of examination are: Visual acuity: this can be examined by using the Snellen chart that is 6/6,6/9, 6/12, 6/18, 6/24,6/36,6/60. if this not done then counting fingers from half meter that should be done for each eye separately by asking the if this not response then hand movement, then light perception as a last choice.Visual field: this can be tested by confrontation test that you as an examiner will sit in front of the patient but both of you should be at the same level then you cover one of your eye and ask the patient to coverthe reverse eye , then you use a subject better with red head and thenmove it to right, left, up, down infront of the patient but ask the patient to look to it only by his opened eye without using the head then repeat it to the other eye to see the field of vision. Light reflex: the light reflex is carried by optic nerve and then will bereturn back by the 3rd CN that causing the constriction of pupil. This reflex is 2 types which is direct (the eye that you put the light on it) and the indirect (or called the consensual reflex) (mean the other eye). This test is done by using the torch from the lateral but should be as a brisk movement on the eye but avoid putting the light in 90 degree on the eye then look to the pupil whether constricted or not.Color vision: by using ishihara test. Fundoscopy: the patient and you should be at the same level and should be at 45 degree position and the patient should look to the primeposition or straight forward then putting one of your hand on the head of patient and then using the scope laterally. The aim is to look to the optic disc to know whether there is optic atrophy (vessels are thin and margin is very white) or the papilledema (which indicate the old lesion in which there is decrease or absent margin, hyperemia and engorgement of vessels occur).Oculomotor ,trochlear and abducent nerves The rule is that SO4, LR6 and MIIS3(medial rectus, inferior oblique, inferior rectus , superior rectus).Defect in 3rd make unable to look up,down,medially(dysconjugate gaze), ptosis , dilated pupil and loss of accommodation reflex and divergent squint occur.The cause maybe DM.Defect in 4th CN the patient can not look downward, and defect in 6th CN there is convergent squint. The examination is as followings:? Ask the patient to look straight forward then by inspection look for 3Ps( pupil to know regular,round , and then look for ptosis-lowset upper eye lid- then the proptosis by doing the Naffziger as stand from behind the patient and then tilt the head inward and look to the eye whether outside the imaginary anterior line or not).* Then in first eye movement as putting one of your hand on the head of patient and then by your finger or a subject better with red head move it to the right, left, up, down and ask the patient to look to it only using the eyes without moving the head, at that time look for any nystagmus or squint or diplopia but this ask the patient do u see that subject in one or two.*Accommodation reflex: the reflex is positive and god only if the followings occurred and this by sitting in front of the patient and using the same above directly between the both eyes and move it toward the patient by looking to it:1. if both eyes are partially ptosed.2. constriction of both pupils.3. converging of both eye medially.*Light reflex.Trigeminal nerveThe nerve has 2 branches motor and sensory. The motor will supply the muscle of mastication which are (Masseter , Temporalis muscle ,lateral and medial pterygoid muscles). The sensory has 3 branches which are ophthalmic, maxillary and mandibular branches and has the sensory function of pain and temperature of scalp, face, lip, mouth, eyes and the ant.2/3rd of the tongue.The lesion of this nerve causing loss of sensation of the previous areas and wasting of temporalis and masseter muscles and called (trigeminal neuralgia- Tic Douloureux) that may be due to tumor, vascular spasm, MS. The examination is done as the followings:Motor examination:(almost done before sensory branch):- Look to the masseter and temporalis for any wasting and then ask the patient to open the mouth for any jaw deviation.- Ask the patient to clinch the teeth then palpate the masseter and temporalis muscles.-Then put your hand under the chin and ask the patient to open it against the ur hand resistant as much as he or she can then move the chin to right and left against your hand beside that side.- Reflex Examination: which is 2 reflexes1. Corneal reflex: use apiece of cotton then suddenly attached it to the lateral corner of eye. This reflex has the sensory by ophthalmic branch of 5th CN and the motor part of 7th CN.2. Jaw jerk: not found normally if +ve mean Bilateral UMNL, it is done by slight opening the mouth then put your index at the angle of jaw then hit your finger by the hammer but in 45 degrees. This reflex is supplied by C3Sensory examination :*Start up examination by using the special pin and move it as a strip like line for each branch.Facial nerveThe nerve has the function of ( expression, motor part of corneal reflex, sensation of salivary and lacrimal gland, sensation of anterior 2/3 of tongueand taste by chorda tympani branch). The paralysis of the nerve called the Bell's palsy that occur as:1-UMNL:There is lesion above the nucleus and characterized by:1. Hypertonia occur as Spasticity of the limb2. There is very mild or no wasting of muscle.3. Reflexes are brisk or exaggerated.4. The upper part of face not involved because the forehead has the dual nerve supply but the lower part will be affected.5. plantar reflex is upgoing mean +ve Babiniski sign.The causes may be CVA, Pyramidal system lesion.2-LMNL:This indicates the lesion in the anterior horn cells and the lesion occur inside the nucleus, it is characterized by:1. Weakness and wasting of muscles.2. Fasciculation3. hypotonic4. Loss of the reflexes.Causes may be :*Poliomyelitis *Warding Hoffman syndrome *Diabetic neuropathy*Alcohol and trauma*Drugs as INH and vincristine and metronidazole* Infectios as diphtheria and Leprosy.* Guillian-Barre syndrome.* Motor neuron dis.?*Vitamin Bi and B12 deficiency.* Amyloidosis.The most common cause for Bell's palsy is idiopathic others may be viral as mentioned above.The effect of the UMNL is that the lower part of the face is more obvious and deviation occur toward the healthy side.The effect of the LMNL is that the upper and lower part will be affected, there is loss of nasolabial fold on the affected side, and deviation of mouth to the normal side occur, the patient can not close the eyes properly, if the patient whistle there is leaking of the air through the affected side , and there is increase the space between the corner of mouth and the tongue of the affected side when the patient open the mouth. Some time the patient will have (Bell's Phenomena) in which the patient try to open the eyes but the sclera is still appear and the eyeball go up and medially.Examination of this nerve is done as the followings:1) Ask the patient to elevate the eye brows and then look to the creases in the forehead if lesion occur there is absence of these creases (Frowning test).2) Ask the patient to close both eyes firmly and then try to open them by your hand to know the ability of closing against the resistance.3) Look to the nasolabial fold whether present or flat.4) Ask the patient to show you his or her teeth as she or he clinching.5) Ask the patient to protrude the tongue then look to the angle between the tongue and the corner of mouth whether increased or not.6) Ask to whistle.7) Ask the patient to make the puffing of the mouth then touch the cheeks for any air leaking or not.8) Corneal reflex.The Bell's palsy can be treated with? prevent drying of the cornea by using artificial tear or methylcellulose ? corticosteroid as prednisolone? massaging and electrical stimulation of the nerve? surgery as tarsorrhaphy and the facial-hypoglossal anastomosisVestibulo cochlear nerveHas function of hearing and balance by cochlear and vestibular part respectively. Defect in vestibular part causing the vertigo, the defect in the cochlear part causing the deafness which is 2 types:conductive Deafness: as due to ear wax , fluid and otosclerosis. The Rinne's test result ( BC>AC) , and the Weber test result is positive on the affected side only.Sensorineural deafness: as due to acoustic neuroma , fracture of pterygotemporal bone and injury to the nerve, Rinne's test=AC>BC and Weber is +ve on the unaffected side.Not: Normally the AC ( Air conduction)>BC ( Bone conduction)Examination is done as followings:1) Roughly just by friction of the fingers near the ear bilaterally.2) Rinne's test: as we used the tuning fork and put it in front of the ear then put it at the mastoid process ask the patient does it feel and hear same or not.Weber test: as by using the tuning fork put it on the forehead ask the patient hearing it normal and equal for both ear or not.4) Calorie test: For vestibular branch5) Rotation test: for vestibular branchGlosso Pharyngeal nerveIts function is elevation of larynx and supply the posterior 1/3 rd of the tongue and supply parotid gland. It is examined with vagal nerve.Vagus nerveIt supplies the pharynx, larynx, heart, movement of palate and viscera. The defect of these nerves make the patient to present with:*Nasal speech*Nasal regurgitation*Aspiration.The causes may be unilateral as due to head injury and tumour or bilateral as due to CVA ,MS, and bulbar and pseudobulbar palsy.Examination is as followings:1) Ask the patient to open the mouth and look whether the uvula is deviated or not.2) Ask the patient to say (Ahhh) then look to the soft palate whether it is elevated or not.3) Gag reflex: put tongue depressor on each side of tongue if found mean it is good but may be absent in bulbar palsy.4) Examination of posterior wall of pharynx by putting tongue depressor on each side of tongue then pin prick of the wall ask whether feeling is same or not.5) Examination of posterior 1/3rd of toungue.Spinal accessory nerveThe nerve supply the SCM and the Trapezius muscle.Examination is as followings:*Ask the patient to look to one side and then by your hand palpate the SCM of opposite side and same for other side.*Ask the patient to shrug the shoulders and then put both hand at the patient's shoulder against the resistance for trapezius mescle.Hypoglossal nerve The nerve supply the muscles of tongue. If there is palsy of the nerve will causing the deviation of the tongue to the opposite site of the lesion and there is atrophy of the affected side with some speech abnormalities as dysarthria and ataxia of tongue.Examination is by asking the patient to open the mouth then look for the symmetry, fasciculation , atrophy, abnormal movement as ataxia or tremor.Name of nerve Rank of the nerveOrigin Motor or sensoryOlfactory1stAnterior part of brain under frontal bone through cribriform plate( cerebral hemisphere)SensoryOptic2ndRetinaSensoryOculomotor3rdMidbrainMixedTrochlear4thMidbrainMotorTrigeminal5thPonsMixedAbucent6thPonsMotorFacial7thPonsMotorVestibule cochlear8thPonsSensoryGlossopharyngeal9thMedullaMixedVagus10thmedullaMixedAccessory11thmedullaMotorHypoglossal12thmedullaMotorSome Say Marry Money But My Brother Says Big Business Makes Money( S = Sensory , M= Motor , b =both ) Examination of Meningeal signsThese signs are important to exclude whether meningitis is found or not. These signs are 3 :Neck stiffness: Patient is lying in supine and then flex the neck feel whether there is rigidity or not, you can put the head of the patient just beside the bed to make the flexion easier.Kernig's sign: this done by flexion of hip and then extension of knee that causing painful sensation in the Hamstring muscles. Brudizinski's sign: this done by flexion of the hip only that causinginvoluntary flexion of neck or can be done by flexion of neck that causing flexion of hip joint.Motor system examinationSteps of the examination include the followings: 1-InspectionLook for the followings:Wasting of the muscles of both limbs: In the upper limb especially look to the interossi muscles and in the lower limb palpate the beside of the shaft of tibia and then if the both sides between the tibial bone was same this mean wasting of muscle so the bulging should be found normally.Fasciculation :( it is the fibrillatory or wavy movement of group of muscles) almost look to the axillary and deltoid region or to the medial aspect of thighAny abnormal movements: include the followings:Tremor : Examine for flapping tremor also by extending the both upper limbs then extend both wrists, close the eyes , then push the hand of patient toward the patient for flapping.Chorea : it is the abnormal restless involuntary movement more at the big proximal joints as around shoulder.Athetosis : slow sinusoidal movement in the distal joints as in the hand. Hemiballismus : sudden violent movement due to sub thalamic lesion.4) Abnormal posture which is occurring as sustained movement what is called Dystonia or the wrist drop....5) Look for any car of previous operation as for tendon replacement.2-Tone:We have 3 degree of tone:*Normal tone*Hypotonia: as occur in cerebellar diseas and in peripheral neuropathy. *Hypertonia: As occur in 2 forms:? Rigidity mean resistance will be continue through out the movement and occur due to lesion in basal ganglia and occur due to extra pyramidal lesion (Remember there is no special structure or organ in body by this name only to differentiate it from the pyramidal tract) and rigidity has 2 main forms:A. cogwheel type-as occur at wrist joint and can be tested by catching the hand of patient at the wrist joint then by other hand do the circular movement of the hand it fond intermittent resistance. Can be found in CVA.B. lead pipe Type -when you put the hand or forearm in a position it will stay at that position as found in Dementia.? Spasticity: mean there is resistance at the start of movement but later become normal and no resistance, occur due to cortico spinal tract lesion. Can be found in form of clasp-knife as in CVA.Best way to examine the tone is by ( Sudden Fast Unexpected movement) , as you handle the forearm at the elbow then by other hand catch the hand of patient then move it to right and left then suddenly move it toward the patientand do the same movement at the lower limb.To examine the clonus which is sustained continuous movement is by catching the ankle and then move the foot toward the patient many times then sudden move toward the patient.3-Power:Remember the 5 degrees of the power:G0 = there is no movement at all by asking the patient to move and raise the hand can not do it.G 1 = there is flicker movement, that the patient will only do some fine movement at the fingers onlyG 2 = movement at bed side, as the patient wi1l move the hand at the bed to right and left without elevating it.G3= there is movement against the gravity as the patient will raise the hand for a while.G 4 = there is movement against the resistance for certain limit as the patient will raise the hand and can raise it against your pressure on the hand of patient.G 5 = full normal movement.The pyramidal weakness may occur in 2 forms:* Central = here ther is paraplegia or hemiplegia and the grade of power not equal around the affected joints.*Peripheral weakness = there is bilateral symmetrical involvement in UL or LL or both, and there is equal grades of power around the joints.CST play very important role and may be affected in case of stroke, SOL, hematoma. Functions include:A- Anti gravity movements in the Upper limb:1) Shoulder abduction2) Elbow extension3) Wrist extention 4) Fingers extensionB- Anti gravity movements at the Lower limb:1) Hip flexion2) Knee flexion3) Dorsiflexion of foot4) Eversion of footSo start the examination from proximal to distal because the myopathy is almost proximal except in case of Myotonia Dystrophica which is distal.Upper Limb: Tone Examination includes 6 muscle groups:1) Deltoid= examine against the abduction of shoulder.2) Latissimus dorsi = examine against the adduction of shoulder.3) Biceps = examine against the flexion of the elbow joint.4) Triceps = examine against the extension of elbow.5) Forearm muscles = as examine against the supination and pronation of forearm.6) Hand muscles = examined by ask the patient to grip your hand strongly, and then against the extension ,flexion, abduction and adduction of fingers.Lower Limb:Examination includes:1) Examine against the abduction, adduction, extension( both of your hands under the thigh of patient-glutei muscles) , flexion (both of your hands on the patella of patient- iliopsoas muscle) of hip joint.2) Examine against the extension( quadriceps) and flexion( Quadriceps Femoris) of knee joint.3) Examine against the dorsi flexion, the plantar flexion, eversion and inversion of the ankle joint.4) Examine against the flexion and extension of toes.Note :?Monoplegia =paralysis of one limb as right hand?Hemiplegia = paralysis of half of the body as right UL and LL ?. ?Quadriplegia = paralysis of all limbs.?Paraplegia = as paralysis of both LLs.4-Reflexes :Before doing the reflex examination following points are important:*Remember the aim is to detect the mild asymmetry in reflexes and not the gross obvious abnormalities.*Almost start distally.*Do complete relaxation of the patient before the examination *Almost handle the hammer from the terminal part.*Not hit the joint more than 2 times as the reflex will be diminished by it self.*Do the reflexes bilaterally and symmetrically as supinator on both sides then the other reflexes.*Elevate the hammer actively then let it hit the joint passively.*Never say there is no reflex or diminished unless you do the re- enforcement as by clinching the teeth or pulling the both hands together.*L5 not share in any reflex.*The most powerful reflex is knee reflex.2 main groups of reflexes:Deep Reflexes —Monosynaptic reflexesUL ( Upeer Limb): include 3 reflexes:Supinator Reflex:By catching the fingers of the patient then hit about one finger or one and half from the wrist joint by the hammer. Supply by C5, 6.Biceps Reflex:Supply by C5,6 and done by flexing the elbow and put it on the abdomen of patient then feel the biceps tendon and put your thumb on it and hit your thumb with the hammer.Triceps Reflex :Supply by C7, done by flexing the elbow and put it on the abdomen of patient then put one of your hand under the elbow joint then hit by hammer about one finger or one and half from the olecranon process. Muscle is triceps muscle and the nerve is radial nerve.B-LL ( Lowe Limb): include 2 reflexes:Knee reflex :Supply by L3,4 and done by flexing the knee then put one of your hand under the knee and by other hit the space between the head of tibia and the lower part of patella. Muscle is quadriceps muscle, nerve is femoral nerve.Ankle reflex :Supply by S1, muscle is Gastrocnemius muscle and the nerve is posterior tibial nerve, is done by mild flexion of foot just do it on the bed no need put that limb on the other one then hit the Achilles tendon and watch the calf muscle.Superficial reflexes- Polysnaptict reflexes2 main reflexes:Abdominal reflex:No specific supply some say it is T7,12, the muscles are rectus abdominis muscles .Abdominal reflex is absent in case of hemiplegia that the condition will be confirmed by plantar up going, in case of obese and multipara female.Plantar Reflex :Is done on the outer border of the foot and should be done painfully and look to the big toe at first, the result is either:*Big toe not move at all= pathological*Big toe going up and down= called equivocal again is pathological.*Big toe is up going =severe pathological*Big toe is down going = it is normal.Note : Remember the babiniski sign is +ve but normal in (neonate and epilepticpatient).In male also we have cremastric reflex (L1) by scratching the inner aspect of the thigh in the creases for example.And also the anal reflex that may be disappear in case of conus medullaris lesion.Note :Hoffman sign is done by extending the wrist then scratch the tip of middle finger then if +ve there is flexion of thumb and other fingers.Co-ordination ExaminationAlso called cerebellar examination, and helpful for parkinsonism , include the following steps:By inspection look to the eyes for the nystagmus (irregular involuntary movements of eyes) , then test the speech of the patient for the dysarthria, ask to protrude the tongue for the ataxia, or intension tremor, hypotonia and decrease the reflexes.Finger-nose test : as stand infront of the patient at first time explain for patient to put the index finger on his or her nose and then on the examiner's finger, then do it while the patient closed his or her eyes. The faster touching your fingers the better the result, the result is either:A.Intention tremor ( dysmetria) , if abnormal or irregular touching of target found.B.Dysnergia : total incoordination and clumsiness.C.Post point: can not identify the target.Rapid-alternating test: touching the other hand by palmar and dorsal surface of the other hand, called Dysdiadochokinesia.Heel-shin test: ask the patient to make the friction of the heel of one foot on the tibial shaft on the other limb.Romberg's sign: ask the patient to stand and then do full abduction and move the upper limb away from him self then close the eyes watch whether falling occur or not.6) Then examine for gait by asking the patient to move on the straight line as if she or he measuring the distance by using the feet.Sensory ExaminationSuperficial sensation: half of touch, pain and temperature. Deep sensation: Half of touch, vibration.Examination Steps:Start from the both sides of face by pin prick or using a piece of cotton wool, then proceed to the volar surface of the upper and lower limb and all other areas, then ask the patient do you feel it same on both side or not?2) For vibration use the tuning fork: by asking to close the eyes and whether feeling same or not put it on the following areas:*Forehead*Patella*Medial malleolus.*Tuberosity of big toe.3) Testing the Proprioception: this by asking to cloth eyes then move the big toe 6 times upward and downward then ask the patient to tell you the direction of the movement.Some Definition :AGNOSIA: The inability to recognize the significance of sensory stimuli, due to parietal lobe lesion. We have visual and olfactory agnosia. APRAXIA: inability to perform the purposeful movement in absence of paralysis.AGRAPHIA: inability to write. ALEXIA : inability to read. DYSCALGUL1A: inability to perform the mathematical procedures.Higher cerebral function ExaminationThe stepwise are:1) Level of consciousness: either:Fully a : the complete loss of awareness to the environment even when the patient is extremely stimulated.Drowsy : inability to sustain the wakefulness without the externalstimuli. Stupor : aroused only by vigorous and repeated stimuli only.The examination is as followings:A- Do quick general examinations for any head trauma then say I will take the vital signs as for high fever and type of respiration.B- Do verbal command: ask the patient to show you 2 fingers( Hard command), or ask the patient to open eyes( easier command).C- Do the Localization of pain: as pinch to ear, cotton to nares, shoulder pinch, calf pinch, pressure over the nail bed.D- Then look to the response whether it is decerebrate (Extensor posture), or Decorticate (Flexor posture). Treatment of focal lesion causing coma need MRI and CT scan, while diffuse coma treated by coma cocktail ( Thiamine 100 mg IV + Dextrose 50 ml IV+ Flumazenil 0.2-1 mg IV) also checking the ICP important.Orientation: do you know this person( Person), Do you know what is this place (Place), do you know what time is it (Time).Memory: we test 3 types of memory: Immediate Memory : give him or her Phone number or 5 numbers but repeat it 3 times for him or her then after a few minutes ask what that number was? Recent Memory : ask the patient what you eat this morning?Remote Memory: ask the patient about the some clear events that occurred in that society to know whether can remember them or not.Speech: include language, phonation and articulation. The content include the followings:* Comprehension: as ask the patient to close eyes, raise left leg, put right hand on the head.* Expression: during speaking you can note whether anydysphasia or dysarthria.* Reading: give the patient some paragraph to read it.* Writing: ask the patient to write his or her name if not illiterate.* Naming: show the patient a pen asking him or her to name it.* Repetition: give a sentence e ask the patient to repeat it after you.The abnormalities in speech occur as:A)Dysphasia: mean the disorder in using the language.Include 4 types :I. Expressive Dysphasia (Motor Dysphasia ): due to lesion in Brocas area, her if ask the patient a question can understand you but can not answer you.II. Receptive Dysphasia (Sensory Dysphasia): occur due to lesion in wernick's area here the answer will influent and use the uncorrected word.III. Conductive Dysphasia.: the patient have abnormality in repetition.IV. Global Dysphasia: include both receptive and expressive Dysphasia due to lesion in arcuate fibers between that 2 areas.B) Dysarthria :it is the disorder in articulation as due to disorder in muscle of face , tongue pharynx or in BS or cerebellum , here all features of speech is normal regarding the grammar and word. As potato's speech.C) Dysphonia: when impair air flow or damage to vocal cord.5- IQ of the patient: include the followings:A- Difference and similarity: tell me what is the difference between the apple and orange as regarding their color and taste. B- Calculation: abstract the 30 from 2 then come down.C-Attention: this can be noted during the history taking whether the patient had attention for your questions or not.D- Judgment: as give the patient a commonly used proverb ask him or her to analyze it for you.E- Insight: whether the patient feels he or she is sick or not if yes means good insight. F-mood and affect: mood is the patient's feeling, the affect is whatyou observe in the patient whether depressed euphoric... 6) Gait: many types are abnormal as stamping gait, shuffling gait,parkinsonian gait, circumduction gait in CVA, or the scissor gait again in CVA.Glasgow Coma Scale – GCSTotal score is = 15Eye opening:None =1Opening to pain=2Opening to speech=3 Spontaneous opening=4Best motor responseNone=IExtension of limb at elbow=2 Abnormal flexion=3Withdrawal=4Localization of pain=5Obey command=6Best verbal responseNone=IIncomprehensive sound =2 Inappropriate word=3 Confused=4Oriented=5References:1-Hutchisons Clinical Method Michael Swash , 21st Edition 20022-Macleods Clinical ExaminationGraham Douglas ,11th Ediction,20053-Mannual of Practical MedicineR.Alagappan, 1st Edition, 19984-Davidsons Principles and Practice of MedicineHaslet , Chilvers , Boon, Colledge,Hunter 19th Edition ,20025-The ECG Made Easy John R. , Hampton , 5th Edition,19986-Essentials of Applied ElectrocardiographyAtul Luthra ,1st Edition ,19937- UC UC San Diego , Division Of Medical Education 8- 9- Practical Lectures By Dr Taha Mahwy10- Contents :History Taking In Neurology ………………………………2Clinical Examination In Neurology…………………………5Cranial Nerve Examination …………………………………6Examination Of Meningeal Sign……………………………..27Motor System Examination ………………………………….28Co-ordination Examination …………………………………..43Sensory System Examination…………………………………..46Higher Cerebral Function Examination………………………48Glasgow Coma Scale GCS ………………………………….....53References……………………………………………………….54Contents ………………………………………………………...56In This series : Preparing the following practical books :Clinical Orthopedic. Clinical Gynecology . Clinical ENT . Clinical psychiatry . Clinical Neurology ( History taking & Physical Examination In neurology)25 Cases in Clinical pediatric . History taking and physical examination in surgery . The most important subject for 4,5, 6th stages that you have to know before the exam . OSCE exam for 6th stage . ECG Interpretation. Common abdominal signs and symptoms .Theory exam Of previous years for 6 th stageHistory taking and physical examination in MedicineCollection Of Physiology exam of previous years for second stage medical students. Preparing the following practical books for newly graduated doctors (Rotator) : About how to learn the routine of treating patient in All department in hospital : 1-Medical emergency & Case Management in CCU. 2-Surgical emergency . 3- Pediatric emergency & Case Management in premature Unit . 4- Obstetrical & Gynecological emergency. 5-Assessing and Management of patients in Primary health care & the most important medications used daily 6-ECG Interpretation. ................
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