elderly male with bleeding PR and difficulty in walking

NEUROLOGICAL EXAMINATION

1. HIGHER MENTAL FUNCTIONS:

a. Consciousness – intact

b. Well Oriented to time, place and person

c. Speech and language – slurring.

d. Memory – immediate-retention and recall, recent and remote - intact

e. No Delusions, hallucinations

f. No Emotional lability

g. MMSE score

I. Orientation

    1. date x, day x, month x, season(rainy) yearx (1)

    2. floor x, hospital x. District (1), state , country (1)

II. Registration

    Name three objects taking one second for each object. Ask him to repeat the same.

    Repeat till he remembers (3)

III. Attention and Calculation

     Serial 7’s 5 times (0)

IV. Recall

     Recall the three objects (3)

V. Language

     1. Name 2 objects (0)

     2. Repeat a sentence (1)

     3. Follow a 3 stage command (3)

     4. Reading “close your eyes”(0) – not able to read

     5. Writing a sentence (0) – not able to write

     6. Copy a design (1)

2. CRANIAL NERVES

CRANIAL NERVE TEST RIGHT LEFT

I Sense of smell

i) Sanitizer

+

+

II i) Pupillary reflex Normal Cataract surgery

III, IV, VI i) Extra-ocular movements

ii) Direct Light Reflex

iii) Consensual Light Reflex

iv) Accommodation Reflex

v) Ptosis

vi) Nystagmus

vii) Horners syndrome full

Present

NT

Present

Absent

Absent

No Full

Absent

NT

Present

Absent

Absent

No

V i) Sensory -over face and

ii) Motor – masseter, temporalis, pterygoids

iii) Reflex

a. Corneal Reflex

b. Conjunctival Reflex

c. Jaw jerk Normal

Normal

Present

Present

 ?+ Normal

Normal

Present

Present

?+

VII i) Motor –

nasolabial fold

hyeracusis

occipitofrontalis

orbicularis oculi

orbicularis oris

buccinator

ii) Sensory –

Taste of anterior 2/3rds of tongue(salt/sweet)

Sensation over tragus

iii) Reflex –

Corneal

Conjunctival

iv) Secretomotor –

Moistness of the eyes/tongue and buccal mucosa

Present

Absent

Good

Good

Good

Good

Normal

Normal

Present

Present

Normal

Present

Absent

Good

Good

Good

Good

Normal

Normal

Present

Present

Normal

VIII i) Rinnes Test

ii) Webers Test

iii) Nystagmus AC>BC

Not lateralised

Absent AC>BD

Absent

IX, X i) Uvula, Palatal arches, and movements

ii) Gag reflex

iii) Palatal reflex Centrally placed and symmetrical

Present

Present

Present

Present

X1 i) trapezius

ii) sternocleidomastoid Good

Good Good

Good

XII i) Tone

ii) Wasting

iii) Fibrillation

iv) Tongue Protrusion to the midline and either side Normal

No

No

Normal Normal

No

No

Normal

3. MOTOR SYSTEM

TEST RIGHT LEFT

I – BULK

a. Inspection

b. Palpation

c. Measurements

Upper limb – 10cm above and below acromion

Lower limb 18 cm above and 10 cm below tibial tubercle

Decreased

Normal

cms

cms

Decreased

Normal

cms

cms

II – TONE

a. Upper limbs

b. Lower limbs

Hypertonia Hypertonia

III – POWER

a. Neck muscles

b. Upper limbs

i) Shoulder

Flexion-Extension

Abduction / adduction

ii) Elbow

Flexion-Extension

iii) Wrist

Dorsi flexion-Palmar flexion

Abduction-Adduction

iv) small muscles of hand

v) Hand grip

c. Lower limbs

i) Hip

Flexion-Extension

Abduction-Adduction

Lateral Rotation-Medial Rotation

ii) Knee

Flexion-Extension

iii) Ankle

Dorsi flexion-Plantar flexion

Inversion-Eversion

iv) Small muscles of foot

d. Trunk muscles

e. Beevor’s sign

Good

5/5

5/5

4/5

5/5

4/5

4/5

Good

Good

4/5

4/5

4/5

4/5

4/5

Weak

Absent

Good

5/5

5/5

4/5

4/5

4/5

4/5

Good

Good

4/5

4/5

4/5

4/5

4/5

Weak

Absent

IV – REFLEXES

A. SUPERFICIAL REFLEXES

1. Corneal

2. Conjunctival

3. Palatal Reflex

4. Plantar Reflex

B. DEEP TENDON REFLEXES

1. Jaw jerk

2. Biceps jerk

3. Triceps jerk

4. Supinator jerk

5. Finger flexion reflex

6. Knee jerk

7. Ankle jerk

8. Clonus

C. PRIMITIVE REFLEXES

D. OTHERS

Hoffmans sign

Wartenbergs sign

Rossalimos sign

Present

Present

Present

Flexor

?Present

-

Present

-

-

-

-

NT

Absent

Absent

Absent

Absent

Present

Present

Present

Extensor

Present

-

Present

-

-

-

-

NT

Absent

Absent

Absent

Absent

V – COORDINATION

TESTED ALONG WITH THE CEREBELLUM

VI – GAIT

VII – INVOLUNTARY MOVEMENTS

A – Athetosis, Asterexis

B – Ballismus

C – Chorea

D – Dystonia

E – Essential tremors

F – Fasciculations

M - Myoclonus No

4. SENSORY SYSTEM

TEST RIGHT LEFT

I – SPINOTHALAMIC

1. Crude touch

2. Pain

3. Temperature

II – POSTERIOR COLUMN

1. Fine touch

2. Vibration

3. Position sense

4. Romberg’s sign

III – CORTICAL

1. Two point discrimination

2. Tactile localisation

3. Graphaesthesia

4. Stereognosis

Normal

Normal

Normal

Normal

Normal

Normal

Absent

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Absent

Normal

Normal

Normal

Normal

5. CEREBELLAR SIGNS

1. Titubation - absent

2. Truncal ataxia/gait ataxia/ stance ataxia – present

3. Nystagmus – absent

4. Dysarthria - absent

5. Hypotonia - absent

6. Rebound phenomenon – absent

7. Intention tremor - absent

8. Pendular knee jerk – absent

9. Tandem Walking – couldn’t elicit due to giddiness

a. Upper Limbs – Finger Nose test, Finger Finger Nose test, Drawing a circle, Putting a dot in the centre of the circle

b. Lower Limbs – Heel Knee test, Drawing a circle

c. Dysdiadokokinesia

6. AUTONOMIC NERVOUS SYSTEM

Postural Hypotension

Resting tachycardia

Abnormal sweating

7. SIGNS OF MENINGEAL IRRITATION

Neck stiffness

Kernig’s sign

Brudzinski’s sign

8. EXAMINATION OF THE SPINE AND CRANIUM

SPINE – bony deformities, bruit, gibbus, tenderness

CRANIUM – bony abnormalities, bruit

9. PERIPHERAL NERVES

Thickened nerves

Trophic ulcers

Wrist drop

Foot drop

10. CAROTID PULSES AND BRUIT