Patient Position
• Examination performed in a well-lit room.
• Patient adequately exposed.
• Patient examined in a comfortable position.
• Verbal consent obtained.
• Female attendant present (if examining a female patient).
General Appearance
• Comfortable at rest / Ill-looking / Distressed
• Consciousness: Conscious/ Drowsy/ Stuporous/ Comatose
• Cooperation: Cooperative/ Uncooperative
• Orientation:
- Time: Oriented / Disoriented
- Place: Oriented / Disoriented
- Person: Oriented / Disoriented
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Higher Mental Functions (HMF)
• Level of Consciousness: Conscious/ Drowsy/ Stuporous/ Comatose
• Cognitive Functions
• Attention and Concentration: Intact / Impaired
• Memory
Immediate memory: Intact / Impaired
Recent memory: Intact / Impaired
Remote memory: Intact / Impaired
• Speech and Language
Normal
Dysarthria
Aphasia: Motor (Broca’s) / Sensory (Wernicke’s)/ Global
• Behaviour: Normal / Abnormal
• Judgment: Intact / Impaired
• Abstract thinking: Intact / Impaired
• Insight: Present / Absent
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Cranial Nerve Examination
• Olfactory Nerve (CN I)
Sense of smell: Intact / Impaired / Absent (Anosmia)
• Optic Nerve (CN II)
Visual acuity: Normal / Impaired
Visual fields: Full / Defective
Fundus examination: Normal/ Papilledema/ Optic atrophy/ Other: ____
• Oculomotor, Trochlear and Abducens Nerves (CN III, IV, VI)
Pupils: Equal / Unequal
Reactive to light: Yes / No
Reactive to accommodation: Yes / No
Ptosis: Present / Absent
Extraocular movements: Full / Restricted
Nystagmus: Present / Absent
Ophthalmoplegia: Present / Absent
• Trigeminal Nerve (CN V)
Facial sensations: Intact / Impaired
Muscles of mastication:
- Bulk: Normal / Wasted
- Power: Normal / Reduced
Jaw jerk: Present / Absent / Exaggerated
• Facial Nerve (CN VII)
Facial symmetry: Maintained / Asymmetrical
Angle of mouth: Central / Deviated
Forehead wrinkling: Present / Absent
Eye closure: Normal / Weak
• Vestibulocochlear Nerve (CN VIII)
Hearing: Normal / Impaired
Rinne’s test: Positive / Negative
Weber’s test: Central / Lateralized to Right/Left ear
• Glossopharyngeal and Vagus Nerves (CN IX, X)
Palatal movements: Symmetrical / Asymmetrical
Gag reflex: Present / Absent
Swallowing: Normal / Impaired
• Accessory Nerve (CN XI)
Sternocleidomastoid power: Normal / Reduced
Trapezius power: Normal / Reduced
• Hypoglossal Nerve (CN XII)
Tongue: Central / Deviated
Bulk: Normal / Wasted
Fasciculations: Present / Absent
Movements: Normal / Restricted
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Motor System Examination
Inspection
• Muscle wasting: Present / Absent
• Fasciculations: Present / Absent
• Involuntary movements: Present / Absent
• Deformities: Present / Absent
• Abnormal posture: Present / Absent
Muscle Bulk
• Right upper limb: Normal / Reduced
• Left upper limb: Normal / Reduced
• Right lower limb: Normal / Reduced
• Left lower limb: Normal / Reduced
• Symmetry: Symmetrical / Asymmetrical
Muscle Tone
• Right upper limb: Normal / Increased / Decreased
• Left upper limb: Normal / Increased / Decreased
• Right lower limb: Normal / Increased / Decreased
• Left lower limb: Normal / Increased / Decreased
• Type of Increased Tone: Spasticity/ Rigidity
Muscle Power (MRC Grading)
• Shoulder
• Elbow
Superficial Reflexes
• Corneal reflex: Present / Absent
• Abdominal reflex: Present / Absent
• Cremasteric reflex: Present / Absent
• Anal reflex: Present / Absent
Deep Tendon Reflexes (DTRs)
- Right: +
• Triceps
• Hoffmann’s sign
• Jaw jerk
• Other: ______________
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Sensory System Examination
Primary Sensations
• Fine touch: Intact / Impaired
• Pain: Intact / Impaired
• Temperature: Intact / Impaired
• Vibration sense: Intact / Impaired
• Joint position sense: Intact / Impaired
Pattern of Sensory Loss
- None
- Dermatomal
- Glove-and-stocking
- Hemisensory Sensory level
- Other: ______________
Cortical Sensations
• Stereognosis: Preserved / Impaired
• Graphesthesia: Preserved / Impaired
• Two-point discrimination: Preserved / Impaired
• Sensory extinction: Present / Absent
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Cerebellar Examination
• Speech : Normal / Scanning speech
• Eye Movements
Nystagmus: Present / Absent
• Coordination Tests
Finger-nose test: Normal / Abnormal
Heel-shin test: Normal / Abnormal
Rapid alternating movements: Normal / Abnormal
• Cerebellar Signs
Dysmetria: Present / Absent
Dysdiadochokinesia: Present / Absent
Intention tremor: Present / Absent
Rebound phenomenon: Present / Absent
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Gait and Station
• Posture: Normal / Abnormal
• Gait:
- Normal
- Hemiplegic gait
- Cerebellar gait
- High-stepping gait
- Parkinsonian gait
- Spastic gait
- Ataxic gait
- Other: ______________
• Tandem walking: Normal / Impaired
• Romberg’s test: Negative / Positive
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Meningeal Signs
• Neck rigidity: Present / Absent
• Kernig’s sign: Positive / Negative
• Brudzinski’s sign: Positive / Negative
The patient is examined in a well-lit room, adequately exposed, in a comfortable position, after taking verbal consent, in the presence of a female attendant (if female patient).
The patient appears comfortable at rest and is conscious, cooperative and well-oriented to time, place and person.
On General Physical Examination, his/her pulse rate is 68 beats/min, regularly regular, of normal volume and character. All peripheral pulses are palpable with no radio-radial delay, radio-femoral delay or vessel wall thickening.
His/her blood pressure is 128/76 mmHg, measured from the right arm in sitting position by the auscultatory method.
His/her respiratory rate is 18/min, thoraco-abdominal/abdomino-thoracic in type, without use of accessory muscles of respiration.
His/her axillary temperature is 98.6°F.
There is no pallor, icterus, cyanosis, clubbing, edema or lymphadenopathy.
On Higher Mental Function examination, attention, memory, speech and language functions are normal, with no evidence of cognitive impairment or behavioural abnormalities.
- Altered sensorium and disorientation may suggest diffuse cerebral dysfunction or metabolic encephalopathy
- Impaired attention and memory deficits may suggest dementia or focal cortical lesions
- Aphasia and behavioural abnormalities may suggest focal cortical lesions
On cranial nerve examination, the sense of smell is intact. Visual acuity and visual fields are normal. Patient correctly identified all Ishihara chart plates, with no evidenceof Colour vision defect. Pupils are bilaterally equal and reacting to light and accommodation. Extraocular movements are full in all directions of gaze, without ptosis or nystagmus. Facial sensations are intact, and muscles of mastication have normal bulk and power. Facial symmetry is maintained with no deviation of the angle of mouth. Hearing is normal bilaterally. The palate elevates symmetrically, and the uvula is central. Gag reflex is present. Sternocleidomastoid and trapezius muscles have normal power. The tongue is central with normal bulk and movements and no fasciculations.
- Anosmia may occur in olfactory nerve lesions and frontal lobe pathology
- Visual impairment and visual field defects suggest optic nerve or visual pathway lesions
- Unequal or non-reactive pupils, ptosis, ophthalmoplegia and nystagmus indicate cranial nerve or brainstem involvement
- Facial asymmetry may suggest facial nerve palsy
- Hearing impairment may occur in vestibulocochlear nerve lesions
- Palatal weakness with uvular deviation, absent gag reflex and tongue deviation suggest involvement of the glossopharyngeal, vagus or hypoglossal nerves
There is no obvious muscle wasting, fasciculations, involuntary movements or deformities. Muscle bulk is normal and symmetrical in all four limbs. Muscle tone is normal bilaterally. Muscle power is Grade 5/5 in all major muscle groups of both upper and lower limbs.
- Muscle wasting, fasciculations and hypotonia suggest lower motor neuron lesions, peripheral neuropathies or myopathies
- Hypertonia and spasticity suggest upper motor neuron lesions
- Rigidity may occur in extrapyramidal disorders
- Reduced muscle power may indicate lesions involving the cortex, corticospinal tract, spinal cord, peripheral nerves, neuromuscular junction or muscles
Superficial reflexes are present and preserved. Deep tendon reflexes, including biceps, triceps, supinator, knee and ankle jerks, are bilaterally equal and normal (2+). Plantar response is bilaterally flexor, and no pathological reflexes are elicited.
- Exaggerated deep tendon reflexes, clonus and an extensor plantar response suggest corticospinal tract involvement and upper motor neuron lesions
- Diminished or absent reflexes may occur in lower motor neuron lesions, peripheral neuropathies and myopathies
- Loss of superficial reflexes may indicate segmental spinal cord lesions or upper motor neuron involvement
All primary sensations, including fine touch, pain, temperature, vibration and joint position sense, are intact in all four limbs. Cortical sensations, including stereognosis, graphesthesia, two-point discrimination and sensory extinction, are preserved.
- Loss of pain and temperature sensation may occur in peripheral neuropathies and spinothalamic tract lesions
- Impaired vibration and joint position sense suggest posterior column involvement
- Cortical sensory deficits indicate parietal lobe dysfunction
- A sensory level may indicate spinal cord pathology
- Glove-and-stocking sensory loss suggests peripheral neuropathy
Speech is normal, and there is no nystagmus. Coordination tests, including finger-nose test, heel-shin test and rapid alternating movements, are normal. There is no dysmetria, dysdiadochokinesia, intention tremor or rebound phenomenon.
- Scanning speech, nystagmus, intention tremor, dysmetria, dysdiadochokinesia and rebound phenomenon suggest cerebellar dysfunction
The patient's posture and gait are normal, with normal arm swing. Tandem walking is normal, and Romberg's test is negative. There are no signs of meningeal irritation such as neck rigidity, Kernig's sign or Brudzinski's sign.
- A hemiplegic gait suggests upper motor neuron lesions
- A cerebellar gait indicates cerebellar dysfunction
- A high-stepping gait suggests peripheral neuropathy
- A Parkinsonian gait occurs in extrapyramidal disorders
- A positive Romberg's sign suggests sensory ataxia due to posterior column disease or peripheral neuropathy
- Neck rigidity, Kernig's sign and Brudzinski's sign suggest meningeal irritation as seen in meningitis or subarachnoid haemorrhage
