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NSI HANDBOOK OF CLINICAL EXAMINATION List of contributors: 1. Examination of higher mental functions Page numbers A (1-19) Dr Sarat Chandra, Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 2. Examination of 1st& XIIth cranial nerves Page numbers B (1-7) Dr Samarendra N Ghosh, Professor and Head, Department of Neurosurgery, Bangur Institute of Neurosciences, Kolkata 3. Examination of visual acuity and fields Page numbers C (1-8) Dr Daljit Singh, Professor, Department of Neurosurgery, G.B.Pant Hospital, New Delhi 4. Fundus examination Page numbers D (1-23) Dr Vikas Kanaujia, Additional Professor , Department of Ophthalmology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 5. Extraocular movement deficits Page numbers E (1-34) Dr Manas Panigrahi, Senior Consultant Neurosurgeon, KIMS, Hyderabad. Ex-Professor, Neurosurgery, NIMS, Hyderabad 6. Supranuclear control of eye movements Page numbers F (1-15) Dr Kumudini Sharma, Professor and Head, Department of Ophthalmology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 7. Examination of nystagmus Page numbers G (1-11) Dr Ashish Suri, Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi Dr Manjul Tripathi, Post Doctoral Fellow, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 8. Examination of Vth cranial nerve Page numbers H (1-12) Dr Awadhesh K Jaiswal, Additional Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr Guruprasad Bettaswamy, Post Doctoral Fellow, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr. Kuntal Kanti Das, Assistant Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr. Sanjay Behari, Professor and Head, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 9. Examination of VIIth cranial nerve Page numbers I (1-14) Dr Suresh Nair, Professor and Head, Department of Neurosurgery, The SreeChitraTirunal Institute for Medical Sciences & Technology, Thiruvananthapuram 10. Bedside hearing assessment Page numbers J (1-5) Dr Sunil K Gupta, Professor, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh Dr Saudaminilele, Senior Resident, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh 11. Examination of vestibular system Page numbers K (1-4) Dr Paritosh Pandey, Additional Professor, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangaluru Dr S Baruah, Senior Resident, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangaluru 12. Examination of IXth, Xth, XIth cranial nerves Page numbers L (1-17) Dr Altaf Ramzan, Professor and Head, Department of Neurosurgery, Sher-e-Kashmir Institute of Medical Sciences, Srinagar 13. Examination of Muscle tone and muscle wasting Page numbers M (1-4) Dr Rabi N Sahu, Additional Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr Arun Srivastava, Associate Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr Amit Keshri, Assistant Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr Kamlesh S. Bhaisora, Postdoctoral Fellow, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 14. Examination of muscle power Page numbers N (1-16) Dr. Sandip Chatterji, Honorary Professor, Department of Neurosurgery, Vivekanand Institute of Medical Sciences and Senior Consultant Neurosurgeon, Park Clinic, Kolkata Dr Anil Chandra, Professor, Department of Neurosurgery, King George Medical University, Lucknow 15. Examination of motor reflexes Page numbers O (1-11) Dr Chandrashekhar Deopujari, Professor and Head, Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai 16. Examination of abnormal movements Page numbers P (1-4) Dr V G Ramesh, Professor and Head, Department of Neurosurgery, Chettinad Hospital & Research Institute, Chennai, Ex- Professor of Neurosurgery, Institute of Neurology,Madras Medical College, Chennai 17. Examination of gait and stance Page numbers Q (1-8) Dr Manmohan Singh, Additional Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi Dr N Damodaran, Senior Resident, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 18. Examination of motor system in brachial plexus injuries Page numbers R (1-9) Dr Dhananjay Bhatt, Additional Professor, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangaluru 19. Examination of Sensory System Page numbers S (1-16) Dr B K Ojha, Professor and Head, Department of Neurosurgery, King George Medical University, Lucknow 20. Examination of cerebellar system Page numbers T (1-14) Dr Manoj K Tewari, Professor, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh 21. Examination of release reflexes and lobar signs Page numbers U (1-10) Dr Vedantam Rajshekhar, Professor and Head, Department of Neurosurgery, Christian Medical College, Vellore Dr Ranjith K Moorthy, Professor, Department of Neurosurgery, Christian Medical College, Vellore 22. Evaluation of a patient in altered sensorium Page numbers V (1-9) Dr RC Mishra, Senior Consultant Neurosurgeon, Rainbow Hospital, Agra and former Professor and Head, SN Medical College, Agra Dr Anant Mehrotra, Assistant Professor, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow Dr Jayesh Sardhara, Postdoctoral Fellow, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow EXAMINATION OF HIGHER MENTAL FUNCTIONS Dr. P. Sarat Chandra, Dr. Manjari Tripathi “This chapter is dedicated to all neurosurgery residents, for most of whom, examination of higher mental functions is limited to just saying that the “patient is conscious, alert and oriented.” “Also to all Neurology residents, who may know more but still fall short of practicing this important component of Neurology.” Definition: The examination of higher mental status involves a structured assessment of the patient's behavioral and cognitive functioning. It provides an objective insight to the examiner on the patient’s level of cognitive functioning, his/her ability to interact with environment and adjust to the existing social structures. It is not a single function, but a constellation of multiple capabilities localized to various parts of the brain. Some functions have a definite localization while other functions cannot be localized to any single area of the brain and occur as a result of interaction of multiple neuronal circuits. Historical Background: Historically, there has been a paradigm shift in our understanding of localization of various cognitive functions. In the medieval times, people could not fully grasp the importance of the brain. Ancient Egyptians thought that the cranium contained “lymph”. They removed it prior to mummification from a hole made through the nose. Even though ancient Greek scholars understood the basic functions of the brain, it was only in the 19th century, when Paul Broca discovered the “expressive language” area that the scientists began to understand how higher mental functions such as language could be localized in the brain. Paul Broca, Carl Wernicke, and Hughlings Jackson developed different models of brain function, and each contributed important insights to the study of aphasia. Broca's contributions were influenced by the fundamental question of whether higher mental function could be localized in the brain at all; Wernicke's contributions were influenced by an attempt to unite more mechanistic and physiological principles to a model of higher brain functions; and Jackson's contributions were influenced by British association psychology. Norman Geschwind (1926-84) made an important contribution towards understanding of dyslexias, the neuroanatomy of cerebral lateral asymmetries, and other areas of neurological dysfunction. He is especially known to have provided an anatomical insight towards disconnection syndromes. Scope Of The Chapter And Importance Of Clinical Examination Of Higher Mental Functions: The current scope of the chapter is to provide “practical guidelines” for clinical examination at bed-side for residents using simple yet objective methods. While examination of higher mental functions (HMF) currently is the field of clinical psychologists, it is still important for the residents to be aware of this aspect of examination for the reasons given below 1. HMF, pre-operatively, prior to cranial surgery provides baseline information for the cognitive status. While the clinical psychologists provide a very extensive examination, an examination by the operating surgeon will provide him/her an idea of the patient’s cognitive status before and after the surgery 2. HMF examination provides an idea to the examiner for the areas of the cognition that need re-training. For e.g, in a patient with aphasia, post operative speech therapy would be more useful. 3. Most of the formal examinations e.g aphasia batteries are quite extensive. Hence a brief clinical examination is many times more useful providing the examiner a better idea
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