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CONSCIOUS LEVEL
CONSCIOUS LEVEL
Conscious alert, self awareness &
attention to the surrounding
Using the GLASGOW COMA SCALE
(GCS):
Eye response (E)
Motoric response (M)
Verbal response (V)
CONSCIOUS LEVEL
Decrease of conscious level
disturbance of the center of consious in
the brainstem and reticular formation,
could be caused by:
- lesion in the brain (stroke, brain tumor,
meningitis, etc)
- from systemic cause effect to the
brain, e.g.: hyperglicemia, hyponatremia.
CONSCIOUS LEVEL
GCS 15 = E4 M6 V5 ( Compos Mentis )
GCS 3 = E1 M1 V1 ( Deep Coma )
GCS =≤7 ( Coma )
GCS = E4 M6 V- ( Motoric aphasia )
GCS = E4 M1 V1 ( Coma Vigil )
Mental Status Exam /
Higher Cortical Function
Mental Status Exam
Family story of memory loss
Orientation
General Information
Recognition of objects
Memory disturbance
Acalculia
Agraphia
Dementia
etc
MENINGEAL SIGNS EXAMINATION
MENINGEAL SIGNS EXAMINATION
1. NUCHAL RIGIDITY
2. KERNIG’S SIGN
< 1350
BRUDZINSKI II
Passive flexion of hip and knee
Response is positive: involuntary flexion of
kontralateral leg.
BRUDZINSKI III
Pressing the zygomaticus bone
Positive: involuntary flexion of the arms on
elbow joints.
BRUDZINSKI IV
Pressing the symphysis bone
Positive: involuntary flexion of the lower
extremities on knee joint.
Cranial Nerves
Olfactory Nerve (N. I)
The sense of smell rarely identifies any
significant pathology.
Use tobacco, soap, orange, coffee,
smelling salts, etc for some idea to get
some idea if they smell.
Ammonia stimulates pain endings of N.
V (Trigeminal) rather than N. I.
• Not routinely examined in clinical
practice.
Result/Interpretation :
Normosmia
Hyposmia - Anosmia
• Two parts:
- Sensory to face
- Motor to muscles of mastication
- Plus: reflexes (corneal & jaw reflex)
• Assess sensation to face
• Determine if patient can open mouth.
• “Clench your teeth” - feel for muscle
bulk at Masseters
V1 – Ophthalmic
V2 – Maxillary
V3 - Mandibular
Facial Nerve (N. VII)
horizontal nistagmus
vertical nistagmus
rotatoir nistagmus
Vertigo
Glossopharyngeal and Vagus (N.
IX & N. X)
Tongue deviation
Fasciculations of tongue
Motor System Examination
Motor System Examination
• Aim is to be systematic
• Ensure you have permission, adequate
exposure and tendon hammer to hand.
Same system for upper and lower limb
• Inspection
• Palpation of Tone (passive & active)
• Power / muscle strenght
• Physiologic Reflexes
• Pathologic Reflexes
• Coordination
Upper Motor Neuron lesions (UMN)
Flaccid Paresis/paralysis
Atonic / hypotonia
Reduced power
Atrophy +
Areflex / hyporeflex
Pathologic reflex is absent
Impaired coordination
Extrapyramidal disorder
• D ysdiadokinesis / dysmetria
• A taxia
• N ystagmus
• I ntension tremor
• S tacatto speech
• H ypotonia
• P endular reflexes
Common etiology: Trauma, alcohol, SOL, old age.
Inspection
Normal strength 5
Active movement against resistance but less 4
than normal strength
Active movement against gravity but not 3
against resistance
Movement occurs only in the plane of gravity 2
A barely detectable flicker or trace of 1
contraction
No muscle contraction detected 0
Reflexes
REFLEX SEGMENTS
Biceps Reflex (BPR) C5 – C6
Brachioradialis reflex C5 – C6
Triceps reflex (TPR) C7 – C8
Knee reflex (KPR) L2 – L4
Ankle reflex (APR) L5 – S2
Tendon Reflex Grading Scale
0 Absent
1 Diminished
2 Normal
3 Increased (may spread to adjacent
muscles)
4 Unsustained clonus (a few beats)
5 Sustained clonus
2. Superficial Reflex
REFLEX Reflex Arc
Corneal reflex Af:N.V, Ef:N.VII
Cremasteric reflex L1 – L2
Abdominal reflex involved supraseg-
mental neurons
Bulbocavernosus reflex S2 – S5
& anal wink
3. Pathological Reflexes
1. Upper Extremities
Hoffman-Tromner
2. Lower Extremities
BABINSKI (Plantar reflex), Chaddock,
Schaefer, Oppenheim, Gordon.
A positive test is when the lateral aspect
of the foot is scratched & the big toe
dorsiflexes & the other toes fan out.
Eliciting Reflexes:
Upper limb:
•“Touch the index finger of your right hand to
your nose (Finger to Nose test) the
disturbance called: Dysmetria.
•Look for intention tremor.
•Repeat for left hand side.
•Can also assess coordination by looking for
dysdiadokinesis (pronation-supination test).
Coordination
Lower limb:
• “Place the heel of your right foot on left
knee and run foot down left shin and back
to knee as fast as possible.” heel-shin test)
Dysmetria.
• Repeat for left hand side.