WRITING A CASE SUMMARY

Name Mr. X
Age
Sex
Occupation
Address

Presenting complaints in chronological order (do not use medical terms)

e.g.
 Fever 30 days
 Cough 15 days
 Vomiting 10 days
 Breathlessness 5 days
 Headache 1 day

History of the presenting complaints

1. Describe each symptom.
For each symptom determine the exact nature as follows
 Onset
The date it began.
How was the onset ? Sudden, gradual / over how long
What was the first symptom
What was he doing at that time
What happened next
If longstanding, why is the patient seeking help now?
 What is the progress, periodicity and frequency?
Is the symptom constant or intermittent?
How long does it last each time?
What is the exact manner in which it comes and goes?
 Change over time
Is it improving or deteriorating?
 Exacerbating factors
What makes the symptom worse?
 Relieving factors
What makes the symptom better?
  Associated symptoms.
Symptoms of other system involvement

For example – regarding fever determine the following

Onset
Whether present through out the day or intermittent .Diurnal variation, Chills and
rigor
Pattern of fall crises (accompanied by sweating) / lysis (step by step fall)
Associated symptoms – Seizure, loss of appetite, weight loss, palpitation, rash , joint
pain

2. Evolution of the disease

Depending on probable etiology ask positive and negative symptoms

3. Review/ enquiry of other system involvement

(Help to find symptoms that the patient had forgotten about or identifying
secondary, unrelated problems)

General symptoms
Weight change (loss or gain), change in appetite, fever, lethargy, malaise, lack of
sleep, change in bowel habits

Respiratory symptoms
Upper respiratory tract – Rhinitis ,nasal block, facial pain , hoarse voice , stridor
Lower respiratory tract - Cough , sputum, hemoptysis, breathlessness, wheeze,
chest pain,

Cardiovascular symptoms
Exertional breathlessness, paroxysmal nocturnal dyspnea, orthopnea, chest pain,
palpitation, cough and hemoptysis, fatigue, ankle swelling, syncope,claudication.

Gastrointestinal symptoms
Upper GI – Appetite,nausea ,vomiting, epigastric pain ,heart burn , dysphagia
hemetemesis ,flatulence
Lower GI - Abdominal pain and distension,constipation, diarrhea, hemetochezia
melena

Hepatobiliary
Jaundice,fatigue,anorexia ,nausea, dark urine, pruritis, pale stools, right
hypochondrial pain, anorexia, hemetemesis,melena , abdominal distention

Genito-urinary symptoms
Urinary frequency, polyuria, dysuria,oliguria, hematuria, nocturia, facial
puffiness,edema, menstrual problems, impotence, vaginal discharge , genital ulcers

Neurological symptoms
Headache , disorders of higher function ( altered consiousness ,seizure, speech
defect) ,cranial nerves, motor( paralysis, involuntry movement s) and sensory
system,bowel and bladder,cerebellum and extrapyramidal system
Locomotor symptoms
Muscle ache, pain, stiffness and swelling, joint pain and swelling, bone pain

Hematologic
Anemia symptoms like lethargy, lightheadedness, syncope, breathlessness. Bleeding,
fever, jaundice due to hemolysis , bone and joint pain
Endocrine
Lethargy, loss and gain in weight, short and tall stature, pigmentation, loss of hair,
hirsutism

Skin symptoms
Lumps, ulcers, rashes, itch, pigmentation, vitiligo, nail, hair

Past history
 DM, HT, CAD, TB, Asthma
 Similar complaints in the past
 Drug history
 Environmental factors

Family history
 Similar complaints, familial diseases
 Consanguinity
 Communicable diseases

Personal history
 Diet
 Work
 Sleep
 Hobby
 Travel
 Alcohol (spirits 30 ml = 1 unit , beer 1 pint= 440ml =2 units ( More than two
drinks (22–30 g) per day in women and three drinks (33–45 g) in men
increases the risk of alcoholic liver disease )
1 unit = 8 gms
Votka / rum – 37.5% of alcohol in 25 ml, wine 10% in 125 ml,
Beer 3.5%in 440ml. Continuous drinking x more than 5 yrs – liver disease
 Smoking in pack years = no of packets /day x smoking in years
More 40 pack yrs –risk of cancer
Smoking index =no of cigarettes per day x no of years. > 300 risk for
carcinoma
 Sexual history
  Females – menstruation
 Socioeconomic factors
 Drug history

General Examination
 Height, Weight
BMI = Wt in kg /( Ht in meter)2 WHO -Normal=18.5-25 , Obese = >30 .
Extreme obesity >40
 Broca’s index= Ht in cms – 100= desired body weight ( rough calculation)
SOS
Other measurements when necessary
 Arm span (distance between the tips of middle fingers of 2 hands with arms
outstretched horizontally outwards from the body. Marfan syndrome – arm
span more than height by 8cm )
 Upper(from vertex to upper border of symphysis pubis): lower segment(top
of symphysis pubis to sole of feet ) ratio= 0.8 ( in Marfan US:LS –less than
0.87)
 Head circumference – supraorbital ridge in front and occiput behind
 Low hair line – below C4 vertebra ( normal hair line stop at or above C4 )
 Short neck – height divided by neck length ( from occiput to C7) more than
13.6 is short neck
 Mid upper arm circumference (MUAC) – at midpoint between acromion and
olecranon on non-dominant arm in sitting or standing position . MUAC
between 23.5 cm and 25 cm the BMI is likely to be between 18.5-20
 Waist circumference (Central obesity = >94cms in men and >80 cms in
women )Waist is the midpoint between ribcage and iliac crest)
 Hip: waist ratio less than 0.8 = pear shaped obesity . more than 0.9 is apple
shaped obesity (Hip is the widest part around the buttocks) Increased risk
occurs when this exceeds 1.0 for men and 0.85 for women.
 Microcephaly is head circumference less than 52 cms in adults

* General appearance and behavior of the patient – cooperative /irritable

* Nutrition - Look for evidence of vitamin deficiency (if ill nourished)
* Pallor – Conjunctiva,tongue,hard palate and oral mucosa , nails
* Jaundice – Sclera ,tongue(under surface)palm,skin
* Cyanosis – Skin and mucous membrane ,finger tips ,lips
* Clubbing – Shamroth’s window test
* Lymphadenopathy –Site, size, number, consistency, mobility, matting, skin over
nodes,tenderness, area of drainage
* Edema - general /local
* Breast – Inspection and palpation
 * In males palpate when the patients hands are behind his head
* In females in sitting position and in lying with the flat of hand
* If breast is large – in semi decubitus position, arm raised and hand
behind her head
* If there is lump define with thumb and forefinger
* Thyroid swelling +/-
* Abnormalities of skin and hair

Vitals

 Pulse
Rate and Rhythm
Character and Volume
Peripheral pulsations (radial, brachial, carotid, femoral, poplitial, posterior
tibial, dorsalis pedes)
Condition of vessel wall
Radiofemoral delay
Pulse deficit (if there is AF)
 BP - mmHg in right upper limb in supine and/or standing position ( if AF–
average of 3 readings )
 Respiratory rate ,rhythm
 Temperature ( measure with thermometer)

Examination of GIT
Stigmata of chronic liver disease (if indicated)
Oral cavity – inspection and palpation

* Lip
* Teeth
* Gum
* Tongue
* Palate
* Mucous membrane
* Tonsil
* Pharynx
Abdomen
Inspection

* Shape / swelling / masses / dilated veins /striae

* Movement with respiration
* Umbilicus
 * Pulsation / peristalsis
* Groin – for hernia
Palpation

* Feel of the abdomen

* Tenderness
* Feel the underlying structures and describe
Movement with respiration, size, shape, surface, border,
consistency, tenderness, and pulsation
i. Liver
ii. Spleen
iii. Kidney
iv. Gall bladder
v. Urinary bladder
vi. Uterus
vii. Any other mass
* Hernial orifices

In special situations
* Bimanual palpation (kidney and hepatic pulsations)
* Dipping palpation (in gross ascitis)
* Murphy’s sign
* Macburny’s point
* Renal tenderness
Percussion

* Shifting dullness
* Fluid thrill
* Puddle sign (if suspect minimal fluid in abdomen)
* Percussion of borders of organs ( if palpable )
* Upper border of liver

Auscultation

* Bowel sound ( N 6-12/mt)

In Special situation
 Arterial bruit over aorta, renal and iliac artery, over liver in hepatoma
 Venous hum –if there is caput medusae
 Fetal heart sounds
 Rub - over liver and spleen
 Succussion splash (in pyloric obstruction)
Examine genitalia and anal canal – inspection and palpation

Examination of Respiratory system

Upper respiratory tract

* Nose
* Throat
* Paranasal sinuses
Neck

* Movement of accessory muscles

* JVP
* Position of trachea - Trails sign

Chest examination
Inspection (preferably in sitting position)

* Position of trachea
* Apex
* Shape of chest
* Wasting and flattening of chest
* Drooping of shoulder
* Movement with respiration
( Intercostal recession – drawing in of intercostal spaces with inspiration –
indicate severe upper airway obstruction )
* Spine and chest deformity
* Skin over chest wall / dilated veins /expansile swelling
Palpation

* Position of trachea and apex

* Movement
* Chest expansion – total and hemithorax
* Anteroposterior diameter and transverse diameter
* Vocal fremitus
* Local tenderness
Percussion

* All 8 areas
* Upper border of liver and cardiac dullness
* Tidal percussion (in special situation)
Auscultation (all 8 areas)
 Breath sounds
* Intensity( loudness)- normal, reduced or increased
* Quality - Vesicular or bronchial
If bronchial – Tubular, Amphoric, or Cavernous
*Added sounds- Crackles ( old term –crepitation) , wheeze( old term rhonchi) ,
Pleural rub
Vocal resonance
If vocal resonance is increased look for
* Bronchophony
* Aegophony
* Whispering pectoriloquy
In special situations
 Succussion splash and shifting dullness ( Hydropneumothorax)
 Coin sound ( Pneumothorax)
 Post tussive suction (Superficial empty cavity
communicating with bronchi)
 Crunching sounds (Surgical emphysema)
 Knocks ( Pneumothorax)

Examination of CVS
BP - check lower limb BP in AR, if there is radiofemoral delay and weak
peripheral pulse
Pulse - full description
JVP - pressure, waves ( hepatojugular reflux)
Epigastric and suprasternal pulsations
Shape of chest and spine
Peripheral signs in AR and infective endocarditis (if indicated)

Precordium examination
Inspection

Shape of precordium
Visible pulsations / Dilated veins / Scars
Apex – visible or not
Palpation

Apex beat – Position , character, thrill, sounds

(look for dextrocardia if apex is not seen on left )
Palpate other areas for sounds and thrills
Left parasternal heave
Pulsations in the 2nd and 3rd intercostal spaces
In special situation: Palpable pericardial rub
Percussion

Right and left borders of heart

Second space – right and left ( near borders of sternum )
Auscultation

* Apex
* Tricuspid area
* Pulmonary area
* Aortic area
* Second aortic area
For

i. Heart sounds – Loudness, character of S1, S2, S3 and /or S4

Opening snap
Clicks
ii. Murmur
* Timing
* Duration
* Quality – pitch
* Grading (1-6)
* Conduction
* Change with respiration, position and isometric exercise
In special situations
Arterial bruit
Venous hum
Pericardia rub

Examination of Nervous system

Look for the following neurocutaneous markers (if necessary)
* Neurofibromas – Soft papules or nodules that exibit the button hole sign ie
invaginate into skin with pressure
* Café-au-lait spots - Flat, uniformly light brown in color,0.5-12 cms.
significant when >6 nos , >than 1.5 cms
* Shagreen patch – Firm ,yellowish red or pink nodules , raised form skin with
the texture of orange peel. few mm – 10 cm .more in
lumbar region
* Ash leaf macule - Hypopigmented patches with a particular shape , 1-3
cm in size
 * Adenoma sebaceum – Multiple angiofibromas on face on central cheek
firm ,pink to flesh colored papules
3 mm to several cms in diameter. Also seen around nails
* Vascular malformations

Higher function
* Handedness
* Level of consciousness
* Appearance and behavior
* Intelligence
* Memory – recent and past
* Orientation in time and place
* Delusions and hallucination
* Calculation
* Language and speech – Writing,reading,comprehension ,repetition ,naming
content , fluency ,articulation and prosody
Cranial nerves

Cranial nerve Tests

1. Olfactory Smell

2. Optic * Visual acquity

* Visual field – confrontation technique
* Color vision
* Optic Fundus

3. Occulomotor * Ptosis and squint , palpebral fissure

4. Trochlear * Eye movement
6. Abduscent * Test diplopia
(Together ) * Nystagmus ( grade , direction, rate and amplitude )
* Pupil – position ,size, shape,symmetry ,margin
* Pupil reaction -light reflex-direct and consensual
and accomodation reflex

5.Trigeminal Sensory – touch, pain and temperature

Motor – muscles of mastication
i. Temporalis and masseter - clench jaw
ii. Medial and lateral pterygoid – open mouth and
side to side movement
Reflex - corneal , conjunctival and jaw jerk
7. Facial * Sensory – taste- anterior 2/3 rd
* Motor
Muscles of facial expression
* Orbicularis oculi
* Frontal belly of occipitofrontalis
* Buccinator
* Orbicularis oris
* Mentalis
* Platysma
Facial Reflexes
* Corneal and conjunctival
* Sucking
* Palmomental
* Glabellar tap
* Snout reflex

8. Auditory Whisper test , Rinne’s and Weber’s test ( 265Hz

tuning fork )

9.Glossopharyngeal Position of uvula and palatal arch

Palatal , pharyngeal reflex (Gag reflex)
Feel the touch

10.Vagus Movement of palate

Palate and pharyngeal reflex

11.Accessory Test sternomastoid and trapezious . look for wasting

12. Hypoglossal Movement of tongue – protrusion and lateral

movement
Wasting and fasciculation
Tone and power of tongue

Motor system
** Bulk – Right and left side , upper and lower limb
** Tone – Right and left side, upper and lower limb
( Supination and pronation at wrist
Flexion and extension at elbow and knee.
Ankle tone by rolling the relaxed leg side to side at knee – look for
normal loose floppiness at ankle )
** Power –
Upper limb
 Shoulder

Flexion Pectoralis major ( clavicular part) C5,6 lateral pectoral nerve

Extension Deltoid ( posterior fibers ) C5 6 ,axillary nerve

Adduction Pectoralis major ( sternocostal ) C5,6,7,8 pectoral nerve

Latissimus dorsi C6,7,8 thoracodorsal nerve
Teres major C6,7,8 subscapular nerve

Abduction Suprasinatus C5,6 suprascapular

Deltoid C5 6 ,axillary nerve

 Elbow

Flexion Biceps brachii brachioradialis C5,6 Musculocutaneus

C5.6 Radial

Extension Triceps C6,7 Radial

 Wrist ( adduction –ulnar flexion ; abduction radial flexion )

Flexion Flexor carpi radialis C6,7 median nerve

Flexor carpi ulnaris C7,8 T1 Ulnar nerve

Extension Extensor carpi ulnaris and C7,8 posterior interroceous

Extensor carpi radialis longus C5.6 radial nerve

 Fingers

Flexion Flexor digitorum superficialis and C7,8 ,T1 median and ulnar
profundus nerves

Extension Extensor digitorum communis C7.8 posterior interosseous

Abduction Dorsal interrosseous (DAB) Ulnar nerve

Adduction Palmar interrossei (PAD) Ulnar nerve

 Thumb- extension and opposition

Adduction Adductor pollicis brevis C8 T1 ulnar nerve

Abduction Abductor pollicis brevis C8T1 median nerve

Flexion (proximal Flexor pollicis brevis C8T1 median nerve

phalanx)

Extension Extensor pollicis longus and C7,8 Posterior

brevis interosseous

Opposition Opponen’s pollicis C8T1 median nerve

Lower limb
 Hip

Flexion Iliopsoas L1,2,3 Femoral nerve

Extension Gluteus maximus L5,S1,2 Inferior gluteal

nerve

Adduction Adductor longus,brevis L2,3,4 Obturator nerve

and magnus

Abduction Gluteus medius and L4,5 S1 Superior gluteal

minimus and tensor
fascia lata

 Knee

Flexion Hamstrings ( Bisceps femoris, L4,5,S1,2 Sciatic nerve

Semitendinosus
Semimembranosus )

Extension Quadriceps femoris (rectus femoris, L2,3,4 Femoral nerve

vastus lateralis, vastus medialis, and
vastus intermedius)

 Ankle and foot

Dorsiflexion Tibialis anterior L4,5 deep peroneal

Plantar flexion Gastronemius and soleus L5,S1.2 posterior

Tibial nerve
( extension of ankle)

Inversion foot Tibialis posterior L4,5 . Tibial nerve

Eversion foot Peroneus longus L5,S1 superficial

peroneal
and brevis

 Toes
Flexion Flexor digitorum longus L5,S1,Tibial nerve
Flexor hallucis longus ( big toe)

Extension Extensor digitorum longus and brevis L5,S1 Deep peroneal

nerve
Extensor hallucis longus ( big toe)

.
Trunk by lifting head and lower limb from bed.
Small muscles of foot – adduct and flex toes together ( cupping) .
Grading of power

0 – No movement
1 – Flicker of contraction but no movement
2 – Lateral movement only (cannot lift. Movement if gravity is eliminated)
3 – Against gravity (can lift but not against resistance)
4 – Against resistance but weaker than normal
5 – Normal power

** Reflexes
i. DTR - Jaw, biceps, supinator, triceps, knee, ankle
Grading of reflexes (except jaw jerk)

0. Absent
1. Present (as a normal ankle jerk or with reinforcement ) +
2. Brisk (as a normal knee jerk) ++
3. Very brisk +++
4. Clonus
ii. Superficial reflexes –abdominal,cremasteric ,anal,
bulbocavernous, plantar
iii. Primitive reflexes – Glabellar, sucking, snout ,grasp, , avoiding,
palmo-mental
** Coordination of movement – Finger nose and heel knee test
** Stance and Gait
** Involuntary movement

Sensory system
i. Superficial
* Tactile sensibility – Light touch (cotton or tip of finger) and pressure
* Pain – Superficial - with sharp pin
* Temperature - Hot (49-50 °C) and cold water (5-10°C)
(Alternate way – touch with metal object eg tuning fork –
at room temperature for cold , tuning fork dipped in hot
water - for hot sensation )
ii. Deep – Deep pain – squeeze calf muscle, biceps or achillis
tendon
iii. Posterior column
* Position sense of joint ( distal interphalangeal joint of great toe and fingers ) ,
Appreciation of passive movement ,Romberg’s test
 Proximal joint sense – at shoulder – Ask patient to bring the 2
index fingers together with arms extended and eyes closed.
Errors of 1 cm or less is neglected
* Vibration (by 128Hz) over bony points beginning distally over distal phalanx of
big toe and over medial malleolus ,in hands dorsally at distal phalanx of fingers
iv . Cortical
* Grasphasthesia
* Stereognosis
* 2-point localization and discrimination
(sensory inattention in case of parietal lobe lesion )

Signs of cerebellar dysfunction

* Titubation
* Nystagmus
* Speech – staccato /scanning speech
* Rebound phenomenon
* Dysdiadacokinesis
* Upper limb coordination – Finger nose test with eyes open and closed
Draw a large circle in air with finger
* Past pointing
* Pendular knee jerk
* Lower limb coordination – Heel knee test, Toe –finger test
Draw a large circle in air with toe
* Hypotonia
* Cerebellar ataxia – truncal and limb
* Wide based gait
* Tandem walking

Autonomic function – look for

 Pupillary response to light and accommodation

 Postural hypotension ( BP in lying position and standing position after 3
minutes .fall of 20 mm hg suggests autonomic failure )
 Resting tachycardia ( indicate autonomic dysfunction due to loss of
cardiovascular reflex)
 Heart rate response during quiet and deep breathing – if there is no sinus
arrhythmia it indicates vagus inactivity
 Handgrip test –( patient lying-ask him to grip a semi-inflated BP cuff as hard
as possible.with another apparatus measure measure DBP after 5 minutes .
normally there is increase in DBP more than 16 mm Hg . in autonomic
dysfunction the increase is less than 10 )
  Valsalva test – There is no slowing of pulse ( patient closes mouth and nose
and try to expire the maximum for 15 sec.)
 Skin –dry –suspect absence of sweating
 Look for trophic changes on distal skin eg absence of hair growth
Loss of cardiovascular reflexes causes the following
i. There is resting tachycardia
ii. Normal slowing of pulse during valsalva maneuver is lost
iii. Normal increase in BP during hand gripping is lost
iv. normal increase in BP during stressful task eg mental arithmetic is lost

Signs of meningeal irritation

 Neck rigidity
 Kernig’s sign
 Brudzinski’s leg sign and neck sign

Peripheral nerve thickening and tenderness

 Supratrochlear and suproorbital nerves on the forehead
 Posterior auricular nerve behind ear
 Great auricular nerve over sternomastoids
 Radial nerve in radial groove in arms
 Ulnar nerve behind the medial epicondyles at elbow
 Median nerve in the middle of the flexor aspect of wrist
 Lateral cutaneous nerve in the anatomical snuff box
 Common peroneal nerve lateral to the head of fibula .
 Sural nerve in the middle of posterior aspect of lower part of leg at ankle
 Superficial peroneal nerve in the lower third of lateral aspect of leg and
crossing in front of the ankle to the dorsum of feet

Skull and spine

Gibbus -localised angular deformity caused by collapsed vertebrae
(due to fracture, pott’s disease, or metastasis from lung, breast,thyroid, GIT,Testes,
prostate, kidney , lymphoma, and multiple myeloma )
Scoliosis – uneven shoulder, one shoulder blade more prominent than other ,
uneven waist,one hip higher than other,leaning to one side,back like S
or C , head tilt
Tenderness
Bruit over spine – AV malformations
Examination of Musculoskeletal system (only when necessary)
Gait
Extraarticular features like
* Skin – nodules , vasculitic lesions,LN, edema, rash
* Enlarged bursae
* Tendon sheath effusion
* Nails
* Eye
* Temporal arteries
Joints
Inspection

* Pattern of involvement – how many, symmetry

* Appearance –posture of affected part in resting position and deformities
* Signs of inflammation -
* Wasting of muscles
Palpation

* Warmth
* Nature of swelling – effusion, soft tissue or bony swelling
* Tenderness
Grading of joint tenderness

1 – Patient says that the joint is tender

2 – Winces
3 – Winces and withdraw the affected part
4 - Will not allow the joint to be touched
Movement

* Active – range, crepitus,stability

* Passive – range, crepitus and stability
Muscles –wasting,tenderness, power
Tendon crepitus
Examination of individual joint and spine

Cervical spine Kyphoscoliosis, lordosis , Gibbus

* Rotation .Flexion and extension
* Lateral bending

Thoracic and Thoracic spine rotation and chest

lumbar expansion
Lumbar spine
* Flexion and Extension
 * Lateral bending
* Shober test
* Straight leg test (SLR)
* Lasegue’s test

Sacroiliac joint Direct pressure over each joint

Firm pressure over sacrum
Inward pressure over iliac bones

Shoulder Flexion and extension

Abduction
Rotation in abduction and neutral
position
Elevation

Elbow Flexion and extension

Wrist Flexion and extension

Ulnar and radial deviation

Fingers Flexion at all joints

Thumb Extension and flexion

Opposition
Abduction

Hip Flexion and extension

Abduction and adduction
Rotation in flexion and extension

Knee Flexion and extension

Patellar tap

Ankle Dorsiflexion and Plantar flexion

Foot Inversion and eversion

Flexion and extension of toes

Summary of the case – include name, age, sex and occupation, brief statement of
problem and findings emphasizing important positive findings and relevant negative
ones
Final diagnosis
e.g
i. CVA – Right hemiplegia – thrombotic stroke probably due to
 atherosclerosis . Lesion in left internal capsule
ii. Type 2 DM
iii. Systemic hypertension
iv. Coronary artery disease

Examination of unconscious patient

(History

 Onset
Sudden onset – CVA
Rapid onset, preceded with abnormal behaviour and confusion suggests
metabolic disorder
Gradual onset – c/c subdural hematoma, tumor etc
 H/o trauma with concussion followed by a few days later by fluctuating
drowsiness – suggest subdural hematoma
 Concussion followed by brief lucid interval before rapidly developing coma
suggest extradural hematoma
 Headache before coma – ICSOL
 Recent onset seizure – suggest cerebral lesions like tumor,abscess,trauma etc
 Empty drug containers and alcohol at home
 History of depression
 History of DM,hepatic, renal ,respiratory failure, hypothyroidism – for
metabolic coma )
 History of fever suggests meningitis,encephalitis and infection or rarely brain
stem lesion disturbing hypothalamic temperature regulating centers causing
central fever

Examination

 Pallor, circulatory failure and evidence of shock – indicate internal

hemorrhage
 Temperature
 PR
 BP
 Smell of breath
* Alcohol
* Uremia Fishy or ammoniacal
* DKA Acetone
* Hepatic coma Mousy
* Suppurative lung disease Putrid smell
 Respiration pattern
 * Kussmaul breathing - deep sighing rapid breathing at
regular rate
*Cheyne-stokes respiration – periodic breathing with
hyperpnea alternating with cycles of apnea
* Central pontine hyperventilation ( neurogenic
hyperventilation )– continious
,regular,rapid deep respiration
*Ataxic breathing-chaotic breathing in which rate ,rhythm and
depth of respiration are irregular
Other systems

o RS
o CVS
o Abdomen
Basic neurological examination

 Assess level of conciousness – Glasgow coma scale

 Signs of head injury – local bruising,( battle sign –bruising behind
pinna )
- fracture and wound & bleeding from ear and nose
 Check for neck stiffness
 Pupil size, and light reflex
a. Bilateral pin point pupil – brain stem lesion , drug intoxication,
pontine infarct
b. Unilateral ptosis , dilated pupil with no light reflex - 3rd nerve palsy
c. Partial ptosis with small reactive pupil – Horner’s syndrome
d. Small pupil and eyes look to tip of nose - Thalamic hemorrhage
e. Fixed ,dilated pupil - brain stem death
2. Drug induced and metabolic coma – light reflex is normal
 Ocular movements – spontaneous and dolls eye movement
 Limbs – posture ,tone and movement
* Spontaneous movement of limbs
* Response to painful stimulus
* Externally rotated position of one limb
* Paralyzed limb falls flaccidly
 Reflexes and plantar
 Fundi