Tooltip
.tooltip {
position: relative;
cursor: pointer;
text-decoration: none;
border-bottom: 1px dashed rgba(0, 0, 0, 0.6);
}
.tooltip::before {
content: attr(data-tooltip);
position: absolute;
top: -40px; /* Trochę niżej nad słowem */
left: 50%; /* Wyśrodkowanie */
transform: translateX(-50%);
background-color: rgba(255, 255, 255, 0.9);
color: #333;
padding: 6px 12px;
border-radius: 8px;
white-space: nowrap;
opacity: 0;
visibility: hidden;
transition: opacity 0.3s ease, visibility 0.3s ease;
font-family: ‘Arial’, sans-serif;
font-size: 14px;
box-shadow: 0px 4px 8px rgba(0, 0, 0, 0.1);
z-index: 10;
}
.tooltip:hover::before {
opacity: 1;
visibility: visible;
}
document.addEventListener(‘DOMContentLoaded’, function () {
const wordsToTooltip = {
“General Inspection”: “Badanie ogólne”,
“Mental Status”: “Stan psychiczny”,
“Central nervous system”: “Ośrodkowy układ nerwowy”,
“Short-term memory”: “Pamięć krótkotrwała”,
“Long-term memory”: “Pamięć długotrwała”,
“Confusion”: “Splątanie”,
“Disorientation”: “Dezorientacja”,
“Cognitive skills”: “Zdolności poznawcze”,
“Posture”: “Postawa”,
“Gait”: “Chód”,
“Tremors”: “Drżenia”,
“Chorea”: “Pląsawica”,
“Athetosis”: “Atetoza”,
“Muscle atrophy”: “Zanik mięśni”,
“Asymmetry”: “Asymetria”,
“Muscle wasting”: “Utrata masy mięśniowej”,
“Contractures”: “Przykurcze”,
“Rigidity”: “Sztywność”,
“Degenerative disorder”: “Choroba zwyrodnieniowa”,
“Speech”: “Mowa”,
“Dysarthria”: “Dyzartria”,
“Aphasia”: “Afazja”,
“Dysphonia”: “Dysfonia”,
“Cerebrovascular event”: “Incydent naczyniowo-mózgowy”,
“Cranial Nerve Examination”: “Badanie nerwów czaszkowych”,
“Olfactory Nerve”: “Nerw węchowy”,
“Anosmia”: “Utrata węchu”,
“Frontal lobe lesion”: “Uszkodzenie płata czołowego”,
“Optic Nerve”: “Nerw wzrokowy”,
“Visual Acuity”: “Ostrość wzroku”,
“Snellen chart”: “Tablica Snellena”,
“Visual Fields”: “Pola widzenia”,
“Hemianopia”: “Niedowidzenie połowicze”,
“Quadrantanopia”: “Niedowidzenie kwadrantowe”,
“Fundoscopy”: “Badanie dna oka”,
“Papilledema”: “Obrzęk tarczy nerwu wzrokowego”,
“Intracranial pressure”: “Ciśnienie wewnątrzczaszkowe”,
“Optic atrophy”: “Zanik nerwu wzrokowego”,
“Retinopathies”: “Retinopatie”,
“Macula”: “Plamka żółta”,
“Oculomotor Nerve”: “Nerw okoruchowy”,
“Trochlear Nerve”: “Nerw bloczkowy”,
“Abducens Nerve”: “Nerw odwodzący”,
“Pupil Examination”: “Badanie źrenic”,
“Anisocoria”: “Anizokoria”,
“Eye Movements”: “Ruchy gałek ocznych”,
“Nystagmus”: “Oczopląs”,
“Diplopia”: “Podwójne widzenie”,
“Cerebellar dysfunction”: “Dysfunkcja móżdżku”,
“Trigeminal Nerve”: “Nerw trójdzielny”,
“Sensory Function”: “Funkcja czuciowa”,
“Ophthalmic”: “Gałąź oczna”,
“Maxillary”: “Gałąź szczękowa”,
“Mandibular”: “Gałąź żuchwowa”,
“Motor Function”: “Funkcja ruchowa”,
“Masseter”: “Mięsień żwacz”,
“Temporalis”: “Mięsień skroniowy”,
“Corneal reflex”: “Odruch rogówkowy”,
“Facial Nerve”: “Nerw twarzowy”,
“Bell’s palsy”: “Porażenie Bella”,
“Hyperacusis”: “Nadwrażliwość słuchowa”,
“Vestibulocochlear Nerve”: “Nerw przedsionkowo-ślimakowy”,
“Rinne test”: “Test Rinnego”,
“Weber test”: “Test Webera”,
“Sensorineural hearing loss”: “Niedosłuch odbiorczy”,
“Romberg test”: “Test Romberga”,
“Proprioceptive impairment”: “Zaburzenia propriocepcji”,
“Glossopharyngeal Nerve”: “Nerw językowo-gardłowy”,
“Vagus Nerve”: “Nerw błędny”,
“Palate Elevation”: “Uniesienie podniebienia”,
“Gag Reflex”: “Odruch gardłowy”,
“Accessory Nerve”: “Nerw dodatkowy”,
“Sternocleidomastoid”: “Mięsień mostkowo-obojczykowo-sutkowy”,
“Trapezius”: “Mięsień czworoboczny”,
“Hypoglossal Nerve”: “Nerw podjęzykowy”,
“Tongue Movements”: “Ruchy języka”,
“Fasciculations”: “Fascykulacje”,
“Motor System Examination”: “Badanie układu ruchowego”,
“Muscle Bulk”: “Masa mięśniowa”,
“Muscle Tone”: “Napięcie mięśniowe”,
“Spasticity”: “Spastyczność”,
“Upper motor neuron lesion”: “Uszkodzenie górnego neuronu ruchowego”,
“Lower motor neuron lesion”: “Uszkodzenie dolnego neuronu ruchowego”,
“Hypotonia”: “Obniżone napięcie mięśniowe”,
“Hypertonia”: “Wzmożone napięcie mięśniowe”,
“Muscle Strength”: “Siła mięśniowa”,
“Resting tremors”: “Drżenia spoczynkowe”,
“Postural tremors”: “Drżenia posturalne”,
“Intention tremors”: “Drżenia zamiarowe”,
“Dystonia”: “Dystonia”,
“Myoclonus”: “Mioklonie”,
“Reflexes”: “Odruchy”,
“Deep Tendon Reflexes (DTRs)”: “Głębokie odruchy ścięgniste”,
“Biceps Reflex”: “Odruch z mięśnia dwugłowego”,
“Triceps Reflex”: “Odruch z mięśnia trójgłowego”,
“Brachioradialis Reflex”: “Odruch promieniowy”,
“Patellar Reflex”: “Odruch kolanowy”,
“Achilles Reflex”: “Odruch Achillesa”,
“Superficial Reflexes”: “Odruchy powierzchowne”,
“Plantar Reflex”: “Odruch podeszwowy”,
“Babinski sign”: “Objaw Babińskiego”,
“Abdominal Reflex”: “Odruch brzuszny”,
“Sensory System Examination”: “Badanie układu czuciowego”,
“Light Touch”: “Dotyk powierzchowny”,
“Pain”: “Ból”,
“Temperature”: “Czucie temperatury”,
“Vibration Sense”: “Czucie wibracji”,
“Tuning fork”: “Kamerton”,
“Proprioception”: “Propriocepcja”,
“Posterior column lesions”: “Uszkodzenia sznurów tylnych”,
“Tabes dorsalis”: “Wiąd rdzenia”,
“Sensory ataxia”: “Ataksja czuciowa”,
“Coordination and Cerebellar Function”: “Koordynacja i funkcje móżdżkowe”,
“Finger-to-Nose Test”: “Próba palec-nos”,
“Dysmetria”: “Dysmetria”,
“Ataxia”: “Ataksja”,
“Heel-to-Shin Test”: “Próba pięta-kolano”,
“Smoothness of movement”: “Płynność ruchów”,
“Rapid Alternating Movements”: “Ruchy naprzemienne szybkie”,
“Dysdiadochokinesia”: “Dysdiadochokineza”,
“Gait and Balance”: “Chód i równowaga”,
“Normal Gait”: “Prawidłowy chód”,
“Shuffling gait”: “Chód szurający”,
“Wide-based gait”: “Chód na szerokiej podstawie”,
“Parkinsonism”: “Parkinsonizm”,
“Hemiparesis”: “Niedowład połowiczy”,
“Tandem Gait”: “Chód tandemowy”,
“Romberg Test”: “Próba Romberga”,
“Meningeal Signs”: “Objawy oponowe”,
“Nuchal Rigidity”: “Sztywność karku”,
“Meningitis”: “Zapalenie opon mózgowo-rdzeniowych”,
“Subarachnoid hemorrhage”: “Krwotok podpajęczynówkowy”,
“Brudzinski’s Sign”: “Objaw Brudzińskiego”,
“Kernig’s Sign”: “Objaw Kerniga”,
“peripheral vision”: “widzenie obwodowe”,
“retina”: “siatkówka”,
“optic disc”: “tarcza nerwu wzrokowego”,
“Oculomotor”: “Okoruchowy”,
“Trochlear”: “Bloczkowy”,
“Abducens”: “Odwodzący”,
“cornea”: “rogówka”,
“cotton wisp”: “wacik bawełniany”,
“conductive”: “przewodzeniowy”,
“Glossopharyngeal”: “Językowo-gardłowy”,
“Vagus”: “Błędny”,
“uvula”: “języczek”,
“soft palate”: “podniebienie miękkie”,
“posterior pharynx”: “tylna ściana gardła”,
“tongue depressor”: “szpatułka językowa”,
“atrophy”: “zanik”,
“hypertrophy”: “przerost”,
“tendon”: “ścięgno”,
“antecubital fossa”: “dół łokciowy”,
“contraction”: “skurcz”,
“extension”: “prostowanie”,
“brachioradialis”: “mięsień ramienno-promieniowy”,
“patellar tendon”: “ścięgno rzepki”,
“flexion”: “zginanie”,
“supination”: “supinacja”,
“dorsiflexed”: “zgięcie grzbietowe”,
“plantar flexion”: “zgięcie podeszwowe”,
“umbilicus”: “pępek”,
“abdominal muscles”: “mięśnie brzucha”,
“pinprick”: “ukłucie szpilką”,
“diminished”: “osłabiony”,
“absent”: “brak”,
“heightened”: “wzmożony”,
“medial malleolus”: “kostka przyśrodkowa”,
“peripheral neuropathy”: “neuropatia obwodowa”,
“diabetic patients”: “pacjenci z cukrzycą”,
“swaying”: “kołysanie”,
“vestibular dysfunction”: “dysfunkcja przedsionkowa”,
“meningeal irritation”: “podrażnienie opon mózgowo-rdzeniowych”
};
// Normalize keys in the dictionary
const normalizedWordsToTooltip = {};
for (const [key, value] of Object.entries(wordsToTooltip)) {
const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses
normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value;
}
function processNode(node) {
if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) {
let content = node.nodeValue;
// Regex to match only the main words (ignores parentheses)
const regex = new RegExp(
`\b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})\b`,
‘gi’
);
if (regex.test(content)) {
const wrapper = document.createElement(‘span’);
wrapper.innerHTML = content.replace(regex, (match) => {
const tooltip = normalizedWordsToTooltip[match.toLowerCase().trim()];
return `
${match}`;
});
node.replaceWith(wrapper);
}
} else if (node.nodeType === Node.ELEMENT_NODE) {
Array.from(node.childNodes).forEach(processNode);
}
}
document.querySelectorAll(‘body *:not(script):not(style)’).forEach((element) => {
Array.from(element.childNodes).forEach(processNode);
});
});
Szacowany czas lekcji:
5 minut
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background-color: #f0f4f8; /* Szarawe tło dopasowane do reszty strony */
padding: 8px 15px; /* Wewnętrzny odstęp */
border-radius: 8px; /* Zaokrąglone rogi */
font-family: ‘Roboto’, Arial, sans-serif; /* Czcionka Roboto, jeśli dostępna */
font-size: 16px; /* Rozmiar tekstu */
color: #6c757d; /* Ciemny szary kolor tekstu */
display: inline-block; /* Wyświetlanie jako element blokowy */
margin-bottom: 20px; /* Odstęp na dole */
border: none; /* Bez obramowania */
}
.lesson-duration-label {
font-weight: 700; /* Pogrubienie dla etykiety */
color: #6c757d; /* Ciemny szary kolor dla etykiety */
margin-right: 5px; /* Odstęp od wartości */
}
.lesson-duration-value {
color: #6c757d; /* Ciemny szary kolor dla wartości */
font-weight: 700; /* Pogrubienie dla wartości */
}
Podświetlanie tekstu z notatkami
body {
margin: 0;
padding: 0;
font-family: Arial, sans-serif;
}
.highlight {
background-color: #cce7ff; /* Highlight color without notes */
position: relative;
display: inline;
}
.highlight.with-note {
background-color: #ffeb3b; /* Highlight color with notes */
}
.note-box {
position: absolute;
background-color: #f9f9f9;
color: #333;
font-size: 14px;
line-height: 1.6;
padding: 10px 15px;
border: 1px solid #ddd;
border-radius: 5px;
box-shadow: 0 2px 5px rgba(0, 0, 0, 0.2);
max-width: 250px;
z-index: 1000;
white-space: normal;
text-align: left;
display: none; /* Hidden by default */
}
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position: absolute;
top: -30px;
right: -30px;
display: flex;
gap: 10px;
z-index: 10;
opacity: 0;
pointer-events: none;
transition: opacity 0.3s;
}
.note-controls.visible {
opacity: 1;
pointer-events: all;
}
.note-controls span {
cursor: pointer;
background-color: gray;
color: white;
padding: 5px 10px;
border-radius: 5px;
font-size: 16px;
font-weight: bold;
}
.note-controls span:hover {
background-color: darkgray;
}
document.addEventListener(“DOMContentLoaded”, () => {
/**
* Checks if an element is a header.
*/
const isHeaderElement = (node) => {
while (node) {
if (node.nodeType === 1 && node.tagName.match(/^H[1-5]$/)) {
return true;
}
node = node.parentNode;
}
return false;
};
/**
* Checks if an element is inside a table cell.
*/
const isInsideTable = (node) => {
while (node) {
if (node.tagName === “TD” || node.tagName === “TH”) {
return node;
}
node = node.parentNode;
}
return null;
};
/**
* Checks if an element belongs to the same list item.
*/
const isWithinSameListItem = (selection) => {
if (selection.rangeCount === 0) return false;
const range = selection.getRangeAt(0);
const startContainer = range.startContainer;
const endContainer = range.endContainer;
const getClosestListItem = (node) => {
while (node) {
if (node.nodeType === 1 && node.tagName === “LI”) {
return node;
}
node = node.parentNode;
}
return null;
};
const startListItem = getClosestListItem(startContainer);
const endListItem = getClosestListItem(endContainer);
// Ensure selection is within the same list item
return startListItem === endListItem;
};
/**
* Validates the selection.
* Ensures the selection is within a single header, table cell, or list item.
*/
const isSelectionValid = (selection) => {
if (selection.rangeCount === 0) return false;
const range = selection.getRangeAt(0);
const startContainer = range.startContainer;
const endContainer = range.endContainer;
const startInHeader = isHeaderElement(startContainer);
const endInHeader = isHeaderElement(endContainer);
// Block selection spanning headers
if (startInHeader !== endInHeader) {
return false;
}
const startCell = isInsideTable(startContainer);
const endCell = isInsideTable(endContainer);
// Block selection spanning table cells
if (startCell && endCell && startCell !== endCell) {
return false;
}
// Block selection spanning multiple list items
if (!isWithinSameListItem(selection)) {
return false;
}
return true;
};
/**
* Highlights the selected text.
*/
const wrapTextWithHighlight = (range) => {
const fragment = range.extractContents();
const highlight = document.createElement(“span”);
highlight.className = “highlight”;
highlight.appendChild(fragment);
range.insertNode(highlight);
const noteControls = document.createElement(“div”);
noteControls.className = “note-controls visible”;
const editNote = document.createElement(“span”);
editNote.textContent = “✎”;
editNote.title = “Edit note”;
noteControls.appendChild(editNote);
const removeHighlight = document.createElement(“span”);
removeHighlight.textContent = “x”;
removeHighlight.title = “Remove highlight”;
noteControls.appendChild(removeHighlight);
highlight.style.position = “relative”;
highlight.appendChild(noteControls);
let noteBox = null;
const updateNotePosition = () => {
const rect = highlight.getBoundingClientRect();
if (noteBox) {
noteBox.style.top = `${rect.height}px`;
noteBox.style.left = `${rect.width / 2}px`;
}
};
const hideControlsAndNoteAfterDelay = () => {
setTimeout(() => {
noteControls.classList.remove(“visible”);
if (noteBox) noteBox.style.display = “none”;
}, 3000);
};
// Show controls for 3 seconds after highlighting
hideControlsAndNoteAfterDelay();
highlight.addEventListener(“click”, () => {
noteControls.classList.add(“visible”);
if (noteBox) noteBox.style.display = “block”;
hideControlsAndNoteAfterDelay();
});
editNote.addEventListener(“click”, () => {
const noteText = prompt(“Add or edit a note:”, noteBox?.textContent || “”);
if (noteText) {
if (!noteBox) {
noteBox = document.createElement(“div”);
noteBox.className = “note-box”;
highlight.appendChild(noteBox);
}
noteBox.textContent = noteText;
noteBox.style.display = “block”;
highlight.classList.add(“with-note”);
updateNotePosition();
hideControlsAndNoteAfterDelay();
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removeHighlight.addEventListener(“click”, () => {
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while (highlight.firstChild) {
parent.insertBefore(highlight.firstChild, highlight);
}
parent.removeChild(highlight);
if (noteBox) noteBox.remove();
});
};
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* Handles the mouseup event to validate and apply highlighting.
*/
document.body.addEventListener(“mouseup”, () => {
const selection = window.getSelection();
if (selection.rangeCount > 0 && selection.toString().trim()) {
if (!isSelectionValid(selection)) {
alert(“Zaznaczenie musi być w obrębie jednego akapitu, komórki tabeli lub punktu listy!”);
selection.removeAllRanges();
return;
}
const range = selection.getRangeAt(0);
wrapTextWithHighlight(range);
selection.removeAllRanges();
}
});
});
General Inspection
The examination begins with a general observation of the patient:
- Mental Status: Observe the patient’s level of consciousness, alertness, orientation, and overall mental status. Evaluate their ability to respond to questions appropriately, assessing memory, attention, and cognitive skills. Signs of confusion, disorientation, or changes in behavior may suggest dysfunction in the central nervous system. Test the patient’s short-term and long-term memory by asking questions such as recalling objects after a delay and remembering significant historical events.
- Appearance and Posture: Assess the patient’s posture, gait, and general body movements. Involuntary movements such as tremors, chorea, or athetosis should be noted, as they can indicate specific neurological disorders. Muscle atrophy, asymmetry, and abnormal positioning should also be documented. Look for signs of muscle wasting, contractures, or rigidity, which could suggest chronic neurological involvement or a degenerative disorder.
- Speech: Assess the patient’s ability to articulate and comprehend language. Note the rate, rhythm, and fluency of speech. Dysarthria (slurred speech), aphasia (difficulty in language comprehension or production), or dysphonia (voice impairment) are indicative of possible neurological involvement. Perform naming, repetition, and comprehension tasks to further assess speech and language function, particularly in cases where a cerebrovascular event is suspected.
Cranial Nerve Examination
Cranial Nerve I: Olfactory Nerve
- Sense of Smell: Test each nostril separately by having the patient identify familiar scents, such as coffee or vanilla. Loss of smell (anosmia) may indicate pathology affecting the olfactory nerve or tract, such as a head injury, tumor, or frontal lobe lesion. Assess whether the loss is unilateral or bilateral, as this may help localize the lesion.
Cranial Nerve II: Optic Nerve
- Visual Acuity: Assess visual acuity using a Snellen chart for each eye. Use corrective lenses if the patient normally wears them to get an accurate representation of their vision.
- Visual Fields: Test visual fields by confrontation to identify any visual field defects, such as hemianopia or quadrantanopia. Compare the patient’s peripheral vision to your own, noting any deficits.
- Fundoscopy: Inspect the retina, optic disc, and vessels for abnormalities such as papilledema, which may indicate raised intracranial pressure, optic atrophy, or retinopathies. Evaluate the macula and note any hemorrhages or exudates.
Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves
- Pupil Examination: Inspect pupil size, shape, and symmetry. Test direct and consensual light reflexes, and accommodation to assess oculomotor nerve function. Note any abnormalities such as anisocoria (unequal pupil sizes), which could indicate cranial nerve damage or autonomic dysfunction.
- Eye Movements: Ask the patient to follow a target through the six cardinal points of gaze to evaluate for nystagmus, diplopia, or restricted eye movement. Assess whether the eyes move smoothly or if there are jerky movements, which may indicate cerebellar dysfunction.
Cranial Nerve V: Trigeminal Nerve
- Sensory Function: Test sensation across the three branches (ophthalmic, maxillary, and mandibular) using a light touch, pinprick, and temperature discrimination. Compare sensations on both sides of the face, and note any differences.
- Motor Function: Ask the patient to clench their teeth while palpating the masseter and temporalis muscles for strength. Test the corneal reflex by gently touching the cornea with a cotton wisp—observe for bilateral blinking. Absence of the corneal reflex may indicate a lesion affecting the trigeminal or facial nerve.
Cranial Nerve VII: Facial Nerve
- Motor Function: Ask the patient to raise their eyebrows, close their eyes tightly, smile, frown, and puff out their cheeks. Assess for asymmetry or weakness, which may indicate Bell’s palsy (a lower motor neuron lesion) or a central lesion (such as a stroke). Look for hyperacusis or changes in taste, which may also suggest facial nerve involvement.
Cranial Nerve VIII: Vestibulocochlear Nerve
- Hearing: Test each ear separately using a whisper test, a ticking watch, or a tuning fork. Perform the Rinne and Weber tests with a tuning fork to distinguish between conductive and sensorineural hearing loss.
- Balance: Assess balance using the Romberg test, in which the patient stands with feet together and eyes closed. Note any instability or swaying, which could suggest vestibular dysfunction or proprioceptive impairment.
Cranial Nerves IX and X: Glossopharyngeal and Vagus Nerves
- Palate Elevation: Ask the patient to say “ah” while inspecting the uvula and soft palate for symmetry during elevation. Deviation of the uvula may indicate a lesion affecting the vagus nerve.
- Gag Reflex: Test the gag reflex by gently stimulating the posterior pharynx with a tongue depressor. Absence may suggest cranial nerve dysfunction, particularly of the glossopharyngeal or vagus nerves.
Cranial Nerve XI: Accessory Nerve
- Shoulder Shrug and Head Turn: Ask the patient to shrug their shoulders against resistance and turn their head to each side against resistance. Assess for any weakness or asymmetry in the sternocleidomastoid and trapezius muscles, which may indicate accessory nerve damage.
Cranial Nerve XII: Hypoglossal Nerve
- Tongue Movements: Ask the patient to protrude their tongue and move it side to side. Look for atrophy, fasciculations, or deviation of the tongue, which may indicate a lower motor neuron lesion. Deviation of the tongue towards one side suggests a hypoglossal nerve lesion on that side.
Motor System Examination
Muscle Bulk, Tone, and Strength
- Muscle Bulk: Inspect the muscle groups for any signs of atrophy or hypertrophy, noting symmetry. Muscle wasting may indicate lower motor neuron involvement or disuse atrophy.
- Muscle Tone: Assess tone by passively moving the limbs through their range of motion. Look for hypertonia (spasticity or rigidity) or hypotonia, which could suggest upper or lower motor neuron lesions. Differentiate between spasticity, which is velocity-dependent and suggests an upper motor neuron lesion, and rigidity, which is seen in extrapyramidal conditions such as Parkinson’s disease.
- Muscle Strength: Test muscle strength bilaterally against resistance in key muscle groups, grading strength on a scale from 0 to 5, where 5 represents full strength and 0 indicates no contraction. Document any asymmetry or focal weakness, and assess whether proximal or distal muscles are more affected, as this can help localize the lesion.
Involuntary Movements
- Tremors: Observe for resting tremors (e.g., Parkinson’s disease), postural tremors (e.g., essential tremor), or intention tremors (e.g., cerebellar lesions). Note the frequency, amplitude, and conditions under which the tremor occurs.
- Chorea and Dystonia: Note any jerky, unpredictable movements (chorea) or abnormal, sustained postures (dystonia). Look for other movement abnormalities, such as myoclonus or athetosis, which may indicate specific neurological conditions.
Reflexes
Deep Tendon Reflexes (DTRs)
- Biceps Reflex (C5-C6): Strike the biceps tendon in the antecubital fossa while the patient’s arm is partially flexed. Observe for a contraction of the biceps muscle, which indicates an intact reflex arc.
- Triceps Reflex (C7-C8): Strike the triceps tendon above the elbow while supporting the patient’s arm. Look for extension of the forearm. Compare reflexes bilaterally for symmetry.
- Brachioradialis Reflex (C5-C6): Strike the brachioradialis tendon near the wrist while the forearm is in a neutral position. Observe for flexion and supination of the forearm.
- Patellar Reflex (L2-L4): Strike the patellar tendon while the patient’s leg hangs freely. Observe for contraction of the quadriceps and extension of the leg.
- Achilles Reflex (S1-S2): Strike the Achilles tendon while the foot is dorsiflexed. Observe for plantar flexion of the foot. Compare responses on both sides for consistency.
Superficial Reflexes
- Plantar Reflex: Stroke the lateral aspect of the sole from heel to ball, curving medially. The normal response is flexion of the toes. A positive Babinski sign (extension of the big toe) indicates an upper motor neuron lesion.
- Abdominal Reflex: Lightly stroke the abdominal skin near the umbilicus, and observe for contraction of the abdominal muscles. Absence of this reflex may indicate a central or peripheral nervous system disorder.
Sensory System Examination
Light Touch, Pain, and Temperature
- Light Touch: Test sensation using a cotton wisp across various dermatomes, comparing sides. Note whether sensation is diminished, absent, or heightened in specific areas, which could indicate sensory neuropathy or radiculopathy.
- Pain: Use a pinprick to test pain sensation across the dermatomes, noting areas of decreased or increased sensitivity. Compare both sides, as asymmetrical responses could indicate a localized lesion or nerve compression.
- Temperature: Use warm and cold objects to assess temperature sensation when pain sensation is abnormal. Loss of temperature sensation is often associated with peripheral neuropathy or spinal cord injury, especially in cases of syringomyelia.
Vibration and Position Sense
- Vibration Sense: Use a tuning fork to test vibration sensation over bony prominences, such as the great toe and the medial malleolus. Loss of vibration sense may indicate peripheral neuropathy, often seen in diabetic patients, or posterior column lesions in the spinal cord, as in tabes dorsalis.
- Proprioception: Test joint position sense by moving the patient’s fingers or toes up or down and asking them to identify the direction of movement. Impaired proprioception is often seen in patients with sensory ataxia due to posterior column lesions or peripheral neuropathy. In advanced cases, patients may have difficulty maintaining balance, especially when their eyes are closed (positive Romberg test).
Coordination and Cerebellar Function
Finger-to-Nose Test
Ask the patient to touch their nose and then your finger repeatedly, assessing for accuracy, intention tremor, or dysmetria. Dysmetria is a hallmark of cerebellar dysfunction. Observe for ataxia, which may manifest as an inability to smoothly complete the movement.
Heel-to-Shin Test
Ask the patient to place their heel on the opposite knee and run it down the shin to the ankle. Look for smoothness of movement, which assesses coordination and cerebellar function. A lack of smooth movement or significant deviation to either side is suggestive of cerebellar disease.
Rapid Alternating Movements
Ask the patient to rapidly pronate and supinate their hands on their thighs. Difficulty performing rapid movements may indicate cerebellar dysfunction or dysdiadochokinesia. Compare both sides for symmetry, as one side being significantly slower or more awkward can help localize a cerebellar lesion.
Gait and Balance
Normal Gait
Ask the patient to walk across the room, observing posture, arm swing, and stride length. Look for abnormalities, such as a shuffling gait (as seen in Parkinson’s disease) or a wide-based gait (indicative of ataxia). Note any asymmetries, difficulties initiating movement, or a lack of arm swing, which may indicate specific pathologies such as Parkinsonism or hemiparesis.
Tandem Gait
Ask the patient to walk heel-to-toe in a straight line. This tests balance and can help detect subtle ataxia. Difficulty maintaining balance during tandem gait may indicate a cerebellar or vestibular problem, or peripheral neuropathy.
Romberg Test
Have the patient stand with their feet together and eyes closed. Observe for swaying or loss of balance, which indicates impaired proprioception or vestibular dysfunction. A positive Romberg test, where the patient cannot maintain balance with their eyes closed, suggests sensory ataxia rather than cerebellar ataxia.
Meningeal Signs
Nuchal Rigidity
Gently flex the patient’s neck forward. Pain and resistance to flexion suggest meningeal irritation, as seen in meningitisor subarachnoid hemorrhage. Always ensure there is no spinal injury before performing this maneuver.
Brudzinski’s Sign
With the patient lying supine, gently flex their neck. A positive sign is involuntary flexion of the hips and knees, indicating meningeal irritation. This reflex is often tested in patients who are suspected of having meningitis.
Kernig’s Sign
With the patient supine, flex the hip and knee to 90 degrees, then attempt to straighten the leg. Pain and resistance to extension of the knee indicate meningeal irritation. A positive Kernig’s sign is consistent with findings in patients with meningitis or subarachnoid hemorrhage.