INTERNATIONAL MEDICAL UNIVERSITY MALAYSIA

Bachelor of Medicine &

Bachelor of Surgery

Intake ME 1/16
Semester 4

A GUIDE TO THE
NERVOUS SYSTEM

Clinical Skills Department

(5th.Oct., 2017 to 2nd. Nov., 2017)

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INTRODUCTION

This is a GUIDE to the nervous system module, listing the Learning Outcomes,
Activities, and Scenarios.

Before attending the sessions at CSSC and for further details you must :
Attend all the PLENARIES- study the plenaries thoroughly as they contain the relevant
details and elaboration for the history taking and physical examination that is essential
for your understanding of the subject .
Read your TEXT BOOKS Use this Manual Guideline and the Plenaries to help you to
focus on the essential topics in the test books that is relevant for this stage of your
learning.
Watch the VIDEOS in the eportal - they help you to understand how the examination is
performed correctly. And by visualizing you have a better and clearer understanding of
the examination technique.
ANATOMY of the system must be clear to you (please study it carefully) to enable you
to know the significance of the various aspects of the history taking and physical
examination.

MODULE LEARNING OUTCOMES

Communication skills
To be able to :
1. Elicit a history of neurological symptoms from a patient
2. Recognize the importance of psychiatric diseases as part of the differential
diagnosis of nervous system symptoms.

Clinical examination skills:

To be able to:
3. Accurately and effectively assess consciousness (GCS), higher cognitive functions
and cerebellar function
4. Demonstrate a mini mental state examination.
5. Perform a fluent and systematic assessment of the peripheral nervous system
(motor and sensory)
6. Perform a fluent and systematic examination of the cranial nerves.
7. Accurately identify abnormal findings on neurological examination
8. Interpret the findings on examination to determine the anatomical site of pathology.
9. Clerk cases with neurological problems at Hospital Tuanku Jaafar (HTJ)

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10. Present and discuss the cases clerked at HTJ

TEACHING AND LEARNING ACTIVITIES

8. Plenary on interviewing patient presenting with neurological symptoms
Physical examination of sensory nervous system, Glascow Coma Scale

10. Plenary on Physical examination of motor system, and c

12. Small group interviewing patient presenting with neurological symptoms

. Small group physical examination of a mini mental examination
14.Small group physical examination of sensory system
15.Small group physical examination of motor system
16. Small group physical examination of cranial nerves
17.Hospital visits (HTJ )- to clerk cases with neurological problems
18.Presentation and discussions of cases clerked at Hospital Visit

SESSIONS OUTLINE- Teaching and learning at CSSC

NERVOUS
SYSTEM
MODULES IN
CLINICAL
SKILLS

1
2 3 4 5

PATIENT PE SENSORY PE MOTOR PE CRANIAL CASE

INTERVIEW SYSTEM, SYSTEM & NERVES DISCUSSIONS
MENTAL OF HOSPITAL
CEREBELLUM
TESTING & VISITS=
GCS PUTTING ALL
TOGETHER

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 VIDEOS:

PLEASE VIEW THE VIDEOS OF THE NERVOUS SYTEM ON E- LEARNING. The following videos are
available at- elearn.imu.edu.my

Examination of Consciousness & Higher Function of the Brain-

VIDEOS by Dr. Susmita + Youtube GCS at 40
Examination of Motor & Sensory System
Examination of the Cranial Nerves

HOSPITAL VISITS (HOSPITAL TUANKU JAAFAR) AND

CASE PRESENTATIONS AND DISCUSSIONS AT CSSC

Learning Outcomes
To be able to:
1) Obtain a comprehensive history from a real hospital patient with a problem affecting the
nervous system and how it affects the
2) Perform a physical examination of the nervous system whenever possible
3) Present orally the clinical case
4) Discuss the differentials and provisional diagnosis with clinical reasoning, and impact of

Teaching Learning Activities

You will:
Be divided into 3 groups and rotate in turn between the medical ward, rehabilitative ward
/physiotherapy department.
Be accompanied by the CSSC nurse to guide you.
In the medical wards:
Interview patients (in a group of 2-3) and perform physical examination if possible.
Document the case for case presentation.
Present orally the cases at CSSC sessions , BJ
Prepare beforehand with provisional diagnosis and differential diagnoses with clinical
reasoning.
Prepare a discussion on and how they impact on
In the physiotherapy/ rehabilitation wards:

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 Observe the physiotherapy/ rehabilitative activities and chat/discuss with patients and
therapist regarding medical conditions and purpose of therapy and outcomes.

WEEK 1. PATIENT INTERVIEW

Learning Outcomes

To be able to:
Interview patient and gather all the relevant information on 2 patients presenting
with neurological problems.
Establish rapport with patient.
Communicate effectively with the patient with the appropriate demeanour, having
good flow of conversation and using all the relevant communication skills.
Analyse whether patient has a physical component as well as a psychological
component in illness.
Summarise the history
Give differential diagnoses and to come to a most likely diagnosis, giving reasons
for them
Activities.
Interview 2 patients
Summarize history
Give differential diagnoses and provisional diagnosis and reasons

COMMON NEUROLOGICAL SYMPTOMS

Chief complaint
Headache/Pain (neck)
Weakness
Seizure or fit-include prodromal and post ictal symptoms
Abnormal movements like tremors
Loss of consciousness, memory loss, dizziness or vertigo
Difficulty in maintaining physical balance and difficulty in walking
Pain in the eye- white eye and red eye
Injury-falls, accident
Visual disturbances- visual loss, double vision, photophobia
Tingling numbness & loss of sensations
Vomiting and nausea
Loss of coordination

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History of Presenting Illness.
For all symptoms, confirm-
1. Time relationships- onset, duration, pattern of symptoms( constant or come & go)
2. Precipitating, exacerbating, relieving factors
3. Side of lesion ( right/left)
Associated Symptoms
Some of the symptoms may not be volunteered by the patient. Please include -
Memory or concentration difficulties,
Sphincter disturbances and sexual dysfunction,
Visual or hearing disturbances,
Mood changes
Loss of sleep and appetite.

Past History
Co-morbidities like hypertension and diabetes.
Birth and development details- Birth trauma can lead to neurological deficiencies
in later life- for example epilepsy.

Drug History
Anti-coagulants in the elderly, (associated with injury/fall)

Consider neurological symptoms when patient is on certain medication.

Common examples are-
Carbamazepine, Phenytoin- Ataxia, Diplopia
Aspirin- Deafness, dizziness, vertigo
Isoniazid, Metronidazole -Peripheral neuropathy

Family History
Genetic disorders- Neuropathies, Ataxias
Genetic Factors- Epilepsy, Multiple sclerosis

Social history

Neuropathies due to entrapment of nerves may be occupation related.

Alcohol and drug abuse may be implicated- alcohol in peripheral neuropathies.

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 Sexual history - HIV and syphilis can cause neurological problems- symptoms of
cognitive impairment typically occur late in symptomatic HIV disease.
Driving as neurological conditions like frequent epilepsy attacks may be a
contraindication.
Support system- family, friends, aid worker, house-help
Problems in the elderly eg depression/anxiety , ability to look after
oneself/presemce of caregiver, emotional support etc

Clinical Scenarios

Scenario:
This 19-year-old student was brought to the hospital by her friend for sudden loss
of consciousness today.
Task:
Please interview her about her condition.
Summarize the information provided.
Give the most likely diagnosis and the reasons for it.

Scenario:
This 64-year-old retired cleaner complains of headache for the past 2 days.

Task list
Interview the patient
Summarize the history
Name 3 differential diagnoses
Name the most likely diagnosis and give reasons for it.

Recommended Reading
: Ch 11-The Nervous system, Section on
Symptoms and Definitions, and The History
Clinical Examination Talley, -The Nervous System>
section on the neurological history
Clinical Methods -Ch 11-The Nervous system, Section on
Introduction, The Neurological History

Refer to Plenary on Interview of Patient

Additional Reading:

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A Brain Wider Than the Sky (Simon & Schuster; 289 pages), which is a memoir of Andrew
fferer.

WEEK 2-EXAMINATION OF SENSORY NERVOUS SYSTEM, GCS AND

MENTAL STATE
Learning outcomes
To be able to:
Perform examination of GCS
Perform mental testing-MMTS and AMTS
Perform a sensory examination including knowledge of dermatomes and
peripheral nerves.
Assess diabetic peripheral neuropathy

Examination of GCS with clinical scenarios

Mental testing-MMSE, AMTS
Examination of sensory system- including revision of the dermatomes and
peripheral neuropathy.

OUTLINE FOR GUIDANCE

(Study and prepare as to how to perform the following physical examination
before attending the CSSC session

I)Sensory modalities:

a)Peripheral sensations
1. Touch
2. Pain
3. Temperature
4. Vibration
5. Proprioception

Sensory testing for peripheral sensations:

Explanation using reference point (forehead/sternum) with patient eyes open
Tes eyes closed.
Perform starting on the normal side and compare both sides

b)Cortical sensations
1. Stereognosis-(Form)
2. Graphesthesia-(Figure)
3. Two point discrimination
4. Sensory inattention

II) Rombergs Test for sensory ataxia-refer to the lecture notes (plenary)

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III) Patterns of sensory loss

IV) GCS at 40-watch the video on the E-portal on GCS40 and

study the GCS chart in the E-portal

V) Testing mental functions:

Abbreviated Mental Test Score (AMTS)
Mental State Examination (MSE)- using Mini-Mental State Examination (MMSE)-
(refer plenary power point slide)

Scenarios
Clinical Scenarios for GCS:
1. Scenario: An 18-year-old man has just had a motor bike accident. His vitals
are stable and though he is restless, he is not talking. There seems to be no
other external injury to the patient.
Task: Please assess his GCS.
2. Scenario: A 60 year old man was found unconscious in his house by his
neighbours and brought him to the hospital.
Task : Please assess his GCS.

Clinical scenarios for Sensory system:

1. Scenario: A 55-year-old diabetic man has come to you with tingling and
numbness in the feet. The patient is on irregular medication
Task:

2 Scenario: A 55- year-man complains of pain in the neck associated with

numbness on the outer side of the right arm and hand.
Task: E s upper limbs
Recommended Reading
-The Nervous system>
section on Examination of the Sensory system >
section on Examination Sequence>
a)The sensory modalities and b)Examination of peripheral nerves
c)Assessment of conscious level
-Ch 10-The Nervous System>
Upper and Lower Limbs >
a)section on The Sensory System
b)The Unconscious Patient> Coma Scale

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 -Ch 11-The Nervous system>
section on The Sensory System

Watch Video at IMU E-learning portal -Examination of motor and sensory system by Dr.
Susmita -watch the section on the sensory examination
Watch Youtube-GCS at 40

WEEK 3 -EXAMINATION OF THE MOTOR SYSTEM AND

CEREBELLUM
Learning Outcomes
To be able to :
Perform examination of motor function including myotomes
Perform examination of cerebellar function.
Activities
Small Group sessions
Examination of the lower limbs
Examination of the upper limbs
(students pair up to perform on each other)
Examination of cerebellum

OUTLINE FOR GUIDANCE

Examination Technique:
Compare both sides starting with the normal side.

Steps in the examination:

Inspection
Palpation
Tone
Power
Reflexes-superficial and deep, and plantar
Clonus

Examination of Cerebellum

Testing central part of cerebellum:

Nystagmus
Speech
Truncal ataxia
Standing swaying, imbalance

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 Ataxic gait and Tandem gait

Testing hemispheres of cerebellum:

Tone
Finger to nose test
Heel to shin test
Dysdiadochokinesia

Clinical Scenarios

Scenario 1
A 33 year old man was stabbed in his right inguinal region with a knife. He
underwent surgery to repair the injury around 1 month back. At present he
complains of pain in the inguinal region and paraesthesia over the anterior thigh
and anteromedial leg. Patient also complains of difficulty in walking since 1

Task: Examine the lower limbs

Scenario 2
A 65 year old widower complains of sudden weakness of the right side of his
body with difficulty in walking. He also has a difficulty in speaking for about 10
days. He is hypertensive on irregular medications.

Task: Examine the patient

Recommended Reading
Clinical Examination Macle -The Nervous system>
Section on Examination of the Motor system>
a)section on Examination Sequence- motor modalities,
b)section on Examination of peripheral nerves
c)section on Coordination, (study examination sequence)
Clinical Examination Talley, -The Nervous System>
a)section on the Limbs and Trunk, Motor system
b)section on examination of the peripheral nerves of the upper and lower
limbs
c)table on Upper and Lower Motor Neurone Lesions
d)section on the cerebellum
-Ch 11-The Nervous system,

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 section on The Motor System, and Coordination of Movement

Watch IMU E-learning portal Video on Examination of motor and sensory system by Dr.
Susmita-watch the section on the motor examination
WEEK 4- EXAMINATION OF THE CRANIAL NERVES
Learning Outcomes:
To be able to:
1. Give clear instructions to patient
2. Test for smell
3. Competently test the eye for vision and accommodation
4. Test for colour vision using an Ishihara chart and explain its use
5. Competently test visual fields and describe the abnormalities expected in
common clinical situations.
6. Elicit & explain pupillary reflexes
7. Competently test eye movements
8. Test the integrity of trigeminal and facial nerves
9. Test the integrity of glossopharyngeql, vagus, accessory and hypoglossal nerve.
10. Test for auditory function-using W forget
preliminary oroscope examination)
11. Describe the abnormalities expected in common clinical disorders involving the
cranial nerves.
Activities
Examination of cranial nerves ( Cranial Nerves I- XII)
-student to role play and preform examination on each other.

Recommended Reading
Clinical Examination Macleo -The Nervous system>
section on examination of the cranial nerves,
Clinical Examination Talley, -The Nervous System>
section on the Cranial Nerves
(EXCLUDE the latter part on multiple cranial nerves lesions, the part on The

syndrome)
-
Ch 11-The Nervous system,
- section on The Cranial Nerves
Ch 12-The Eye- visual acuity, colour sense, visual fields (omit from section the
Eyelids until the fundus)
Ch 13-The Ear, Nose and Throat-Examination of the Ear concentrate on
assessment of hearing-
assessment of the vestibular function and beyond)
section on examination of throat and mouth for Cranial nerves IX, X & XII

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 Watch Video at IMU E-learning portal -Examination of cranial nerves by Dr. Susmita
Refer OUTLINE FOR GUIDANCE IN FOLLOWING TABLE (next page)

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WEEK 5-CASE PRESENTATION AND DISCUSSION AT CSSC OF
CASES CLERKED IN THE HOSPITAL (PAT)

Learning Outcomes
To be able to
Present orally a comprehensive history and physical examination findings of patients
with nervous system disorders clerked at HTJ, Seremban.
Discuss how th es.
Give a summary
Discuss as to how to come to differentials and provisional diagnosis and provide clinical
reasoning.

Activities
REMEMBER TO BRING TO CSSC YOUR NOTES ON THE CASES CLERKED AT
THE HOSPITAL POSTING FOR PRESENTAITON
Cases clerked at HTJ, Seremban.

Presentation, orally -on history and physical examination

Summary
Discussion on Differential Diagnoses
Discussion on the most likely diagnosis and reasons for it

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Practical Exercises and Scenarios

(A) History taking

Scenario: This 65-year-old man complains of hand tremors, getting progressively

worse for the past 6 months. He walks unsteadily for the past 3 months.

i)From the chief complaint list the possible conditions for it.
You may like to group the conditions according to the possible systems involved.
-the conditions within the nervous system and those outside the nervous system.
ii)) What questions would you ask to be able to differentiate the different types of
hand tremors and pathology?

iii)List the associated symptoms in the different conditions presenting with

Hand Tremors.
What are the associated.relevant symptoms to assist you in confirming
or excluding the various possible conditions/ diagnoses
iv)How

(B) Physical Examination

2)Scenario: This is a 26-year-old man who was involved in a fight .He was hit on the
mid left arm by a metal rod.
Work out what would happen if you have a fracture of the humerus in the part where
the radial nerve is going around the humerus and the radial nerve is cut.
Task: You are instructed to perform a motor examination on this patient.
List the steps in the performance of the physical examination in this patient.

Task: You are instructed to perform a sensory examination on this patient.

List the steps in the performance of the physical examination in this patient

3)Scenario: This 30 year-old man complains of inability to move both lower

limbs after he fell on his back from a ladder.

Task: Examine his lower limbs for motor functions

1) List the steps in the performance of the physical examination
Task: Examine his lower limbs for sensory functions
2) List the steps in the performance of the physical examination

Work out the expected findings for the above physical examination scenarios.

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Terminologies
Dysarthria hemiplegia coma paraesthesia
Dysphasia hemiparesis athethosis hypoaesthesia
Dysphonia paraplegia

Glossary

English Malay

Headache Sakit kepala

Seizure Sawan
Loss of sensation Tak rasa
Weak Lemah
Strong Kuat
Push Tolak
Pull Tarik
Walk Jalan
Faint Pengsan
Hear Dengar
Feel Rasa
Headache Sakit kepala
Terrible Pain Betul sakit.
-Exclamation
expression
Sad, depressed, upset Susah hati
Unconscious, not aware Tak sedar
Bit the tongue Gigit lidah Gigit lidah
Jerking, shaking Goncang-goncang
Two minutes Dua minute
Eyes closed Mata tutup
Friend was frightened Kawan takut

References:
1. :
2. Clinical Examiantion-
3. Oxford Handbook of Clinical examination and Practical Skills-section onThe
Nervous System
4. .
5. Kum

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