SECHENOV MOSCOW MEDICAL ACADEMY

_______________

MEDICAL FACULTY

Division for Foreign Students with Instruction Conducted in English

Department of Neurology

NEUROLOGICAL STATUS

NAME

Medical Faculty, English Medium, Group

Scientific Supervisor (Tutor):

MOSCOW – 2009/10
PATIENT BIODATA

NAME :

GENDER :

DATE OF BIRTH :

AGE :

OCCUPATION :

WARD :

COMPLAINTS

 On


ANAMNESIS MORBI


ANAMNESIS VITAE

PATIENT’S CONDITION

 General condition :
 Nutrition :
 Skin :
 Build :

NEUROLOGICAL STATUS
A) Higher cortical function
 B) Meningeal signs

 Rigidity of neck muscles :

 Kernigs’s symptom :
 Brudzinski’s symptom :

C) Cranial nerves examination

I) Olfactory Nerve

Observation:

II) Optic Nerve

Observation: -

III) Oculomotor Nerve

Observation: - ]

IV) Trochlear nerve

Observation: -

V) Trigeminal nerve

Observation: - a) Motor function

b) Sensory function
VI) Abducens nerve

Observation: -

VII) Facial nerve

Observation: a) Motor part

b) Parasympathetic part
-
c) Sympathetic Part
-

VII) Vestibulocochlear nerve

Observation: -

IX) Glossopharyngeal nerve & X) Vagus nerve

Observation: -

XI) Accessory nerve

Observation: -

XII) Hypoglossal nerve

Observation: -

D) Oral automatism

MOTOR SYSTEM

Reflex of tendons

UPPER EXTREMITIES LOWER EXTREMITIES

Right Left Right Left
Triceps reflex

Biceps reflex

Carpo-radial

Knee jerk reflex

Achille’s tendon

Tone of muscles

RIGHT LEFT
Extensor Flexor Extensor Flexor
Upper Proximal
extremities
Distal

Lower Proximal
extremities
Distal

Strength of muscles

RIGHT LEFT
Extensor Flexor Extensor Flexor
Upper Proximal
extremities Distal
Lower Proximal
extremities Distal

Pathological reflex

 Babinski’s test :
 Rossolimo’s test :
 Hoffman’s test :

COORDINATION SYSTEM
  Romberg’s test ;
 Finger to nose test ;
 Knee to shin test ;
 Intention tremor :
 Dysmetria
 Dysdiachokinesia ;
 Steward Homes :
 Gait :
SENSORY SYSTEM

I. Superficial sensory system:

- pain and temperature sensation is normal

-Upper limbs-

RIGHT LEFT
Distal Proximal Distal Proximal
Pin-prick test
Light touch
test
Temperature
test

-Lower limbs-

RIGHT LEFT
Distal Proximal Distal Proximal
Pin-prick test
Light touch
test
Temperature
test
II. Deep sensation – normal

 Muscle-tendon

HIGHER CORTICAL/COGNITIVE FUNCTION

SYNDROMAL DIAGNOSIS

1.

2.

TOPICAL DIAGNOSIS
1.

CLINICAL DIAGNOSIS