History

I- Personal history
1-     Name:
2-     Age: - 1st 3y  Duchen type of myopathy.
limb pelvis girdle myopathy.
- 2 – 3 decade
nd rd

Fascio scapulohumoral
- 2 – 15y  Fredreich’s ataxia
Syringomyelia.
- 15 – 30y
D.S.
S.C.D.
- 4 – 5 decade
th th

Motor neurone disease

Myasthenia gravis.
3- Sex:
Sex ♀
Chorea.
Meningioma (80% in ♀).
4- Marital state: esp. repeated abortions or still birth ($).
5- Occupation:  Lead and  Peripheral neuritis (P.N )
Arsenic.
Mn parkinsonism.
Driver disc prolapse
6- Residence:  Migrain is common in urban area, which
nutritional disorders are common.
7- Special habits: - Alcohol  P.N.
8- Lt. Handed or Rt. Handed:  Why?
(Broca’s area )
• Speach center is located in dominant hemisphere.
• The dominant one so: in Rt. handed people it is
located in lt hemisphere and vice - versa.
II- C/O: in the patient own words
If there is more than one complaint list them according
to their importance.
Cardiac
Onset Chest
C/O abdominal
Course
Duration (only in neurological sheet)

II- C/O: in the patient own words

Epilepsy.
1- Similar attacks
D.S.
Vascular lesions.
2- Fevers:
• T. myelitis.
• Poliomyelitis.
• Encephalitis.
• D. encephalomyelitis.
• Meningitis and its sequalae.
• Brain abscess.
• Pontine hage.
• Infective polyneuropathy.
3- Trauma and op.: in case of paraplegia& cauda equinui lesion.
4- T.B. , B ,  1ry (chancre) sore in gentalia. = Painless and
disappear without treatment.
 2ry fever, headache, irridocyclitis,
generalized LNs., Skin rash
not itchy. not vascular
6- Drugs as:  Steroids
 Sedatives  ataxia
 Analgesics. + contraceptives
 Vaccination.
 Primperan (metaclopramide) 
 Extra  in children

7- Ear diseases and eye diseases:

8- Convulsions & loss of consciousness.
9- Cardiac disease & Rhe. Fever  valve lesions e.g
Ms + AF  embolic hemiplegia.
10- Syphilis
 Acute meningitis.
S in CNS. Meningeal Chronic meningitis.
Vascular (E.A.O)  (end arteritis obliterans)
Tabes.
GPT.
Trumma of brain.
III- Family history:
1. of similar condition.
2. history of consanguinity.
3. of any nervous disease.
4. of cong. Abnormalities.
- Nervous diseases with +ve F.H
(Heredofamilial disease)
 V- Present history:
1. Onset, course and duration
2. Patient tells his story with analysis of each.
3. Ask leading questions
4. Write +ve data chronologically then –ve data.
5. Symptoms of other system Embolism
Hge
Acute  Dramatic (within seconds)
Trauma
Sudden (within hours)  thrombosis,DS & DEM
Rapid (within days)  Inflammations as meningitis
Onset encephalitis
Gradual (within weeks, months and years)
Systemic degenerative diseases:myopathy, H. Cereb.
Ataxia . MND.
Space occupying lesion brain tumour (unilat. Or bilat)
 N.B: Demyelinating disease usually of acute onset but may be gradual
Course:
inflammatory.
Regressive
Vascular lesion except hage. As

Thrombosis Embolism
Space occupying lesion
Progressive
Systemic degenerative disease
Motor neurone disease hage

Intermittent (episodic) Epilepsy

Migraine
- Remittent (Remission and exacerbation) not reach base
line Demyelinating disease as D.S
Rec. embolism
Vascular causes as
Hypertensive encephalopathy
Angiomatous malformation
 Stationary: = fate of any disease
Duration: long duration exclude malignancy
Leading questions

1- Symptoms of  I.C.T: Occipital  neck

Early hours of morning
Headache: characterized by
Bursting
Awaken pt. from sleep
Poor response to analgesics
And good response to
dehydrating drugs (diuritics) at
its peak  vomiting
Blurring of vision

Not necessary projectile

May be proceeded by nausia or not
Vomiting:
Usually at peak of headache
Related to meal or not.

Convulsions
♀: menstruation disturbance
Endocrinal dist.:
♂: Impotence
Sleep disturbance
 2- History of fits and loss of consciousness:
With fits or not.
Preictal 1. Aura ( visual, auditory, olfactory )
2. Special march (start in thumb, big toe & angle of
the mouth)
3. Generalized or localized  tonic & clonic.
4. With loss of conciousness or not + injuries + biting
tongue + Micturation.
Ictal 5. Duraltion.
Postictal 6. Post effect. (few hours or days) sleep, fatigue &
Automatism.
 Dysarthria
3- Speech disorders: Receptive.
Aphasia
Expressive
A) Aphasia = disturbance in higher neurological and psychological

functions of speech.

Receptive (Sensory): Auditory (Word deafness).

Visual (Word blindness).

For spoken speech (Broca’s area 44)

Expressive (Motor):
For written speech(agraphia , extensor
area 45)
B) Dysarthria: = Defective articulation or disturbance in
peripheral motor function of Speech

7  ms of face
9,10  Voice
12  tongue

- Types: (6)   Slurred - Cerebellar  stacatto

extra   Slow montonous -  & Cerebellar  scanning
- 9 & 10   Nasal tone
- 10 th  Hoarsness of Voice
- (1),(2),(3) = cerebral symptoms.
 4- Cranial nerves:
nerves
Anosmia
(a) Olfactory:
Hyosmia.
Hallucinations of smell
Parosmia and cacosmia = bad odours hallucination seen in uncinate fits.
NB: - Unilateral anosmia is more significant than bilateral  tumours.
- Most common cause is local cause (influenza)

(b) Optical nerve: 1- Visual acuity. 2- Visual field.

3- Visual hallucination. 4- ± color of vision
(c) III, IV, VI (oculamotor, trochlear and abducent):
1-Diplopia. 2- Ptosis.
3- Squint. 4- Dazling.
5- ± Exophthalmos
(d) V (Trigeminal):
Trigeminal
Pain, tingling, numbness.
Sensory
Temperature , Disturbance.
Touch.
Motor : Difficulty in mastication

(e) VII (Facial n.):

1- Inability to close eye.

2- Accumulation of food on one side.
Motor
   3- Drippling of saliva from one side.
4- Deviation of mouth to same side of paralysis.
Sonsory  5-Taste of food (ant. 2/3).
(f)VIII ( Vestibulo-choclear n)

1. Deafness.

2. Tinnitus. Cochlear

3. Hallucination.

4. Vertigo Vestibular Palate

(g) IX, X (glossopharyngeal and vagus) Pharynx

1. Nasal tone of voice. Larynx

2. Regurge of food from nose.

3. Dysphagia.
4. Hoarseness of voice.
= aphonia or dysphonia.
(h) Accessory (XI):

1. Can not rotate his face to other side.

2. Can not raise his shoulder properly on the diseased side. 
Sign > symptom

(i) Hypoglossal (XII):

1. Difficulty of speech.
2.  weakness 3- Distal or pro Movement of the
tongue or deviated tongue.
3. ± Difficulty of mastication.
5- Motor system

1- State.
2- Tone.
1- Unilateral or bilateral.
3- Power
2- Symmetrical or asymmetrical.
3- Distal or proximal.
Weakness
4- flexor or extensor.
5-Abductor or adductor.
6-Trunk muscles: abd. Ms. Or back ms.

4- Fasciculation.
5- Involuntary movement.
 Atrophy (wasting).
1- State
Pseudo hypertrophy e – weakness.
Flaccidity (hypotonia) = LMNL, cerebellar,
2- Tone: chorea
Stiffness (hypertonia) =  or extra 
3- Power: Weakness or paralysis
1. Unilat. Or bilat.
2. Symmet. Or asymm.
3. Distal or proximal.
UL

Distal Proximal
LL

Distal Proxima
- Dorsiflexion - Plantiflexion
4- Flexor or extensor:

UL

Floxer Extensor
LL

Floxer Extensor
5- Abductor or adductor:
UL

Abd. Add.
LL

6- Back ms.
Trunk
7- Abd. Ms.
4- Fasciculations:
If +ve  A.H. cell lesion.
 5- Involuntary movement:
1. Proximal or distal.
2. Static or kinetic.
3. Rhythmic or jerky.
4. What  (emotions).
5. What  (sleep).
6. Discreption ( Pill rolling ).
Sensory
Effect of closure of the eyes = Sensory ataxia.
1. Intention tremors
2. Dysmetria
3. Dysdiadokokinesia
7- Sensory system:

• Irritation  tingling + pain.

• Root pain: occurs at the site of certain dermatome and  by
Coughing and straining.
•  Numbness.
Pain
1- Superficial sensation: Temp.
2- Deep sensation. Touch

3- Cortical sensation.
Sign > symptom
8- Sphencteric disturbances:

1- Bladder: (common) : bilat . represented so not affected in

hemplegia.

(a) Desire. (A)

(b) Control.
(c) Voluntary act. (E)
(d) Retention.
(e)  Hesitancy.
2- Rectum  as Bladder  very late affected
3- Erection and ejaculation.
Types of bladder disturbances - Precipitency = 
- Hesitancy =
• Not feel desire = afferent lesion = Sensory atomic Bladders
as in TD
• Not able to evacuate = Efferent lesion = motor atonic
• Autonomic B L = No aff & eff
• Automatic BL = No cortical control

Hypothalamic
1. Polyphagia or anorexia with rapid loss or gain of weight.
2. Polyurea, polydepsia (D.I.).
3. Sleep rhythm disturbance.
Amenorrhoea.
4. Heat regulation disturbance.
Loss of libido
5. Hypogonadal function
Atrophy of gentalia.
Loss of hair.
10- Gait: disturbance or not.

Symptoms of other systems.

Summary

1. Age of onset of the disease.

2. Family history.
3. Past history. Onset.
4. Present history Course. Motor.
+ve data of Sensory.
Speech
1- Pyramidal lesion:
1. No atrophy.
2. Hypertonia. D>P
3. Weakness or paralysis of distribution Abd > Add
4. Superf. Reflexes: lost + extensor planter. Ex > F in UL
5. Deep reflexes: hyper-reflexia. Fl > Ex in LL
6. +ve path . reflexes
7. Presence of clonus
2- LMNL:
1. Weak or paralysis.
2. Atrophy.
3. Hypotonia. Lost at level.
4. Superf. Reflexes: Lost planter.
5. Deep reflexes: Lost
 3- Cerebellar :
• Nystagmus
• Ataxia.
• Kinetic tremors.
• Speech disturbance.
• Gait disturbance

4- Extra - ∆: involuntary movement at rest.

A- General exam:
As usual by stress on:
• Pellagric rash.
• Skin manifestation of leprosy.
• Bed sore.
• Cong. Anomalies as
o Pes cavus
o High arched palate.
• Heart in hemiplegia.
(B) Neurological examination :
1. Mental state.
2. Speech. Sitting
3. Cranial nerves.
4. Motor system.
5. Reflexes.
6. Coordination. Supine
7. Involuntary movement.
8. Sensory system.
9. Gait rombergism.
Standing
10. Rombergism.
1- Mental or intellectual function:
 Percussion in paraplegia
 Heart exam
 Exam of : 
Skull
 Spine
 Skel . deformities

 Trophic changes
 Patient is: Fully conscious
 Well oriented to place, time and person.

 With average intelligence.

 Intact memory (recent & remote )

 Proper mood (no euophoria or depression).

 Normal behaviour.

 No hallucination = perception without stimulus. Visual

Auditory
 No illusion = mis-interpretation of real stimulus

 No delusion = false fixed believes not subjected to logic.

 Slurred = lesion.
Stactto = cerebellar lesion.

2- Speech Scanning =  & cerebellar lesion.

Slow monotonus = extra  (parkinsonism)
(A) Dysarthria
Nasal tone = 9 & 10 paralysis.
Hoarseness of voice = 10 perralysis.
(B) Aphasia
Motor = lesion in Broca’s area.
• Inability to express himself in sopken words.
• Inability to formulate written words.
Sensory
Visual aphasia =
• Word blindness
• Inability to understand written words.
• Lesion in the supramarginal gyrus

Auditory aphasia =
• Word dealness.
• Inability to understand spoken words.
• Lesion in the upper post. part of temporal lobe.
(C) Aphonia and dysphonia:  in 9th and 10th n.
paralysis  Palatal.
Paralysis  nasal tone.
Bilateral vocal cord paralysis.

3- Cranial nerves:
I- Olfactory: 1. Each nostril separate.
2. Familiar sub & Not irritant substances.
3. Closure of eyes.
II- Optic:
1. Visual acuity by counting fingers at one meter hand
movement & perception of light.
2. Field of vision by confrontation method.
3. Colour of vision.
4. Fundus exam.
(III- Oculomotor, IV- Trochlear, V- Abducent).
Inspect: Ptosis.
Squint. * size. * Shape.
* Centrality. * Equality
*Reaction to light (Direct , Consensual)
 Pupil *Accommodation reaction.
 Single movement on each eye.
• Voluntary.
 Conjugate movement
• Reflex.
Reflex
 Accommodation and convergence.
 Nystagmus: • Positional or on fixation
• Horizontal or vertical or rotatory.
• Pendular or has slow and rapid Movement.
• Direction of rapid phase.
• Amplitude on both sides
Types of Nystagmus?
Vestibular, Cerebellar, Occular, Brain stem
V- Trigeminal n:
Motor Reflexes
1-Temporalis: 1- Corneal: 5-7
afferent in 5th + motor nu. Of 7th on
2- Masseter both sides closure of both eyes.
Lesion of 5th Rt.: touch the Rt. cornea
3- Pterygoid  lost corneal on both sides.
Touch the Lt. cornea nor. Reflex
on both sides.
Lesion of 7th Rt.: touch the Rt. lost
Rt. reflex but nor. Lt.
Touch the Lt. corena Lost Rt.
reflex but nor. Lt.
2- Jaw reflex: 5-5 
Normally absent.
It present bilateral ∆ lesion above the
level of trigeminal nu.
Sensory
1- Compare the 3
divisions on both sides
 
2- Compare the 3
divisions on the same side
related to each other.
3- Compare the
sensations of the central
part of the face with the
peripheral one
 
 
4- Compare C2 (angle of
jaw) with other areas.
 NB Causes of exaggerated Jaw R.?
(3) M.N. disease.
Bil. Hemiplegia above pons.
D.S.
VII- Facial nerve:
Motor Sensory Scretory Reflexes
= Muscles of Taste of the ant. Efferent secretory 1. Corneal R S
expression. 2/3 of the tongue. to: &S
1- Frontalis. (Joins the facial n. - Sublingual. 2. Glabellar R.
2- Orbicularis oculi. in the facral canal - Submental. (7=7)
of the temporal
3- Buccinator. lobe. - Lacrimal.
4- Zygmotic & Retractor
angylii.
5- Buccalis oris.

Q: DD. between UMNL. and LMNL. of facial n.?

 Exam of the facial n.
1- Inspection:
Wrinkles.
(A) Asymmetry of the face:
Wasted nasolabial folds.
(B) Deviated angle of the mouth towards nor. side.
C) Dribbling of saliva.
(D) Dropping of lower eyelids with tears flowing over it.
(E) Fasciculations and invol. Movement.
N.B: long-standing paralysis  Contracture  Deviation of
Mouth towards the paralysed side.
2- Motor: ( 5 muscles )
3- Taste: •Protrude the tongue. 1- Sweat.
•Hold Rt. with gauje. 2- Soure.
•Apply substances to the lat. Sides: 3- Salt.
4- Bitter.
VIII- Vestibulo-cochlear:
1- Audiatory:  Hearing
1- Whispering test:  Normal heard at one meter.
2- Tunning fork test: to diffe. Between C.D and N.D.

Normally
1- Air condition > bone conduction.
2- Middle ear disease or blockade of ext. meatus 
air condition but nor. bone condition.
3- In disease of cochlea and auditory n. both air
condition and bone condition are equally impaired.
(a) Rinne’s test:
1st near a ear.
The tunning fork is placed
Then, on the mastoid process.
• Normally: air cond. Is stronger and last longer than B.C.
• Deafness due to cochlear lesion  maintained normal level.
• Deafness due to middle ear disease  reversed relation.

(b) Weber’s test: 

Tunning tork is placed on the pt. forehead in the mid-line
and compare sounds in 2 ears.
• Normally: heard equally well on both sides.
• Nerve deafness or cochlear  sounds on normal side.
• Middle ear disease  sounds on the diseased side due
to  bone conduction.
(2) Vestibular: not routinely tested except in vertigo.

1. Positional nystagmus.
2. Caloric test.
3. Galvanic test = electric (+) of mastoid.
IX-Glossopharyngeal:
• Motor: Pharynx.
• Sensory: post. 1/3 of tongue, tonsils and pharynx.
• Taste: post. 1/3 of tongue.

Dysphagia.
• Paralysis: Anaesthesia of pharynx.
Lost taste on post. 1/3 of tongue.
X - Vagus nerve:
palate.
Motor: Larynx.
Pharynx.

Palatal paralysis.
Paralysis: Laryngeal paralysis.
anaesthesia of the larynx on the affected side.
  Pharynx.
Larynx.
Viscero-sensory: G.I.T.
Heart.
Lung.
 Paralysis
Palale.  Palatal Paralysis
Vagus nerve * motor Pharynx.  Laryngeal paralysis
Larynx.  anaesthesia of larynx
On affected side.

Pharynx
* Viscero – sensory Larynx. + heart & lung.
G.I.T.
Heart.
- Efferent:
Bronchi.

G.I.T.
 Dysphagia.
- History:
Nasal regurge.
Change of voice.
Insp. Stridor on exertion.

- Exam: 1- Open the mouth and say ah. Deviation of

uvula.
Limitation of
movement.
2- Stim-palate patatal R , bitateral.
 
3- Stim. Post. Pharyngeal wall
pharyngeal R.
4- Taste to the post. 1/3 of tongue + laryngeoscope
for vocal cords.
 N.B.: Palatal reflex: touch uvval (5) more up (10).
Pharyngeal reflex: touch post . ph . wall (q) gagging
(10)
By use of 2 tonque depressors

XI- Accessory nerve:

1- Sternomastoid: ask the patient to move his head to one side
against the resistance.
Push the chin downwards against resistance
muscles should be palpated to feel
contractions

2- Trapezius: ask the pt. to raise his shoulder against resistance.

 pt. can not rotate his face to one
N B Paralysis of both side.
Weak evaluation of shoulders on
one side.
Upper angle of scapula rotates
upward.
XII- Hypoglossal: all the interensic ms. of the tongue on one side.
1. Inspect atrophy or fasiculations. 
2. Ask pt. to protrude his tongue in the mid. line.

And lock for Inability to protrude it.

Any deviation.
Any invol. movement.
 3. Ask the pt. to press his check with his tongue.
4. Tap the tongue if you suspect myotonia

- Unilateral UMNL or LMNL  deviated tongue towards the

LMNL  atrophyparalyzed side.

or fasciculations.

 - Bilateral UMNL or LMNL  can not protrude his tongue.

+ spastic
atrophy and fasciculations
Motor system
Atrophy UMNL  Little atrophy
1- State LMNL Marked atrophy
Hypertrophy:  Myopathy as Duchene’s myopathy

• Inspect all the muscles of the body and see

thenar and hypothenar ms.
• Tibia.
 Normal LMNL
2- Tone UMNL. In shock stage
Hypoyonia: Cerebellar ataxia
Chorea
Ms. disease

Hypertonia:  Clasping Knife spasticity. of

UL antigravity ms. +
Hand shaking test(up&down) Suddenly give way.
Elbow F1&ext UL During extension and LL.
with flextion= ∆ lesion.
Shalder circumduction
LL all through (lead pipes)
Ankle shaking test (l at) = extra ∆ .
Knee : flex & ext. Regidity or Cog wheel = lead pipe
interrupted by tremors.
Hip - Circumducyion = ext ∆.
Hysterical rigidity:
- Rollong test - Frog`s sign resistance gradually.
3- Power:  weakness or paralysis.
Comment:
1. Is there is weakness.
2. Bilat. or unilat.
3. If bilat.  Symmetrical or asymmetrical.
4. Is weak more distal or proximal in LL dorsiflex or
plantiflexian.
5. Is weak more flexor or extensor.
6. Is weak more abductor or adductor.
7. Is weak has special predilcation to certain gp. Of muscles.
8. Back & abd . ms .exam.
UL (2-2-2-4)
hand grip.
Hand
Opponence ms.

Wrist : Flex & ext.

Elbow : Flex & ext.

.Flex
Shoulders .Ext
.Abd
LL(2-2-4) Add
Ankle ( dorsi & plantiflexian ).
Knee ( flex & Ext ).
Hip ( F & Ext . from heed).
( F & Ex . from thogh).
( F & Ex . Ex in prone position)
( Abd & add)
 Examples
Case I Case II Case III Case IV
-Weak in UL. & - Weak in UL. - Weak of UL. - Weak of LL.
LL. & LL. & LL.  
- Bilat. - Bilat. - Bilat. - Bilat. Or unilat
- Symm. - Symm. - Symm. - Asymm.
- Distal > prox. - Distal > prox. - Prox. > distal - Prox. & distal,
In UL. & LL. In UL. & LL. in UL. & LL.
- Ext. > flex. in UL. - Ext. > flex. In - Flex. = Ext. in - Flex & ext.
Flex > Ext. in LL. both UL. & both UL. & variable from
LL. LL. pt. to pt. and
    from limb to
limb
- No sp. - No sp. - Sp. Predilicatn.
Predilicatn. Predilicatn.
Weak of ∆ Weak of Weak of Cauda equina
pheripheral Myopathy Lesion
neuritis
4-Fasciculations.
5- Invol . movements.

5- Reflexes:
A- Superficial:
1. Abdominal: DZ-12.
(a) Normally contraction of ms.
(b) lesion absent contraction.
(c) could detect level in per preplegia.
(d) Umblical level = 10th .
2. Planter reflexes (S1):
3. Cremastric R.
 Causes of extensor planter: (6).
1. UMNL.
2. Infants (1st. y).
3. Under anesthesia.
4. Deep sleep.
5. Deep coma.
(B) Deep reflexes:
(1) U.L.:
1. Biceps: C 5-6.
2. Triceps: C 6-7.
3. Bracheo-radilalis: C 5-6.
4. Einger jerk C 8 – T 1 Normally absent
If present ∆ lesion
Above c8. =
Jerk flexion of fingers.
 2-Hoffmann’s sign:

Sudden flexion of the terminal phalanx of middle finger.

Normally nothing.
∆  Flex other fingers and adduction of the thumb.
It ∆ lesion above c8.

3- Warten-berg:
Pt. supine his hand and slightly flex his fingers while the
examiner pronate his hand and flex both fingers against each
other resistance.
Normally  thumb is extended.
 ∆ thumb is adducted and flexed strongly.
(2) LL
• Ankle R s 1,2
Pin ∆
• Ankle R l2,3 (l 2,3,4)

(C) Path reflexes:

1- Finger Jerk.
2- Hoffman’s R.
3- Jaw R.
4- Corasping R.
5- Suckling R.
6- Coordination:
UL 1. Finger nose test UL.
Eye opened.
2. Finger finger test UL.
Eye closed.
3. Finger finger test.
4. Dysdiadokokinesia.
5. Redband test.
6. Buttoning & Unbuttoning.
LL •Standing (suraying).
•Walking along astraight line.
•Heel knee test.
•Hyporeflexia ( pendular knee jerk).
 NB :
• Sensory ataxia: = post. column lesion  pt. perform.
• These tests correctly under vision.
• The above tests carried on opening and closed eyes.

7- Involuntary movement:
• Static or kinetic.
• Distal or proximal.
• Rhythmic or jerky.
• Effect of voluntary movement.
• Effect of emotions.
• Effect of sleep.
8- Sensations: Pain  pin prick.
(a) Superficial:
Temp.
Touch  cotton.
*From below upwards to detect a level.
*Compare 2 sides to detect hemianaesthesia.
*Around a circumference of a limb to detect wether:
Peripheral neuritis  equality.
Sensory loss  along the affected radicle.
(b) Deep sensation:
1. sense of movement.
2. Sense of position: up.
3. Muscle sense. Down.
Maleoli
4. Vibration sense: Tibial tuberosities.
ASIS.
 Radial tuberosity.
UL Olecranon.
Clavicle.
Sternum.
Trunk Olecranon

Reflexes
* Test for myotonia
Vol.myotonia  hand fist & shake hands
Mechanical Tap thenar eminenceadduct thumb & delayed abd.
Tap tongue  dimple sign
* Test for fatigability to exclude myasthenia
- Look up for 1 min (ptosis)
- Abduct shoulder at “ go ” for one min
- Blow cheeks against resistance
Test for myopathy:
 Gower sign ( climbing ) test = weak glut max & spine extensor
 Wadding gait = weak glut. med. & mininws
 Exag. lumber lordosis = weak back extensor
 Pot belly abdomen = weak Abd . ms
 Winging of scapula = weak serratus ant . & trapezius
 Rhombolds ms : ask pat. to catch his hands post .
 Latis . dorsi hold post axil . fold & ask pat . to cough while
pt . clasp his hands behind back.
 Clavicular head of pect . major ( not effected in myotonia &
myop.) stretch arms & clasp hands .
 Beevor`s sign .pt sit
* shifted umb. up weak lower abd ms. (pelvic girdle)
* detect level of lesion in paraplegia.
(c) Cortical sensation:
1- Tactical localization = localize the site of pin prick.
2-Tactilc discrimination = dilt . 2 pricks.
3-Stereogenosis.
4- Graphaesthesia.
Deformities
Spine Shape
Tenderness
Exam Skull Swelling defects
Skeletal deformities Brut
Bladder : percussion.
Coldness.
Trophic changes : Bed sores and ulcers.
Charcot joint.
Other systems.
(9) Gait and (10) Rombergism :
Types of gait :
1. Circumduction gait  unilateral U.M.N.L. uni.
2. Spastic ( scissor ) gait  bilateral U.M.N.L = cerbral palsy. bil
3. High steppage gait : due to root drop  P.N. esp. personal ms
Dystrophy. P.N
4. Stamping gait  sensory ataxia.
5. Shuffling gait  parkinsonism Short steppage (mild), prepulsion &
Retrepulsion.
6. Wadding gait  muscle dystrophy( pseudo – hypertrophic ) - 
myopathy).
7. Drunken gait :  bilateral cerrebellar ( wide base ) as Friedreiches.
deviation (unilateral corebeller).
8. Waking along astaight line
Zigzag (Marie`s) bilat.
9. Dancing gait : chorea due to hypotonia + involuntary movements.
ext 
10.Hysterical  various bizzre type , non injurious, suggestible .
Patterns of sensory loss :
1. Mononeural (e.g. ulnar N. lesion )
2. Stoke & glove (P.N.)
3. Patchy loss (leprosy)
4. Radicular loss ( root lesion)
5. Level (tract lesion – paraplegia )
6. Jacket with sleeve (intramedullary lesion)
7. Hemianaesthesia (hemiplegia)
8. Crossed hemianaesthesia (PICA occlusion)
9. Brown – sequard syndrome
10. Saddle loss (cauda & conus)
11. Dissociated loss (syringomylia)
12. Deep sensory loss (SCD)
13. Thalamic los (thalamic syndrome)
14. Cortical sensory los (post central gyrus loss)
15. Face : loss of inner sensation in Tables dorsalis – loss of outer
sensation in syringobulbia.
Causes of dissociated sensory loss “loss of pain & temp.
with preserved touch” :
1. Syringomylia & syringobulbia.
2. Brown sequard syndrome.
3. Intramedullary tumours.
4. Cerebellar artery occlusion syndrome.

Causes of tender calf muscles :

1. Diabetic neuropathy.
2. Landry-Guillian-Barre syndrome.
3. Neutritional neuropathy.
4. Others : DVT & myositis.
 Examination of sensory system
Superficial sensation :

- Pain using pin prick

- Touch using a piece of cotton
- Temp using hot & cold test tubes.
a. Compare both sides of body (leg to lef, arm to arm) to
detect hemihypothesia in hemiplegia.
b. Descending search to detect level (in focal paraplegia)
jacket sensory loss (intramedullary lesion), stock &
glove hyposthesia (in P. Neuropathy).
c. Compare different dermatomes (for radicular sensory
loss), test sensation all around limb.
Sensory Supply of Body :
C2 Angle of jaw, lateral aspect of the neck
C3,4 Shoulder, down to manubrium
C5 Lateral aspect of arm
C6 Lateral aspect of forearm, thenar eminence & thumb
C7 Middle aspect of forearm, middle of palm, middle 3 fingers
C8 Medial aspect of forearm, hypothenar & little finger
T1 Medial aspect of arm
T2-T7 Thorax (T5 : nipple)
T8-T12 Abdomen (T10:umbilicus – T12:inguinal ligament)
L1 Upper 1/3 front of the thigh
L2 Middle 1/3 front of the thigh
L3 Lower 1/3 front of the thigh
L4 Anterolateral aspect of thigh, front of knee, med.aspect of leg, foot & toe.
L5 Lat. Aspect of the thigh, lat. Aspect of leg , middle 1/3 of dorsum of the foot &
middle 3 toes.
S1 Posterolateral aspect of the thigh & leg, lateral 1/3 of dorsum of the foot & little toe.
S2 Posterior aspect of thigh, leg & sole of foot.
S3,4,5 Anal, perianal,& gluteal region (saddle area) in concentric manner.
Examination of coordination
 Cerebellar ataxia : tests are +ve with
opened eyes & ↑ with eye closure.
 Sensory ataxia tests are +ve only with eye
closure.
1. Eye : nystagmus
2. Tongue : staccato speech
3. Neck : nodding
4. Trunk : titubation
5. Limb : intention “kinetic tremors”
In UL :
a) Finger – to nose test : tip of finger from a distance  nose
b) Finger – to finger test : each tip of hid forefinger travel to
meet each other in midline.
c) Finger – to doctor’s finger test.
d) Dysdiadokokinesia : inability to perform rapid alternating
movement e.g. pronation & supination.
e) Rebound phenomenon : with sudden release of flexed elbow,
the forearmmay hit patient face .
f) Buttoning and unbuttoning test : earlies sign.
In LL :
a) Standing : Swaying (trunkal ataxia).
b) Walking along straight line (Gait).
c) Heel-to knee test : patient raises his leg, brigs down its
heel onto his other leg slides it down along shaft of tibia.
d) Hypotonia & hyporeflexia : pendulous knee jerk.