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CENTRAL NERVOUS SYSTEM

HIGHER MENTAL FUNCTIONS
1) Appearance ........................
2) Behavior ........................
3) Conscious level ........................ Orientation in time ........................
                                                      Orientation in place ........................
4) Memory & general Intelligence ........................
5) Check for released reflexes (if evidence of brain damage)
Glabbelar tap ........................ Snout reflex ........................ Roolting reflex ........................
Grasping ........................ Palmomental ........................

SPEECH
1) Dysarthria ( )
2) Stammering ( )
3) Aphasia Motor ( ) Sensory ( ) Global ( )
4) Dyslexia ( )
5) Dysgraphia ( )

CRANIAL NERVES (compare bilaterally)
I) Olfactory nerve                        Right nostril                          Left nostril
                                                    ........................                    ........................
II) Optic nerve                              Right eye                              Left eye
1) Visual acuity                              ........................                   ........................
2) Visual field                                 ........................                   ........................
3) Color vision                               ........................                   ........................
4) Fundoscopy                               ........................                   ........................
III- Occulomotor nerve
1) Size of palpebral fissure(ptosis)  ........................                   ........................
2) Pupils
        i. Size                                     ........................                   ........................
        ii. Shape                                 ........................                   ........................
        iii. Direct light reflex                ........................                   ........................
        iv. Indirect light reflex              ........................                   ........................
        v. Accommodation reflex        ........................                   ........................
3) movements
        i. Superior rectus                    ........................                   ........................
        ii. Inferior rectus                     ........................                   ........................
        iii. Inferior oblique                  ........................                   ........................
        iv. Medial rectus                    ........................                   ........................
IV- Trochlear   Superior oblique ........................                   ........................
VI- Abducent    Lateral rectus      ........................                   ........................
V - Trigeminal
Sensory:
        i. Over face & cranium          ........................                   ........................
        ii. Conjunctival reflex             ........................                   ........................
        iii. Corneal reflex                   ........................                   ........................
Motor:
        i. Massetor                           ........................                   ........................
        ii. Lateral ptyregoid               ........................                   ........................
        iii. Medial pterygoid              ........................                   ........................
        iv. Temporalis                       ........................                   ........................
        v. Jaw jerk                           ........................                   ........................
VII- Facial
Motor:
        i. Wrinklig of fore head         ........................                   ........................
        ii.Closure of eyelids              ........................                   ........................
        iii.Nasolabial folds                ........................                   ........................
        iv.Inflation of cheeks             ........................                   ........................
        v.Showing of teeth                ........................                   ........................
        vi.Whistling                           ........................                   ........................
Sensory
        i. Hearing hyperacusis(stapedius) ........................            ........................
        ii. Taste(ant 1/3 of tongue )   ........................                    ........................
VIII- Vestibulocochlear           Right                                  Left
Cochlear function (Hearing)
        1) Whisper test                    ........................                    ........................
        2) Watch test                       ........................                    ........................
        3) Tuning fork tests
        Rinne's test                          ........................                    ........................
        Weber's test                        ........................                    ........................
Vestibular fuction
1) Positional nystagmus
        (Halpike maneuver)             ........................                    ........................
2) Occulovestibular reflex            ........................                    ........................
3) Occulocephalic reflex
        (Doll's eye Movements)       ........................                    ........................
IX- Glossopharyngeal
        1) Gag reflex                       ........................                    ........................
        2) Taste on post.1/3
        of tongue                             ........................                    ........................
X- Vagus
        1) Position of uvula              ........................                    ........................
        2) Movements of soft palate ........................                  ........................
        3) Gag reflex                       ........................                    ........................
XI- Accessory
        1) Trapezius                        ........................                    ........................
        2) Sternocleidomastoid        ........................                    ........................
XII- Hypoglossal
        1) Shape of tongue (symmetry) ........................              ........................
        2) Fasciculations                 ........................                    ........................
        3) Deviation upon protrusion ........................                 ........................
        4) Powerof tongue musculature ........................             ........................

MOTOR SYSTEM (compare bilaterally)
Muscles Upper limbs Lower limbs
                                                Rt.              Lt.              Rt.              Lt.
        Bulk                                  .............     ..............    .............     .............
        Tone                                 .............     ..............    .............     .............
        Power                               ............      .............     ............     .............
(012345)
Reflexes
a)Deep                                    Right                                    Left
        i. Ankle reflex (S1, S2)      ........................                     ........................
        ii. Knee reflex (L3, L4)      ........................                     ........................
        iii. Biceps reflex (C5, C6) ........................                     ........................
        iv. Triceps reflex(C6,C7)   ........................                     ........................
        v. Supinator reflex(C5,C6) ........................                    ........................
        vi. Ankle /pattelar Clonus ........................                      ........................
        vii. Hoffman's reflex .          .......................                      ........................
b) Superficial
1. Abdominal reflexes (T7, T11) .......................................
2. Cremasteric reflex (only men) (L1) ........................            ........................
3. Anal reflex .......................................
4. Babinski's sign (Planter reflex) (L1) ........................           ........................
Coordination of movements
1. Upper limbs (finger nose test) ........................                    ........................
2. Lower limbs (heel shin test)    ........................                    ........................
Involuntary movements (if present)
        i. Type ......................................
        ii. Involved part............................
        Gait Type............................................

SENSORY SYSTEM
Primary sensations (mention the involved dermatome on each side )
        1. Touch ( )
        2. Pain ( )
        3. Temperature ( )
        4. Deep pain ( )
        5. Vibration ( )
        6. Position &proprioception ( )
        7. Romberg's sign ( )

Cortical sensations (if needed)
        Localization ( )
        Two point discrimination ( )
        Steriognosis ( )
        Agraphasthesia ( )
        Perceptual rivalry ( )

CEREBELLAR SIGNS
        1. Nystagmus ( )
        Type................... Direction..............
        2. Scanning speech ( )
        3. Intention tremor ( )
        4. Incoordination ( )
        5. Dysdiadocokinesia ( )
        6. Rebound phenomenon ( )
        7. Past pointing ( )
        8. Pendular knee jerk ( )
        9. Hypotonia ( )
        10. Ataxia ( )

MISCELLANEOUS TESTS
Signs of meningeal irritation:
        1. Neck rigidity ( )
        2. Kerning 's sign ( )
        3. Brudzinski's sign ( )

Root irritation: SLR test ( )
Latent tetany:
        1. Chvostek's sign ( )
        2. Trousseau's sign ( )

EXAMINATION OF AUTONOMIC NERVOUS SYSTEM
        1. Light reflex ( )
        2. Accommodation reflex ( )
        3. Skin sweating ( )
        4. Pulse rate( effect of valsalva's maneuver , respiration)
        ...........................................
        5. Postural hypotension ( )


PROVISIONAL DIAGNOSIS

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Composed by,
Muhammad Irfan Iqbal
Final year MBBS
PUNJAB MEDICAL COLLEGE FAISALABAD

• Foreword
• History taking and Examination
• General Physical Examination & CVS
• Respiratory system & Alimentary system