Neurological Status for 30 Neurology Clinical Diagnoses

1. Cerebral Infarction - Right Carotid Basin, Moderate Hemiparesis + Right Parietal Lobe Syndrome

2. Cerebral Infarction - Left Carotid Basin, Deep Hemiparesis + Left Occipital Lobe Syndrome

3. Cerebral Infarction - Vertebrobasilar Basin, Ataxia + Apraxia

4. Cerebral Infarction - Left Anterior Cerebral Artery Basin, Moderate Hemiparesis + Left Frontal Lobe Syndrome

5. Cerebral Infarction - Right Anterior Cerebral Artery Basin, Moderate Hemiparesis + Right Frontal Lobe Syndrome

6. Recovery Period - Brainstem Infarction, Left-Sided Mild Hemiparesis + Left Temporal Lobe Syndrome

7. Cervical Osteochondrosis, C6-C7 Disc Herniation, Left-Sided Radicular Syndrome C6-C7

8. Cervical Osteochondrosis, C6-C7 Disc Herniation, Bilateral Radicular Syndrome C6-C7

9. Lumbar Osteochondrosis, L5-S1 Disc Herniation, Left-Sided Radicular Syndrome L5-S1

• L5 radiculopathy: weakness of left foot and great toe dorsiflexion (extensor hallucis longus, tibialis anterior). "Steppage" gait. Strength 3-4/5.
• S1 radiculopathy: weakness of left plantar flexion (gastrocnemius, soleus). Difficulty walking on tiptoes. Strength 3-4/5. Reflexes: Left Achilles reflex reduced or absent (S1). Knee jerk intact (L3-L4). Sensory: Hypoesthesia along left L5 dermatome (lateral shin, dorsum of foot, 1st-2nd toes) and S1 dermatome (posterior calf, heel, plantar surface, 5th toe). Coordination: Intact. Trophic changes: Possible mild hypotrophy of left calf (S1) or anterior tibial compartment (L5) if chronic. Pelvic functions: Intact (pure radiculopathy). If S1-S2 compression with cauda equina: possible bladder/bowel dysfunction.

10. Recovery Period - Spinal Cord Injury, Compression C7-Th1, Paresis + Pelvic Dysfunction

• Below C7-Th1 level: residual spastic paresis of both legs (upper motor neuron - hyperreflexia, spasticity, pathological reflexes).
• Arms (C7-Th1 level): lower motor neuron pattern at level - weakness and hyporeflexia of triceps (C7), intrinsic hand muscles (T1 - interossei, lumbricals), finger flexors (C8). Hypotrophy of hand intrinsics. "Claw hand" possible (T1 involvement).
• Recovery period: partial recovery, strength varies 2-4/5 depending on completeness. Reflexes:
• Arms: absent triceps reflex (C7 level), absent finger flexors reflex (C8). Reduced biceps (C6 partially affected).
• Legs: hyperreflexia (upper motor neuron pattern), clonus possible. Babinski, Rossolimo bilateral.
• Abdominal reflexes: absent below T7. Sensory: Sensory level at C8-T1: hypoesthesia/anesthesia of both arms from medial aspect, chest, trunk and legs below the injury level. Impaired proprioception bilaterally in lower limbs. Coordination: Sensory ataxia in lower limbs possible. Autonomic/Pelvic dysfunction: Neurogenic bladder (detrusor-sphincter dyssynergia or atonic bladder in acute phase, spastic neurogenic bladder in recovery). Constipation/bowel dysfunction. Sexual dysfunction. Orthostatic hypotension (if sympathetic outflow disrupted at T1-T4).

11. Recovery Period - Spinal Cord Injury, Compression L1-L2, Paresis + Pelvic Dysfunction

• Conus medullaris / upper cauda equina injury at L1-L2: mixed picture.
• Lower extremities: mixed paresis - proximal muscles (hip flexors, L1-L2, iliopsoas) weak (LMN at level). Distal leg muscles may show UMN pattern if conus affected.
• Recovery period: residual paraparesis, strength 2-4/5 in lower limbs. Possible foot drop. Reflexes:
• Knee jerk: variable (may be reduced at L1-L2 level, or increased if upper conus with UMN damage).
• Achilles reflex: may be reduced/absent (LMN involvement at cauda equina level).
• Bulbocavernosus and anal reflexes: impaired (conus/S2-S4 level involvement).
• Babinski: may be present (UMN) or absent (LMN predominance). Sensory: Saddle anesthesia (S3-S5 dermatomes - perineum, inner thighs, perianal area). Hypoesthesia in L1-L2 dermatomes (inguinal region, anterior thigh). Impaired proprioception in lower limbs. Coordination: Sensory ataxia in lower limbs. Autonomic/Pelvic dysfunction: Conus syndrome - atonic neurogenic bladder (overflow incontinence, inability to void with straining). Bowel incontinence or retention. Erectile/sexual dysfunction. Absent voluntary perianal contraction.

12. Chronic Cerebral Ischemia (DE Stage 2), Moderate Cognitive Decline + Hyperkinetic Syndrome

13. Chronic Cerebral Ischemia (DE Stage 3), Marked Cognitive Decline + Hypokinetic-Rigid (Akinetic-Rigid) Syndrome

• Bradykinesia/akinesia (slowness and poverty of movement).
• Rigidity: plastic (lead-pipe) or cogwheel rigidity in both arms and legs (extrapyramidal hypertonia). Bilateral.
• Reduction in automatic movements (absent arm swing on walking).
• Postural instability (positive pull test - retropulsion, no correction). Reflexes: Bilateral hyperreflexia. Bilateral Babinski signs. Prominent frontal release signs bilaterally. Absent abdominal reflexes. Sensory: May be globally reduced. Cortical sensory loss possible. Coordination: Impaired, but difficult to assess due to rigidity/bradykinesia. Gait: Festinant gait, shuffle gait. Freezing. Turns with multiple small steps. Falls frequent. Pelvic functions: Urinary incontinence (detrusor overactivity). Constipation.

14. Jackson's Syndrome, XII Pair Insufficiency, Central Paralysis, Hemihypesthesia

• XII pair (hypoglossal): Peripheral (nuclear/fascicular) palsy on the side of lesion - tongue deviation toward the lesion side on protrusion, atrophy and fasciculations of the ipsilateral tongue half.
• Other cranial nerves intact (distinguishes from more extensive medullary syndromes). Motor: Contralateral (opposite side to tongue palsy) central hemiparesis/paralysis - arm and leg. Spastic type. Strength 0-3/5 contralateral. Reflexes: Contralateral hyperreflexia. Contralateral Babinski, Rossolimo. Absent abdominal reflexes contralateral. Sensory: Contralateral hemihypesthesia (all modalities - corticospinal and medial lemniscal tracts both affected contralaterally at medullary level). Coordination: Intact. Pelvic functions: Possible bilateral - intact in unilateral medullary lesion.

15. Brown-Séquard Syndrome, C7-Th1, Central Paralysis, Hemihypesthesia

• Ipsilateral (same side as lesion) central (UMN) paresis/paralysis below C7-Th1 level: spastic paresis of ipsilateral arm (C7-T1 = triceps, hand intrinsics, finger extensors/flexors) and ipsilateral leg. At-level LMN weakness of ipsilateral arm muscles (C7-T1 segments: triceps, hand intrinsics, wrist extensors).
• Contralateral side: no motor deficit. Reflexes:
• Ipsilateral: hyperreflexia below lesion level (legs - Babinski, clonus); absent/reduced triceps (C7), absent finger flexors (C8), reduced intrinsic hand reflexes (T1) - at-level LMN.
• Contralateral: normal reflexes. Sensory (classic Brown-Séquard pattern):
• Ipsilateral: loss of proprioception and vibration sense (posterior column, dorsal funiculus) below C7-T1 level - ipsilateral proprioceptive hemianesthesia.
• Contralateral: loss of pain and temperature sensation (spinothalamic tract, crosses 1-2 levels above lesion) below approximately T2 level - contralateral thermoalgic hemianesthesia.
• At-level: bilateral band of hypo/anesthesia (all modalities) at C7-T1 dermatome level. Coordination: Ipsilateral sensory (proprioceptive) ataxia in ipsilateral limbs. Pelvic functions: May be partially affected; bladder dysfunction if bilateral descending pathways involved.

16. Meningitis - Chronic Course, Cerebral + Meningeal Syndromes, Moderate Cognitive Decline

• Nuchal rigidity (resistance to neck flexion) - present but may be mild in chronic phase.
• Kernig sign positive (inability to extend knee with hip flexed 90°).
• Brudzinski signs positive (neck, pubic, contralateral).
• Photophobia, phonophobia.
• Hyperesthesia of skin. Cerebral syndrome:
• Diffuse headache (increased ICP component).
• Nausea, vomiting (central).
• Papilledema (if raised ICP chronic - fundoscopy). Cranial nerves: May have CN palsies in chronic infectious/granulomatous meningitis (tuberculous, fungal): VI (diplopia), VII (facial palsy), VIII (deafness, vertigo), II (visual loss from optochiasmatic arachnoiditis). Motor: Generally preserved, or mild diffuse weakness if toxic encephalopathy. Reflexes: Hyperreflexia diffuse. Pathological reflexes possible (Babinski) in encephalitic component. Sensory: Hyperesthesia (allodynia of skin). Pelvic functions: Generally intact.

17. Subarachnoid Hemorrhage, Pseudobulbar Syndrome + Dislocation Syndrome, Moderate Course

• Bilateral central (UMN) lesion of corticobulbar tracts.
• Dysarthria (spastic, nasal quality).
• Dysphagia.
• Dysphonia.
• Pathological crying/laughing (pseudobulbar affect - forced crying/laughing without emotional trigger).
• Mandibular reflex increased. Palatal reflexes preserved (distinguishes from true bulbar palsy). Dislocation syndrome (herniation):
• Rostrocaudal deterioration signs: progressive decrease in consciousness.
• Anisocoria (ipsilateral pupil dilatation with uncal herniation - CN III compression).
• Oculomotor dysfunction (fixed dilated pupil, "down-and-out" eye position).
• Contralateral or bilateral Babinski.
• Decerebrate posturing in severe cases (bilateral extensor response).
• Changes in respiratory pattern (Cheyne-Stokes breathing). Motor: Bilateral pyramidal signs (spastic tone, hyperreflexia, pathological reflexes bilaterally). Reflexes: Bilateral hyperreflexia, bilateral Babinski. Sensory: Difficult to assess due to impaired consciousness. Pelvic functions: Urinary incontinence (acute).

18. Severe TBI - Consequences, Bulbar Syndrome + Marked Cognitive Decline

• Dysarthria (flaccid, nasal, quiet, slurred).
• Dysphagia (aspiration risk, requires soft/pureed diet, possibly PEG tube).
• Dysphonia (nasal, breathy voice).
• Atrophy of tongue with fasciculations (XII nuclear lesion).
• Absent/reduced gag reflex (IX, X).
• Nasal regurgitation of fluids.
• Palatal paresis (uvula deviation to unaffected side). Cranial nerves: IX, X, XII - peripheral pattern palsy. Possible VII peripheral palsy (temporal bone fracture). Motor: Residual hemiparesis or tetraparesis depending on TBI extent. Spastic hypertonia. Possible decorticate/decerebrate residual posturing elements. Reflexes: Hyperreflexia diffuse. Bilateral Babinski. Frontal release signs prominent. Sensory: Variable - hemisensory loss or intact depending on lesion location. Coordination: Cerebellar ataxia (cerebellar contusion) or intact. Pelvic functions: Urinary incontinence common. Bowel dysfunction.

19. Epilepsy

• Inter-ictally: normal OR focal deficits if underlying structural lesion (tumor, stroke).
• Post-ictally: Todd's paresis - transient contralateral hemiparesis after focal motor seizures.
• During seizure: tonic-clonic movements (generalized), focal clonic movements (focal motor seizure), automatisms (temporal lobe complex focal seizures). Reflexes: Normal inter-ictally. Post-ictally: transient Babinski sign may be present. Sensory: Normal inter-ictally. Sensory aura possible (focal sensory seizure - somatosensory cortex - contralateral paresthesia spreading in Jacksonian fashion). Coordination: Intact inter-ictally. Tongue bite injuries, urinary incontinence: Associated with generalized tonic-clonic seizures. Pelvic functions: Urinary incontinence during generalized tonic-clonic seizures.

20. Compression-Ischemic Neuropathy - Left Ulnar Nerve

• Weakness and atrophy of left intrinsic hand muscles innervated by ulnar nerve: interossei (all 4), medial 2 lumbricals, hypothenar (abductor/flexor/opponens digiti minimi), adductor pollicis.
• "Claw hand" deformity (main en griffe): hyperextension at MCP joints + flexion at IP joints of ring and little fingers (prominent because lateral lumbricals, innervated by median nerve, are spared).
• Positive Froment's sign (flexion of thumb IP joint when pinching paper - adductor pollicis weakness, compensated by FPL).
• Positive Wartenberg sign (little finger abduction at rest - weakness of 3rd palmar interosseous).
• Weakness of left wrist flexion (flexor carpi ulnaris) and ring/little finger DIP flexion (FDP medial half) - if proximal enough to affect forearm muscles. Reflexes: Normal. Sensory: Hypoesthesia/anesthesia in left ulnar nerve territory: medial palm, little finger, medial half of ring finger, medial forearm (if above elbow). Coordination: Intact.

21. Compression-Ischemic Neuropathy - Left Radial Nerve

• "Wrist drop" (inability to extend wrist) - extensor carpi radialis, extensor carpi ulnaris weakness.
• Finger drop (inability to extend fingers at MCP joints) - extensor digitorum, extensor indicis, extensor digiti minimi weakness.
• Thumb drop - extensor pollicis longus/brevis, abductor pollicis longus weakness.
• Weakness of elbow extension (triceps) only if compression above the spiral groove.
• Brachioradialis spared (innervated above spiral groove in most cases) - preserved elbow flexion in mid-supination.
• Supination weakness (supinator muscle - posterior interosseous nerve). Reflexes: Brachioradialis reflex absent or reduced. Triceps reflex preserved (unless very proximal lesion). Sensory: Hypoesthesia over left dorsum of hand, lateral forearm (posterior cutaneous nerve of forearm, superficial radial nerve territory: dorsal thumb web space, dorsal 1st-2nd-3rd fingers to PIP joints). Coordination: Intact.

22. Compression-Ischemic Neuropathy - Left Median Nerve

• Weakness and atrophy of left thenar eminence (abductor pollicis brevis, opponens pollicis, flexor pollicis brevis - superficial head).
• "Ape hand" deformity (flat thenar, thumb adducted in plane of palm - loss of opposition).
• Weakness of opposition (Oppenheimer test: opposition resistance test).
• Lateral 2 lumbricals weakness (minimal functional deficit).
• If above the carpal tunnel (anterior interosseous nerve or proximal median): weakness of FPL, FDP (index), pronator quadratus - "anterior interosseous syndrome."
• Pronator teres syndrome (median nerve in forearm): similar to CTS + weakness of pronation + forearm pain. Reflexes: Normal. Sensory: Hypoesthesia/anesthesia in left median nerve territory: palmar surface of thumb, index, middle fingers, radial half of ring finger, palmar skin over thenar eminence. Nocturnal tingling/numbness (thenar, index, middle fingers).

23. Post-Traumatic Neuropathy - Right Femoral Nerve

• Weakness of right quadriceps femoris (knee extension) - main function of femoral nerve (L2-L4). Strength 2-4/5 in knee extension.
• Difficulty standing from seated position, climbing stairs, running.
• Weakness of hip flexion (iliopsoas) if lesion is proximal to inguinal ligament.
• Difficulty walking (quadriceps give-way, buckling at knee). Reflexes: Right patellar (knee jerk) reflex absent or significantly reduced. Sensory: Hypoesthesia of right anterior and medial thigh (femoral cutaneous distribution). Medial lower leg hypoesthesia (saphenous nerve - below knee along medial tibia to medial foot). Coordination: Right leg sensory and motor ataxia possible. Trophic changes: Atrophy of right quadriceps muscle (visible if chronic).

24. Neuropathy of the Facial Nerve on the Left (Bell's Palsy)

• VII (facial nerve) - peripheral palsy on the left (all facial muscles ipsilateral):
  • Inability to close left eye (lagophthalmos) - Bell's phenomenon visible (eye rolls upward on attempted closure).
  • Inability to wrinkle left forehead (distinguishes peripheral from central VII palsy).
  • Inability to raise left eyebrow.
  • Smoothed left nasolabial fold.
  • Drooping of left corner of mouth.
  • Inability to puff cheeks (buccinator paresis).
  • Inability to whistle.
  • Asymmetric smile (deviation to right).
• Chorda tympani branch (if lesion proximal): Loss of taste on anterior 2/3 of left tongue.
• Greater petrosal nerve (if lesion proximal to geniculate ganglion): Decreased lacrimation (left).
• Stapedial branch: Hyperacusis on the left. Motor: No limb weakness. Reflexes: Normal. Corneal reflex absent on the left (afferent V intact, efferent VII impaired). Sensory: Possible mild hypoesthesia in left external auditory canal (Ramsay Hunt area - if herpetic zoster). Pelvic functions: Intact.

25. Trigeminal Neuralgia on the Right (Tic Douloureux)

• V (trigeminal) - sensory examination: Inter-ictally, sensation typically intact (classical idiopathic TGN). If secondary (symptomatic - MS, tumor): sensory deficit may be present in right V1-V3 territory.
• Corneal reflex: intact bilaterally (reflex arc intact in classical TGN).
• V motor: masseter, temporalis strength normal (pure sensory in classical TGN).
• Trigger zones on right face: touching them reproduces pain. Patient guards face.
• No trophic changes, no allodynia over face (beyond trigger zone pattern). Motor: No weakness. Reflexes: Normal. Sensory: Tactile and pain sensation normal inter-ictally in classical TGN. Abnormal sensory exam suggests secondary etiology. Pelvic functions: Intact.

26. Parkinson's Disease

• Hypomimia: masked facies, reduced blinking (stare).
• Dysarthria: hypokinetic dysarthria - monotone, quiet (hypophonia), rapid, mumbled.
• Dysphagia in advanced stages (aspiration risk).
• Oculomotor: impaired vertical saccades (especially downward in PSP-like variants), convergence reduced. Square wave jerks.
• Anosmia (hyposmia) - early non-motor sign. Motor (Cardinal Signs):

1. Tremor: Resting ("pill-rolling") tremor, 4-6 Hz. Predominantly hands (unilateral onset, contralateral spread). Reduces with intentional movement. "Re-emergent" postural tremor.
2. Rigidity: Cogwheel rigidity (tremor superimposed on lead-pipe rigidity) in arms > legs. Increased with contralateral arm movement (Froment's maneuver).
3. Bradykinesia/Akinesia: Slowness and fatiguing of movement. Micrographia (progressively smaller handwriting). Reduced arm swing (unilateral initially). Paucity of spontaneous movement.
4. Postural instability (late sign): Positive pull test (retropulsion without correction). Falls. Reflexes: Normal or mildly increased. Pathological reflexes absent (distinguishes from MSA/PSP where they appear). Glabellar sign positive (Myerson's sign - failure to habituate to repeated glabellar taps). Sensory: Normal (sensory complaints: pain, aching in affected limbs possible). Coordination: Impaired due to bradykinesia and rigidity, not true cerebellar ataxia. Gait: Festinating gait (start hesitation, shuffling small steps, reduced arm swing, stooped posture, festination/acceleration of steps, freezing of gait). Turning: multiple small steps (en-bloc turning). Autonomic: Orthostatic hypotension, constipation, seborrhea, urinary urgency, hypersalivation (drooling - reduced swallowing, not excess production).

27. Encephalitis - Recovery Period

• HSV encephalitis (temporal-frontal): amnestic syndrome (medial temporal - hippocampus), behavioral change, personality changes, possible Klüver-Bucy syndrome elements (hypersexuality, hyperorality, visual agnosia).
• General: attention deficits, slowed processing, variable memory impairment. Cognitive recovery ongoing. Cranial nerves: Variable. Residual CN deficits if brainstem involved. Dysarthria (residual). Motor: Residual weakness depending on lesion location (hemiparesis, monoparesis). Spastic hypertonia if pyramidal tract involved. Tremor or movement disorder if basal ganglia involved. Reflexes: Residual hyperreflexia, Babinski if pyramidal involvement. Frontal release signs if frontal lobe affected. Sensory: Residual hemihypesthesia if thalamic/cortical involvement. Coordination: Residual ataxia if cerebellum involved (cerebellitis). Psychiatric/Behavioral: Post-encephalitic psychiatric symptoms: depression, anxiety, PTSD-like symptoms, psychosis (especially anti-NMDAR encephalitis - behavioral and psychiatric symptoms prominent). Seizures: Post-encephalitic epilepsy - common residual. Pelvic functions: Incontinence may persist if frontal/subcortical involvement.

28. Multiple Sclerosis

• Optic neuritis (II): Unilateral visual loss with pain on eye movement. Afferent pupillary defect (Marcus Gunn pupil - RAPD). Impaired color vision (red desaturation). Optic disc pallor (post-neuritis atrophy).
• Internuclear ophthalmoplegia (MLF lesion): Adduction failure + contralateral abducting nystagmus (Hallmark of MS). May be bilateral.
• VI palsy: Diplopia.
• V (trigeminal neuralgia): Bilateral trigeminal neuralgia suggests MS.
• VII (peripheral or central facial palsy).
• VIII: Vertigo (brainstem/cerebellar plaque). Motor: Variable - spastic paresis (monoparesis, hemiparesis, paraparesis, or tetraparesis). Spastic hyperreflexia. Bilateral Babinski signs common. Lhermitte's sign (cervical flexion produces electric shock sensation down spine and limbs - posterior column cervical cord lesion). Reflexes: Hyperreflexia. Bilateral Babinski. Clonus (ankle, patellar). Absent abdominal reflexes (early, sensitive sign of corticospinal tract involvement). Sensory: Multifocal sensory symptoms - paresthesia, numbness, band sensation, tight "MS hug" (thoracic cord lesion). Posterior column loss (vibration, proprioception) often > spinothalamic (pain, temperature). Coordination: Cerebellar ataxia - limb ataxia, gait ataxia, dysarthria (scanning speech), intention tremor, nystagmus. Charcot's triad (nystagmus, intention tremor, scanning speech) - classical but not common. Uhthoff's phenomenon: Worsening of symptoms with heat/exercise. Gait: Spastic ataxic gait (combination of pyramidal and cerebellar involvement). Pelvic functions: Neurogenic bladder (urgency, frequency, incomplete emptying, detrusor-sphincter dyssynergia) in most patients. Sexual dysfunction. Bowel dysfunction (constipation).

29. Brain Tumor

• Headache: progressive, worse in morning, aggravated by Valsalva/lying down.
• Nausea and vomiting (projectile, "cerebral" - without nausea).
• Papilledema (fundoscopy: blurred disc margins, engorged veins, hemorrhages in severe ICP).
• Cushing triad (late: hypertension + bradycardia + respiratory irregularity = herniation imminent). Cranial nerves:
• False localizing signs: CN VI palsy (bilateral - due to raised ICP stretching nerve, not direct compression).
• True localizing signs: CN deficits based on tumor location (e.g., CPA tumor: unilateral hearing loss, V, VII involvement; pituitary tumor: bitemporal hemianopia from chiasmal compression; posterior fossa: cerebellar/brainstem signs). Motor: Contralateral hemiparesis (hemispheric tumor). Paraparesis (parasagittal - meningioma). Bilateral if midline or multifocal. Spastic hypertonia. Pathological reflexes (Babinski). Reflexes: Contralateral hyperreflexia. Babinski. Absent abdominal reflexes. Sensory: Contralateral hemihypesthesia. Cortical sensory deficits (parietal tumor). Coordination: Ipsilateral cerebellar ataxia (cerebellar tumor - same side as lesion). Truncal ataxia (vermis tumor - bilateral/central). Gait: Wide-based ataxic gait (cerebellar). Hemiparetic gait (hemispheric). Apraxic gait (bifrontal). Seizures: New onset focal or generalized seizures (especially slow-growing tumors - meningioma, low-grade glioma). Pelvic functions: Frontal - urinary incontinence. Parasagittal - paraparesis + incontinence.

30. Spinal Cord Tumor

• UMN signs below lesion level: spastic paresis/paralysis. Increased muscle tone (spastic). Clonus.
• LMN signs at level of lesion: flaccid paresis, hypotonia, atrophy, fasciculations (anterior horn/nerve root compression at the tumor level).
• Extramedullary tumor: often radicular pain first, then Brown-Séquard syndrome, then spastic paraparesis.
• Intramedullary tumor: central cord pattern (arms > legs, cape-like dissociated sensory loss), ascending paraparesis. Reflexes:
• Hyperreflexia below lesion (UMN). Bilateral Babinski. Clonus.
• Hyporeflexia/areflexia at level of lesion (LMN - affected segments).
• Absent abdominal reflexes below lesion level. Sensory:
• Sensory level: sensory loss below a horizontal dermatomal line.
• Intramedullary (central cord): dissociated sensory loss - pain and temperature impaired (spinothalamic decussation disrupted centrally), posterior column (proprioception/vibration) relatively preserved early. Cape/suspended pattern.
• Extramedullary: posterior column involvement early (ipsilateral proprioceptive loss), spinothalamic later (contralateral thermoalgic loss - Brown-Séquard pattern). Coordination: Sensory ataxia below level (posterior column loss). Positive Romberg sign. Lhermitte's sign (if cervical cord). Radicular pain: Girdle pain, band-like pain at level of tumor (root compression), worse at night (extramedullary). Pelvic functions:
• Early: urgency, frequency, incomplete bladder emptying.
• Late: urinary retention or incontinence (neurogenic bladder - detrusor-sphincter dyssynergia or atonia).
• Constipation, bowel dysfunction.
• Sexual dysfunction.
• Loss of perianal sensation if conus/cauda equina involved. Trophic changes: Pressure sores (if motor-sensory paralysis advanced). Muscle atrophy at level of lesion.

Summary Reference Table

NEUROLOGICAL STATUS - EXAM & VIVA GUIDE

How to Present Each Case

Consciousness → Cognitive/Speech → Cranial Nerves → Motor → Reflexes → Sensory → Coordination → Autonomic/Pelvic

CEREBRAL INFARCTIONS (1-6)

1. Cerebral Infarction - Right Carotid Basin

Moderate Hemiparesis + Right Parietal Lobe Syndrome

• Left-sided spatial neglect - patient ignores everything on the left side of space (doesn't eat from left side of plate, doesn't dress left arm). Why? Right parietal lobe controls spatial attention for BOTH sides.
• Anosognosia - patient denies having weakness ("my arm is fine"). Very characteristic of right hemisphere.
• Astereognosis - cannot identify objects by touch with left hand (e.g., cannot tell a coin from a key with eyes closed).
• Agraphesthesia - cannot identify numbers drawn on left palm.
• Constructional apraxia - cannot copy a clock face or cube drawing.
• Dressing apraxia - struggles to put on clothes correctly.

💡 Viva tip: Parietal lobe = "where is it" brain. Damage = patient loses awareness of left body and left space.

• CN VII (facial): Central paresis on the LEFT - lower face only droops (forehead spared because forehead has bilateral cortical representation). Nasolabial fold flattened on left. Corner of mouth droops left.
• CN XII (hypoglossal): Tongue deviates to the LEFT on protrusion (toward the weak side). This is central palsy - no atrophy, no fasciculations.

💡 Viva tip: In central CN VII - forehead is SPARED. In peripheral CN VII - forehead IS involved. This distinguishes stroke from Bell's palsy.

• Left arm and left leg weakness (moderate = strength 3/5).
• Tone is increased (spastic) - resistance increases with rapid passive stretch ("clasp-knife" pattern).
• Arm tends to be more affected than leg in MCA territory (vs. ACA where leg > arm).
• Wernicke-Mann posture developing: arm flexed at elbow, wrist, fingers; leg extended.

• Deep tendon reflexes increased on the left (biceps, triceps, knee, ankle).
• Babinski sign positive on the left (big toe extends upward, other toes fan out - indicates upper motor neuron damage).
• Rossolimo sign positive on the left (tapping toe pads causes toe flexion).
• Abdominal reflexes absent on the left.

💡 Viva tip: Babinski = UPPER motor neuron lesion. Always present it as pathological.

• Left-sided cortical sensory loss: impaired two-point discrimination, graphesthesia, stereognosis.
• Basic sensation (pinprick, temperature) may be relatively preserved (these are processed deeper - thalamus/primary somatosensory).

2. Cerebral Infarction - Left Carotid Basin

Deep Hemiparesis + Left Occipital Lobe Syndrome

• Right homonymous hemianopia - patient cannot see anything on the RIGHT side of their visual field in BOTH eyes. Ask: "Can you see my hand on this side?" Tests visual field by confrontation.
• Visual agnosia - can see objects but cannot recognize/name them.
• If angular gyrus involved: alexia (cannot read), acalculia (cannot calculate), finger agnosia, left-right disorientation (Gerstmann syndrome).
• No neglect (neglect is RIGHT hemisphere feature).

💡 Viva tip: Occipital lobe = "what is it" visually. Visual cortex is on the medial surface of occipital lobe. Left occipital cortex receives fibers from RIGHT half of both retinas → left occipital lesion = RIGHT visual field loss.

• CN II visual fields: Right homonymous hemianopia (key finding).
• CN VII: Central paresis on the RIGHT (right lower face droops) - left hemisphere damaged = right face affected.
• CN XII: Tongue deviates to the RIGHT.

• Right arm and right leg deep paresis (strength 1-2/5 - very weak, only trace movement or none).
• Marked spastic hypertonia developing.
• Deep hemiparesis suggests internal capsule involvement (where all pyramidal fibers are tightly packed).

• Marked hyperreflexia on the right.
• Babinski, Rossolimo, Oppenheim positive on the right.
• Abdominal reflexes absent on the right.

3. Cerebral Infarction - Vertebrobasilar Basin

Ataxia + Apraxia

• Ideomotor apraxia - cannot perform learned movements on command ("show me how to comb your hair") even though limbs work. Due to disconnection of cerebellar-cortical motor planning circuits.
• Posterior cortical features if occipital/parietal: visual spatial difficulties.

• CN III, IV, VI: Diplopia (double vision). Eyes don't move together.
• Nystagmus: Involuntary rhythmic eye movement. Horizontal nystagmus = pontine. Vertical nystagmus = brainstem/cerebellar.
• CN V: Facial numbness (trigeminal - if lateral medullary lesion).
• CN VII: Facial weakness possible.
• CN VIII: Vertigo, nausea, vomiting (vestibular nucleus in pons/medulla).
• CN IX, X: Dysphagia, dysphonia, hoarseness (if lateral medulla - Wallenberg syndrome).
• Dysarthria: Cerebellar dysarthria = scanning/staccato speech (slurred, irregular rhythm, like speaking while being shaken).

💡 Viva tip: Crossed syndromes = IPSILATERAL face deficit + CONTRALATERAL body deficit. This is the hallmark of brainstem lesions. Example: Wallenberg - ipsilateral face numbness + contralateral body pain/temperature loss.

• No significant hemiparesis if pure cerebellar lesion.
• Hypotonia (reduced muscle tone) on affected side - cerebellar lesion causes DECREASED tone.
• If pontine: contralateral hemiparesis.

• Normal or slightly reduced (cerebellar hypotonia).
• No Babinski unless corticospinal tract involved.

• Crossed pattern (Wallenberg): ipsilateral face + contralateral body pain/temperature loss.
• Diplopia, vertigo are the dominant complaints.

• Dysmetria - past-pointing on finger-nose test (goes past the target).
• Dysdiadochokinesis - cannot perform rapid alternating movements (slap hand back-and-forth rapidly).
• Intention tremor - tremor that INCREASES as hand approaches target.
• Gait ataxia - wide-based, staggering, "drunken sailor" gait.
• Positive Romberg test (ataxic type) - falls with eyes open AND closed (pure cerebellar). Compare to posterior column Romberg: falls only with eyes CLOSED.
• Truncal ataxia if vermis involved - cannot sit still without swaying.

4. Cerebral Infarction - Left Anterior Cerebral Artery

Moderate Hemiparesis + Left Frontal Lobe Syndrome

• Abulia/Akinetic mutism - profound apathy, reduced spontaneous movement and speech.
• Perseveration - keeps repeating same action or word.
• Disinhibition - inappropriate social behavior, impulsivity.
• Executive dysfunction - cannot plan, sequence, or organize tasks.
• Transcortical motor aphasia - reduced speech output BUT repetition is INTACT. (This differentiates from Broca's aphasia where repetition is also impaired). Occurs if left SMA involved.
• Frontal release signs:
  • Grasp reflex on the right - stroking palm causes automatic grasping (primitive reflex).
  • Palmomental reflex - stroking palm causes ipsilateral chin twitch.

💡 Viva tip: Frontal lobe = "CEO of the brain." Damage = patient loses ability to initiate, inhibit, and plan. Frontal release signs = regression to infant reflexes.

• Right-sided moderate hemiparesis with LEG PREDOMINANCE (strength 3-4/5 in right leg, 4-4+/5 in right arm).
• Why leg > arm? ACA supplies the medial cortex where the LEG area of motor homunculus sits (paracentral lobule).
• Increased spastic tone on right.

• Hyperreflexia on the right.
• Babinski positive right.
• Grasp reflex present in right hand.

5. Cerebral Infarction - Right Anterior Cerebral Artery

Moderate Hemiparesis + Right Frontal Lobe Syndrome

• Disinhibition, impulsivity, emotional dysregulation (right frontal more associated with emotional control and behavioral regulation).
• Left spatial neglect (milder than right parietal neglect, but present).
• Motor perseveration on the left side.
• Frontal release signs on LEFT side.
• NO aphasia (right hemisphere = non-dominant in most people).

• Left-sided moderate hemiparesis with LEG PREDOMINANCE (left leg weaker than left arm).
• Increased tone on the left. Wernicke-Mann posture.

• Hyperreflexia on the left.
• Babinski positive left.
• Grasp reflex present in left hand.

6. Recovery Period - Brainstem Infarction

Left-Sided Mild Hemiparesis + Left Temporal Lobe Syndrome

• Wernicke's aphasia (or amnestic aphasia): Patient speaks fluently but makes errors (paraphasias - substituting wrong words). Cannot understand spoken speech well. Comprehension worse than output. Speech sounds like "word salad."
• Verbal memory deficit - cannot recall word lists, stories.
• Auditory agnosia - cannot recognize sounds.
• Right superior quadrantanopia ("pie in the sky" defect) - if Meyer's loop of optic radiation involved.

💡 Viva tip: Left temporal = language comprehension (Wernicke's area in posterior superior temporal gyrus). Damage = fluent but meaningless speech.

• Residual dysarthria (brainstem recovery - slurred speech).
• Residual dysphagia (brainstem - CN IX/X).
• Possible nystagmus (residual vestibular).
• Crossed CN signs possible from original brainstem lesion.

• Left-sided mild (residual) hemiparesis - strength 4/5 in left arm and leg (recovery stage = partial improvement).
• Mild spastic tone on the left.

• Mild hyperreflexia on the left.
• Babinski equivocal or positive on the left.

SPINAL / RADICULAR CONDITIONS (7-11)

7. Cervical Osteochondrosis, C6-C7 Herniation

Left-Sided Radiculopathy C6-C7

• C6 root: controls biceps (flexion), brachioradialis. Sensation: lateral forearm, thumb and index finger.
• C7 root: controls triceps (extension), wrist extensors, finger extensors. Sensation: middle finger.

• Cervicobrachialgia - pain starts in neck, radiates down LEFT arm.
• C6 pattern: radiates to thumb and index finger.
• C7 pattern: radiates to middle finger.
• Aggravated by neck movement, sneezing, coughing (increases intradiscal pressure).
• Spurling's test positive (examiner presses down on head + lateral flexion toward affected side = reproduces arm pain).

• C7 weakness: Left triceps weak (elbow extension). Left wrist extensors weak (wrist drop tendency). Left finger extensors weak. Strength 4/5.
• C6 weakness: Left biceps and brachioradialis slightly weak. Forearm supination weak.

• Left triceps reflex reduced or absent (C7).
• Left biceps reflex reduced (C6).
• Left brachioradialis reflex reduced (C6).

💡 Viva tip: Reflex level = the segment compressed. C5-6 = biceps and brachioradialis. C7 = triceps. No Babinski (this is peripheral = LMN).

• Hypoesthesia (reduced sensation) along left C6 dermatome: lateral forearm, thumb, index finger.
• Hypoesthesia along left C7 dermatome: middle finger, posterior forearm.
• Paresthesia (pins and needles) in same distribution.

8. Cervical Osteochondrosis, C6-C7 Herniation

Bilateral Radiculopathy C6-C7

• If central canal is also narrowed (stenosis), watch for myelopathy signs:
  • Spastic weakness in LEGS (not just arms).
  • Bilateral Babinski signs.
  • Bladder urgency/dysfunction.
  • Loss of fine hand coordination.

💡 Viva tip: Bilateral C6-C7 radiculopathy = always suspect midline disc herniation or central canal stenosis. Must exclude myelopathy.

9. Lumbar Osteochondrosis, L5-S1 Herniation

Left-Sided Radiculopathy L5-S1

• L5 root: Foot dorsiflexion (lift foot up), great toe extension. Sensation: outer shin, dorsum of foot, big toe.
• S1 root: Plantar flexion (stand on tiptoes), Achilles reflex. Sensation: heel, sole, little toe, posterior calf.

• Sciatica - pain from lower back → left buttock → posterior thigh → calf → foot.
• L5 pattern: Pain to outer shin and big toe.
• S1 pattern: Pain to heel, sole, little toe.
• Lasègue sign (SLR - Straight Leg Raise) POSITIVE on the LEFT at 30-60° (pain radiates down the leg when examiner raises straight leg). This is the most important radicular tension sign.
• Antalgic posture: Patient leans away from pain (list to right), walks stiffly.
• Pain worsens with coughing, sneezing, straining.

• L5: Left foot drop - cannot lift left foot up (dorsiflexion weak). Cannot walk on heels. Strength 3-4/5 for ankle dorsiflexion and great toe extension. "Steppage gait."
• S1: Cannot stand on left tiptoes (plantar flexion weak). Strength 3-4/5 for gastrocnemius.

• Left Achilles reflex absent or reduced (S1) - most important finding.
• Knee jerk intact (L3-L4 = not affected).

💡 Viva tip: Achilles reflex = S1. Knee jerk = L3-L4. Absent Achilles = S1 root problem.

• Left L5 hypoesthesia: lateral shin, dorsum of foot, first two toes.
• Left S1 hypoesthesia: heel, sole, lateral foot, 5th toe, posterior calf.

10. Recovery Period - Spinal Cord Injury C7-Th1

Paresis + Pelvic Dysfunction

💡 Key concept - TWO LEVELS apply:

• AT THE LEVEL (C7-T1): Lower Motor Neuron signs (flaccid, atrophied, absent reflexes) in muscles innervated by those segments.
• BELOW THE LEVEL: Upper Motor Neuron signs (spastic, hyperreflexic) in everything below.

• Horner's syndrome ipsilateral (ptosis + miosis + enophthalmos) - T1 sympathetic preganglionic neurons are in the ciliospinal center of Budge. Compressed at T1 → loss of sympathetic to eye.

• At C7-T1 level (LMN - ARMS):
  • Triceps weakness (C7) - LMN, atrophied.
  • Hand intrinsic muscle weakness (T1 - interossei, lumbricals) → "claw hand" tendency.
  • Wrist and finger extension weakness (C7-C8).
  • Hypotonia, atrophy, fasciculations in hand muscles.
• Below T1 level (UMN - LEGS):
  • Spastic paresis of both legs.
  • Increased tone (spasticity).
  • Recovery period = partial improvement, strength 2-4/5.

• Arms: Absent/reduced triceps (C7), absent finger flexors (C8). These are LMN levels.
• Legs: Hyperreflexia, clonus, Babinski bilateral (UMN below the lesion).
• Abdominal reflexes absent below T7.

• Sensory level at C8-T1: everything below this level has reduced/absent sensation.
• Medial forearm, medial hand = hypoesthesia (C8-T1 dermatomes).
• Proprioception impaired in legs.

• Spastic neurogenic bladder in recovery (detrusor-sphincter dyssynergia).
• Urinary urgency, frequency, incontinence or retention.
• Constipation.
• Sexual dysfunction.
• Orthostatic hypotension possible (T1-T4 sympathetic outflow disrupted).

11. Recovery Period - Spinal Cord Injury L1-L2

Paresis + Pelvic Dysfunction

💡 Key concept: L1-L2 = transition zone between conus medullaris (end of spinal cord, contains S2-S5 sacral segments) and cauda equina (nerve roots). This gives a MIXED picture.

• Proximal leg weakness (hip flexors = L1-L2 = iliopsoas): cannot flex hip against resistance. LMN type (flaccid, atrophied).
• Distal leg function partially preserved.
• Recovery period: residual paraparesis 2-4/5.

• Knee jerks: variable (may be reduced - LMN, or increased if upper conus UMN).
• Achilles reflexes: reduced/absent (cauda equina involvement, LMN).
• Bulbocavernosus reflex absent (S2-S4 reflex arc in conus destroyed = important for bladder/bowel).
• Anal reflex absent (perianal wink absent when skin is stroked).

• Saddle anesthesia - loss of sensation in perineum, perianal region, inner thighs, genitalia. (S3-S5 dermatomes = conus level). This is PATHOGNOMONIC of conus lesion.
• L1-L2 dermatome hypoesthesia: inguinal region, anterior thigh.

• Atonic neurogenic bladder - cannot feel when bladder is full. Overflow incontinence (dribbling). No voluntary micturition. Requires Credé maneuver (manual suprapubic pressure) or catheterization.
• Bowel incontinence or retention (atonic sphincter).
• No voluntary anal contraction - patient cannot tighten anus on command.
• Sexual dysfunction - loss of reflex erection (sacral parasympathetic S2-S4 destroyed).

💡 Viva tip: Conus = atonic/flaccid neurogenic bladder. UMN (thoracic cord above conus) = spastic/hyperreflexic neurogenic bladder. Know this distinction.

CHRONIC CEREBRAL CONDITIONS (12-13)

12. Chronic Cerebral Ischemia - DE Stage 2

Moderate Cognitive Decline + Hyperkinetic Syndrome

• MoCA score approximately 15-21 (moderate decline).
• Impaired: attention, concentration, working memory, executive function, verbal fluency.
• Preserved: personal orientation, remote memory, basic language.
• Can still perform basic ADLs but struggles with complex tasks (finances, driving, medication management).
• Emotional lability - sudden inappropriate crying or laughing.
• Mild depression, fatigue, irritability.

• Postural/action tremor of hands - tremor present when hands are held outstretched or during purposeful movement (not at rest - distinguishes from Parkinson's).
• Possible chorea - brief, irregular, involuntary jerky movements of hands, face, trunk.
• Myoclonus - sudden muscle jerks.

💡 Viva tip: Hyperkinetic = TOO MUCH movement. Hypokinetic (like Parkinson's) = TOO LITTLE movement. Striatal damage can cause either.

• Mild dysarthria (slurred, slow speech).
• Mild facial hypomimia.
• Convergence insufficiency.

• No focal hemiparesis.
• Mild diffuse increase in extrapyramidal tone.
• Hyperkinetic movements visible in outstretched hands.

• Mild diffuse hyperreflexia.
• Frontal release signs: palmomental, snout reflex, grasp reflex - indicate frontal lobe/subcortical damage.
• Babinski may be equivocal.

13. Chronic Cerebral Ischemia - DE Stage 3

Marked Cognitive Decline + Hypokinetic-Rigid (Akinetic-Rigid) Syndrome

• MoCA < 15, MMSE < 20 = Dementia territory.
• Severe impairment in: memory (cannot recall recent events), orientation (time and place), judgment, abstract thinking.
• Cannot perform IADLs independently (needs help with dressing, bathing, medications).
• Behavioral disturbances: agitation, wandering, sleep disturbances, possible psychosis (hallucinations).
• Poverty of speech → eventual mutism in advanced stage.
• Echolalia (repetition of examiner's words).

1. Akinesia/Bradykinesia - extreme slowness and poverty of movement.
   • Reduced arm swing when walking (bilateral).
   • Hypomimia (fixed expressionless face - "mask").
   • Micrographia (tiny handwriting).
   • Slow, monotone, quiet speech (hypokinetic dysarthria).
2. Rigidity - increased resistance throughout range of passive motion.
   • Lead-pipe rigidity or cogwheel rigidity (ratchet-like).
   • Present in both arms and legs.
   • Bilateral (distinguishes from Parkinson's which starts unilaterally).
3. Postural instability - falls backward easily.
   • Positive pull test: examiner pulls patient's shoulders backward → patient cannot correct, falls backward (retropulsion).

• Significant dysarthria.
• Dysphagia (aspiration risk).
• Reduced eye movements (convergence, saccades impaired).

• Bilateral hyperreflexia.
• Bilateral Babinski signs (distinguishes vascular Parkinsonism from idiopathic Parkinson's disease where Babinski is absent).
• Prominent bilateral frontal release signs (grasp, palmomental, snout, glabellar).
• Absent abdominal reflexes.

💡 Viva tip: In idiopathic Parkinson's disease - NO Babinski, NO hyperreflexia, NO frontal release signs early. In vascular Parkinsonism (DE3) - these ARE present because there is also UMN/cortical damage.

• Freezing of gait - cannot initiate walking, feet feel "glued."
• Shuffling, festinating gait.
• Falls frequent.
• Turns with multiple tiny steps.

BRAINSTEM SYNDROMES (14-15)

14. Jackson's Syndrome

XII Pair Insufficiency + Central Paralysis + Hemihypesthesia

💡 Viva tip - Jackson's syndrome anatomy: Lesion in the ANTERIOR medulla. The CN XII fascicles exit anteriorly. The corticospinal tract is also anterior (pyramidal decussation happens at medulla-cord junction). So: ipsilateral CN XII palsy + contralateral hemiplegia.

• CN XII - PERIPHERAL palsy on the side of lesion (ipsilateral):
  • Tongue deviates TOWARD the side of lesion on protrusion (the weak tongue is pushed by the healthy side).
  • Atrophy of affected tongue half (visible wasting).
  • Fasciculations of tongue on affected side (LMN = peripheral palsy).
  • This is the KEY distinguishing feature from CENTRAL CN XII palsy.

💡 Viva tip - Peripheral XII vs. Central XII:

• Peripheral (Jackson's): Atrophy + fasciculations + deviation TOWARD lesion.
• Central (Stroke): No atrophy, no fasciculations, deviation TOWARD weakness (contralateral to cortical lesion).

• Contralateral (opposite side to tongue palsy) central hemiparesis/hemiplegia - arm and leg.
• UMN type: spastic, hyperreflexic, Babinski positive.

• Contralateral: hyperreflexia, Babinski, Rossolimo.
• Abdominal reflexes absent contralaterally.

• Contralateral hemihypesthesia (all modalities - both medial lemniscus and spinothalamic tract cross or are already crossed at medullary level → both give contralateral sensory loss).

15. Brown-Séquard Syndrome - C7-Th1

Central Paralysis + Hemihypesthesia

💡 This is one of the most classically tested syndromes in neurology. Learn the dissociation pattern.

• Intact.
• LEFT Horner's syndrome (ptosis + miosis + enophthalmos): descending sympathetic pathway runs ipsilaterally in lateral cord → hemisection at T1 destroys it on left side.

• At C7-T1 level (LMN - AT level): Left arm - flaccid weakness of triceps (C7), hand intrinsics (T1). Atrophy, absent reflexes.
• Below T1 level (UMN - BELOW level): Left leg - spastic paresis, hyperreflexia, Babinski.

• Left arm (at level): Absent triceps (C7), absent finger flexors (C8) - LMN.
• Left leg (below level): Hyperreflexia, clonus, Babinski - UMN.
• Right: Normal.

• Ipsilateral LEFT: Loss of position sense, vibration, fine touch → left leg is "clumsy" (sensory ataxia) but can still feel hot/cold.
• Contralateral RIGHT: Loss of pain and temperature → right leg cannot feel pinprick or hot/cold, but proprioception is intact.

💡 Viva tip: Brown-Séquard = "paradoxical" examination. The leg that is PARALYZED (left) has lost proprioception. The leg that can MOVE normally (right) has lost pain/temperature. Classic dissociation.

INFLAMMATORY / VASCULAR (16-18)

16. Chronic Meningitis

Cerebral + Meningeal Syndromes + Moderate Cognitive Decline

• Impaired attention, concentration, processing speed.
• Memory difficulties.
• Intellectual slowing.
• School/work failure.
• Personality change.

💡 Viva tip: These signs are due to irritation of the meninges and nerve roots. Learn the mechanism for each.

1. Nuchal rigidity (neck stiffness): Cannot flex neck forward (chin doesn't reach chest). Passive neck flexion causes pain/resistance.
2. Kernig's sign: With hip flexed to 90°, patient cannot extend knee >135° (hamstring spasm from meningeal irritation of L3-L5 nerve roots).
3. Brudzinski's signs:
   • Neck sign: Passive neck flexion → involuntary hip and knee flexion.
   • Pubic sign: Pressure on symphysis → hip/knee flexion.
   • Contralateral sign: Flexing one leg → contralateral leg also flexes.
4. Photophobia - light hurts the eyes.
5. Phonophobia - sounds are painful.
6. Hyperesthesia - even light touch on skin is unpleasant.

• Diffuse headache - worse in morning (recumbent position raises ICP overnight), worse with coughing/Valsalva.
• Nausea and vomiting (central - not preceded by nausea in severe cases).
• Papilledema - blurred disc margins on fundoscopy (chronic raised ICP).

• CN VI (abducens) palsy → diplopia, esotropia (false localizing sign - raised ICP stretches CN VI).
• CN VII → peripheral facial palsy.
• CN VIII → sensorineural deafness, vertigo (cochlear involvement).
• CN II → visual loss (optochiasmatic arachnoiditis - in TB meningitis especially).

17. Subarachnoid Hemorrhage

Pseudobulbar Syndrome + Dislocation Syndrome - Moderate Course

• Nuchal rigidity (takes 6-24 hours to develop after bleed).
• Kernig/Brudzinski positive.
• Photophobia.
• Terson syndrome on fundoscopy: subhyaloid (preretinal) hemorrhages.

💡 Viva tip: Pseudobulbar vs. Bulbar:

	Pseudobulbar (UMN)	Bulbar (LMN)
Tongue atrophy	NO	YES
Fasciculations	NO	YES
Jaw jerk	INCREASED	Decreased/absent
Gag reflex	Preserved or increased	Absent/reduced
Pathological crying/laughing	YES	NO
Cause	Bilateral cortical/UMN lesion	Brainstem/lower CN nuclei

• Dysarthria - spastic, strained, nasal quality.
• Dysphagia - cannot swallow safely.
• Dysphonia - nasal, spastic voice.
• Pathological affect - forced crying or laughing without emotional trigger (pseudobulbar affect).
• Jaw jerk increased (masseter/temporalis hyperreflexia - bilateral UMN CN V damage).
• Gag reflex preserved or exaggerated.

💡 Viva tip: Dislocation = brain structures being pushed through foramina by raised ICP. Most common = uncal (temporal lobe) herniation through tentorial notch.

• Progressive decrease in consciousness (rostrocaudal deterioration: alert → drowsy → stupor → coma).
• Anisocoria - unequal pupils. Ipsilateral pupil dilated and unreactive (CN III compressed by uncal herniation = "blown pupil").
• "Down-and-out" eye - ipsilateral eye deviated down and out (CN III palsy).
• Contralateral hemiparesis (cerebral peduncle compressed).
• Bilateral Babinski signs.
• Cheyne-Stokes breathing → central hyperventilation → ataxic breathing (progression of herniation).
• Decerebrate posturing in severe cases (bilateral extensor rigidity).

18. Severe TBI Consequences

Bulbar Syndrome + Marked Cognitive Decline

• Severe memory impairment (especially new learning - hippocampal/temporal damage).
• Executive dysfunction (frontal).
• Severe personality change (disinhibition or apathy - frontal).
• Disorientation.
• Possible post-traumatic psychosis.
• Speech poverty, echolalia.
• Cannot live independently.

💡 Contrast with pseudobulbar (#17 above).

• Dysarthria - FLACCID type: Nasal, breathy, very quiet, slurred. Cannot be heard from distance.
• Dysphagia: Cannot protect airway. Aspiration of food/liquids → recurrent aspiration pneumonia. May require PEG tube (percutaneous gastrostomy).
• Dysphonia: Breathy, nasal voice.
• Tongue: Atrophy and fasciculations of tongue (CN XII nuclear damage - LMN sign).
• Palatal paresis: Uvula deviates away from lesion side (healthy side pulls harder). Nasal regurgitation.
• Gag reflex absent (CN IX, X - LMN, direct brainstem damage).

• IX, X - absent gag, dysphagia, dysphonia.
• XII - peripheral pattern (atrophy, fasciculations).
• VII - possibly peripheral (temporal bone fracture) → forehead also affected.

EPILEPSY (19)

19. Epilepsy

• Inter-ictally (between seizures): Clear, normal.
• During seizure: Impaired in generalized seizures. Variable in focal seizures.

• Inter-ictally: May be normal. Or mild deficits (attention, processing speed) if chronic AED therapy or underlying structural cause.
• Post-ictally: Confusion, drowsiness, amnesia for the event (lasts minutes to hours).

1. Sudden loss of consciousness.
2. Tonic phase (10-30 sec): generalized muscle rigidity, tongue bite, apnea, cyanosis.
3. Clonic phase (1-2 min): rhythmic jerking of all extremities.
4. Post-ictal phase: Deep sleep, confusion, headache, Todd's paralysis.

💡 Todd's paralysis - KEY exam point: Transient (30 min - 48 hrs) focal weakness after a focal seizure. Mimics stroke. Resolves spontaneously. If patient has Todd's paresis → tells you the seizure started in that area (e.g., right arm Todd's paresis → seizure focus in left motor cortex).

• Inter-ictally: Normal (unless structural lesion).
• During seizure: Eyes deviate AWAY from the focus (frontal eye field activation pushes eyes contralaterally).

• Inter-ictally: Normal, OR focal deficit if structural cause (tumor, stroke).
• Focal motor seizure: Jacksonian march - clonic movements starting in face or hand, spreading up the limb (motor cortex activation spreading like a "wave").
• Post-ictally: Todd's paresis in affected limbs.

• Inter-ictally: Normal.
• Post-ictally: Transient Babinski may be present (temporary UMN-like state).

• Focal sensory seizure (somatosensory cortex): paresthesia, tingling spreading Jacksonian-style.
• Visual aura (occipital): flashing lights, zigzag lines.
• Olfactory aura (temporal): smell of something burning or unusual.

PERIPHERAL NERVE INJURIES (20-25)

💡 Master rule for peripheral neuropathies: All are LMN (lower motor neuron) = flaccid weakness + reduced/absent reflexes in the distribution + reduced sensation in the territory. No Babinski. No spasticity.

20. Ulnar Neuropathy - Left

• Interosseous muscles (all 4) weak → cannot spread or adduct fingers.
• Hypothenar muscles weak (abductor digiti minimi) → cannot abduct little finger.
• Adductor pollicis weak → Froment's sign: when patient pinches paper between thumb and index finger, they compensate by flexing thumb IP joint (FPL substitutes for adductor pollicis).
• Wartenberg's sign: little finger spontaneously abducts at rest (cannot adduct due to 3rd palmar interosseous weakness).
• Claw hand (4th-5th fingers): Hyperextension at MCPs + flexion at IPs of ring and little fingers.

💡 Why only ring and little fingers claw? Index and middle finger lumbricals are innervated by MEDIAN nerve, so they are spared. Only ulnar (4th, 5th) lumbricals are affected.

21. Radial Neuropathy - Left

• Wrist drop - cannot extend left wrist.
• Finger drop - cannot extend fingers at MCP joints.
• Thumb drop - cannot extend or abduct thumb.
• Brachioradialis intact (innervated above spiral groove → preserved elbow flexion in mid-supination).
• Triceps may be intact (also innervated above spiral groove in most cases).

• Brachioradialis reflex absent on left.
• Triceps reflex preserved (unless lesion very proximal to spiral groove).

💡 Viva tip: Radial nerve = EXTENSION. Wrist drop + no finger extension = radial nerve injury. Motor deficit is much more prominent than sensory deficit in radial neuropathy.

22. Median Neuropathy - Left

• Phalen's test positive: Wrist flexed for 60 seconds → reproduces symptoms.
• Tinel's test positive: Tapping at left carpal tunnel (wrist crease) → tingling in median distribution.

• Thenar atrophy - flattening of the thenar eminence (APB, opponens pollicis waste away).
• Ape hand - thumb lies flat in the plane of the palm (cannot oppose).
• Cannot bring thumb tip to little finger tip (opposition loss).

💡 Viva tip: Thenar sensation spared + thenar motor affected = carpal tunnel (not more proximal median lesion). If both sensation AND motor of thenar area are affected = proximal lesion.

23. Post-Traumatic Femoral Neuropathy - Right

• Femoral stretch test positive (patient prone, knee flexed: anterior thigh pain = femoral nerve root tension sign).

• Quadriceps femoris weakness (right knee extension) - most prominent finding.
• Cannot extend knee against gravity or resistance.
• Difficulty rising from chair, climbing stairs.
• Knee buckles when walking (quadriceps suddenly gives way).
• Iliopsoas weakness if lesion proximal to inguinal ligament (cannot flex hip).
• Steppage-like gait adapted to avoid knee buckling.

• Right patellar (knee jerk) reflex absent or markedly reduced.

💡 Viva tip: Absent knee jerk = femoral nerve or L3-L4 root pathology. Absent ankle jerk = sciatic/tibial nerve or S1 root.

24. Facial Nerve Neuropathy - Left (Bell's Palsy)

• Forehead: Cannot wrinkle left forehead, cannot raise left eyebrow (this is the single most important sign distinguishing peripheral from central palsy).
• Eye: Cannot close left eye (lagophthalmos). When attempts to close → Bell's phenomenon - eye rolls upward (protective reflex → shows you the white sclera).
• Lower face: Smoothed left nasolabial fold, drooping left corner of mouth, deviation of mouth to right when smiling.
• Cannot puff cheeks (air escapes through left side).
• Cannot whistle.

• Loss of taste on anterior 2/3 of left tongue (chorda tympani branch - before stylomastoid foramen).
• Hyperacusis (stapedial branch - sounds seem louder in left ear).
• Reduced lacrimation left (greater petrosal nerve - if at or above geniculate ganglion).

💡 Critical viva distinction:

	PERIPHERAL CN VII (Bell's)	CENTRAL CN VII (Stroke)
Forehead	AFFECTED (cannot wrinkle)	SPARED (cortical bilateral representation)
Upper face	Affected	Spared
Lower face	Affected	Affected
Cause	Bell's palsy, herpes zoster	Stroke, tumor (above pons)

25. Trigeminal Neuralgia - Right (Tic Douloureux)

• Character: Electric shock-like, lancinating, stabbing. "Worst pain imaginable." Lasts 2-10 seconds to 2 minutes.
• Location: Right face, typically V2 (cheek, upper lip, upper teeth) and/or V3 (lower lip, jaw, lower teeth, tongue). V1 (forehead) rare.
• Triggers: Eating, talking, chewing, toothbrushing, wind on face, touching a specific trigger zone (small area of face, lip, or gum).
• Pain-free intervals between attacks (distinguishes from other facial pain syndromes).
• Patient guards face, avoids touching trigger zone.
• In severe cases: patient refuses to eat, loses weight.

• CN V sensory: NORMAL in classical (idiopathic) TGN. If sensory deficit is found → suspect SECONDARY cause (MS plaque, acoustic neuroma, posterior fossa tumor).
• CN V motor (masseter, temporalis): Normal - no jaw weakness.
• Corneal reflex: Intact bilaterally.

💡 Viva tip: Normal neurological exam between attacks + unilateral paroxysmal facial pain triggered by light touch = Trigeminal neuralgia. Abnormal sensory exam = think secondary cause (MS, tumor, vascular compression).

MOVEMENT DISORDERS / DEGENERATIVE (26)

26. Parkinson's Disease

• Hyposmia/anosmia - reduced sense of smell (early).
• REM sleep behavior disorder - patient acts out dreams, kicks, punches during REM sleep (history from bed partner).
• Constipation (years before diagnosis).
• Depression and anxiety.
• Orthostatic hypotension (autonomic dysfunction).

• Cognitively intact early (distinguishes from PSP, DLB).
• Bradyphrenia - slowed thinking.
• Executive dysfunction later.
• Parkinson's disease dementia - late stage.

• Tremor present at REST, reduces with voluntary movement.
• "Pill-rolling" - thumb rolls over fingers like rolling a pill.
• Usually starts UNILATERALLY (asymmetric onset = hallmark of idiopathic PD).
• Increases with stress, walking.

• Cogwheel rigidity - catch-and-release sensation when passively moving joint (tremor superimposed on rigidity).
• Lead-pipe rigidity - uniform resistance throughout range.
• Increased by contralateral arm movement (Froment maneuver).
• Arms and neck predominantly.

• Slowness and fatiguing of repetitive movements.
• Ask patient to tap thumb and index finger rapidly, or tap foot → movement progressively slows and diminishes (decrement = hallmark).
• Micrographia - handwriting progressively smaller.
• Reduced arm swing when walking.
• Expressionless face (hypomimia).
• Reduced blinking (stare).

• Pull test positive - examiner pulls patient backwards by shoulders → patient falls (no corrective step).
• Falls and fractures.

• Hypomimia (reduced facial expression - "mask face").
• Hypokinetic dysarthria - quiet (hypophonia), monotone, rapid, mumbled.
• Dysphagia - late.
• Glabellar sign positive (Myerson's sign) - tapping forehead repeatedly → normal person habituates and stops blinking; PD patient keeps blinking.
• Saccadic pursuit movements.

• Normal deep tendon reflexes.
• NO Babinski (distinguishes from vascular Parkinsonism).
• Glabellar reflex positive (frontal release sign in PD).

• Stooped posture (flexed neck, flexed trunk, semi-flexed arms and knees).
• Shuffling small steps (marche à petits pas).
• Absent arm swing (bilateral in advanced).
• Festination - accelerating walking, cannot stop easily.
• Freezing at doorways, turning, narrow spaces.
• En-bloc turning - turns body as one unit with multiple tiny steps.

INFECTIOUS / IMMUNE (27-28)

27. Encephalitis - Recovery Period

• Amnestic syndrome - severe anterograde amnesia (cannot form new memories - hippocampal damage).
• Behavioral change - aggression, hypersexuality, inappropriate behavior.
• Temporal lobe epilepsy (post-encephalitic seizures - very common residual).
• Aphasia - if dominant temporal involved.
• Klüver-Bucy syndrome elements - hyperorality, placidity, visual agnosia.

• Psychiatric symptoms prominent (psychosis, catatonia, agitation).
• Movement disorder (orofacial dyskinesias).
• Autonomic instability.
• Seizures.

💡 Viva tip: In encephalitis recovery - the COMBINATION of: (1) amnesia, (2) personality/behavioral change, and (3) epilepsy = strongly suggests herpes simplex encephalitis (temporal lobe involvement). Anti-NMDAR encephalitis = young women, psychiatric symptoms, ovarian teratoma (search for it!).

28. Multiple Sclerosis

• Cognitive impairment in ~50%: processing speed, working memory, attention.
• Fatigue - profound, disproportionate exhaustion (most common and disabling symptom).
• Uhthoff's phenomenon - worsening of ALL neurological symptoms with heat (hot shower, fever, exercise). Pathognomonic.
• Depression (common).

1. Optic neuritis (CN II): Unilateral visual loss with pain on eye movement. Color vision impaired (red desaturation). RAPD (Marcus Gunn pupil) - swinging flashlight: affected eye shows paradoxical dilation. Optic disc pallor on fundoscopy (chronic). Often first presenting symptom.
2. Internuclear ophthalmoplegia (INO) - MOST CHARACTERISTIC OF MS:
   • MLF (medial longitudinal fasciculus) lesion in brainstem.
   • On looking to the LEFT: LEFT eye abducts fine, but RIGHT eye (adduction) is incomplete/slow.
   • LEFT eye shows NYSTAGMUS on abduction (compensation).
   • Bilateral INO in a young adult = MS until proven otherwise.
3. CN VI palsy - diplopia on lateral gaze.
4. Lhermitte's sign - on neck flexion, electric shock sensation radiates down spine into arms/legs. Indicates posterior column (cervical cord) lesion. NOT specific to MS but very characteristic.

• Variable - any combination of spastic paresis (monoparesis, hemiparesis, paraparesis).
• Spastic tone - increased, clasp-knife.
• Spastic paraparesis with hyperreflexia, bilateral Babinski is very common.

• Bilateral hyperreflexia (especially lower limbs).
• Bilateral Babinski signs.
• Absent abdominal reflexes (early sensitive sign - often absent even before other signs).
• Clonus (ankle, patellar).

• Patchy, multifocal sensory disturbances.
• Posterior column loss (vibration, proprioception) often predominates - impaired tuning fork, impaired joint position sense.
• "MS hug" - tight band sensation around trunk (thoracic cord plaque).
• Paresthesia - various levels.

• Cerebellar ataxia.
• Charcot's triad (classic, but not always all 3): Nystagmus + Intention tremor + Scanning speech (staccato dysarthria).
• Dysmetria, dysdiadochokinesis.

• Neurogenic bladder in majority - urgency, frequency, incomplete emptying.
• Sexual dysfunction.
• Constipation.

💡 Viva summary for MS: Young adult + relapsing-remitting attacks + optic neuritis + bilateral INO + spastic paraparesis + posterior column sensory loss + neurogenic bladder + Uhthoff phenomenon = MS.

SPACE-OCCUPYING LESIONS (29-30)

29. Brain Tumor

• Morning headache - pressure highest after lying recumbent all night. Aggravated by bending over, coughing, straining (Valsalva).
• Projectile vomiting - without preceding nausea (direct ICP stimulation of vomiting center).
• Papilledema on fundoscopy: blurred disc margins, venous engorgement, hemorrhages around disc.
• False localizing sign - Bilateral CN VI palsy (abducens nerve stretched over petrous ridge by raised ICP → diplopia even without direct CN VI compression).
• Cushing's triad (late, pre-herniation sign): Hypertension + Bradycardia + Irregular respiration.

💡 Where is the tumor? The focal signs tell you:

• New onset focal seizures in adults = tumor until proven otherwise.
• Focal motor (Jacksonian march) = motor cortex involvement.
• Complex partial (automatisms, aura) = temporal lobe involvement.

30. Spinal Cord Tumor

💡 Two types to know:

• Extramedullary (outside cord, compresses from outside): Meningioma, neurofibroma. Starts with radicular pain → Brown-Séquard → bilateral UMN.
• Intramedullary (within cord itself): Ependymoma, astrocytoma. Starts with central cord pattern (dissociated sensory loss).

• LMN signs: flaccid weakness, atrophy, hyporeflexia/areflexia in muscles at that segmental level.
• Radicular pain: girdle pain (wraps around trunk like a band), worse at night (extramedullary tumors particularly notorious for nocturnal pain).

• UMN signs: spastic paresis, hyperreflexia, Babinski bilateral.
• Progressive paraparesis (if thoracic level).

• Sensory level = horizontal line below which ALL sensation is reduced.
• Example: T6 tumor → cannot feel pinprick below nipple line.
• Intramedullary dissociated pattern: Pain/temperature lost (spinothalamic crossed centrally affected first) but proprioception/vibration preserved early → "cape pattern" (cervical cord) or "suspended" sensory loss.

• At level: LMN - atrophied, flaccid, absent reflexes.
• Below level: UMN - spastic, hyperreflexia, Babinski bilateral, clonus.

• At level: absent (LMN - anterior horn/nerve root damage).
• Below level: hyperreflexia (UMN). Bilateral Babinski.

• Sensory level on trunk.
• Posterior column vs. spinothalamic dissociation helps localize.
• Lhermitte's sign if cervical cord.

1. Early: urgency, frequency.
2. Middle: incomplete bladder emptying (post-void residual).
3. Late: urinary retention or overflow incontinence (neurogenic bladder).
4. Bowel dysfunction: constipation → incontinence.
5. Sexual dysfunction.
6. Loss of perianal sensation (S3-S5) if conus/cauda equina involved.
7. Loss of voluntary anal sphincter contraction.

Quick Reference Exam Card

Final viva tip: Always present findings in anatomical order: consciousness → higher functions → cranial nerves → motor → reflexes → sensory → coordination → pelvic. Examiners reward systematic presentation above all else.

• Format: A4 Landscape, designed for printing
• All 30 diagnoses organized into 10 colour-coded sections:
  • Teal - Cerebral Infarctions (1-6)
  • Blue - Spinal / Radicular (7-11)
  • Purple - Chronic Cerebral Ischemia (12-13)
  • Red - Brainstem Syndromes (14-15)
  • Orange - Inflammatory / Vascular (16-18)
  • Green - Epilepsy (19)
  • Brown - Peripheral Neuropathies (20-25)
  • Dark Green - Movement Disorders (26)
  • Indigo - Infectious / Immune (27-28)
  • Dark Red - Space-Occupying Lesions (29-30)
• 8 columns per diagnosis: No. | Diagnosis | Motor | Reflexes | Sensory | Cranial Nerves | Coordination | Special/Key Signs
• Key abbreviations legend at the bottom
• Alternating row shading for easy reading
• All critical exam differentiators (e.g. UMN vs LMN, peripheral vs central VII, etc.) highlighted in the Special column

THE SIMPLE BRAIN & NERVE GUIDE

30 Diagnoses Made Easy

FIRST: THE 3 GOLDEN RULES YOU NEED FOR EVERYTHING

RULE 1: Which side is weak tells you where the lesion is

Brain lesions = OPPOSITE side weakness The brain controls the OPPOSITE side of the body. Always.

• Right brain damaged → LEFT arm/leg weak
• Left brain damaged → RIGHT arm/leg weak

Spinal cord & nerve lesions = SAME side weakness (with one famous exception: Brown-Séquard, covered later)

RULE 2: UMN vs LMN — the most important distinction in neurology

BRAIN → [Upper Motor Neuron = UMN] → SPINAL CORD → [Lower Motor Neuron = LMN] → MUSCLE

Memory trick: UMN = "Upper = Up" - tone UP, reflexes UP, Babinski UP (toe goes up)

RULE 3: The 5 brain lobes and what they do

SECTION 1: CEREBRAL INFARCTIONS (Strokes)

Diagnoses 1-6

DIAGNOSIS 1: Right Carotid Basin Stroke + Parietal Lobe Syndrome

The parietal lobe is your "body awareness GPS"

• Don't eat from the left side of your plate
• Don't dress your left arm
• Don't notice people standing on your left
• Might even deny your left arm is yours ("That's not my arm!")

What you find on exam:

Memory trick:

"Right brain damage = LEFT body ignored. Right parietal = patient FORGETS their left side exists."

DIAGNOSIS 2: Left Carotid Basin Stroke + Occipital Lobe Syndrome

Deep stroke = very severe weakness

The occipital lobe handles vision

What you find:

Memory trick:

"Left occipital = right visual field gone. Deep stroke = severe (1-2/5) weakness. The deeper the damage, the worse the paralysis."

DIAGNOSIS 3: Vertebrobasilar Stroke + Ataxia + Apraxia

The vertebrobasilar system supplies:

• The brainstem (controls breathing, heart rate, consciousness, swallowing, eye movements)
• The cerebellum (controls coordination and balance)

Ataxia = coordination failure

Apraxia = cannot perform learned movements on command

What you find:

• Finger-to-nose: patient's finger swings past the target (dysmetria)
• Rapid hand slapping: cannot do it rhythmically (dysdiadochokinesis)
• Tremor that GETS WORSE as hand approaches target (intention tremor)

Memory trick:

"Cerebellar stroke = drunk. Cannot coordinate. Eyes jiggle. Falls either way (eyes open or shut). FLOPPY tone, not stiff."

DIAGNOSIS 4: Left Anterior Cerebral Artery (ACA) Stroke + Frontal Lobe Syndrome

Think of the motor homunculus

The frontal lobe = the CEO of the brain

• Lose initiative and drive (sits and stares - abulia)
• Repeat the same action over and over (perseveration)
• Lose impulse control
• Cannot plan ahead
• Automatically grab anything placed in their right palm (grasp reflex - like a baby)
• Cannot speak much (reduced output) but can REPEAT words just fine (transcortical motor aphasia)

Special finding: Urinary incontinence

What you find:

Memory trick:

"ACA = medial brain = LEG area. Frontal syndrome = CEO gone. Grasp reflex = baby behavior. Wet pants = lost frontal bladder control."

DIAGNOSIS 5: Right ACA Stroke + Frontal Lobe Syndrome

• LEFT leg mostly weak
• LEFT arm barely affected
• RIGHT frontal lobe syndrome
• LEFT grasp reflex
• Disinhibition, impulsivity (right frontal is more emotional/behavioral)
• Urinary incontinence
• NO aphasia (right hemisphere, not dominant for language in most people)

Memory trick:

"Mirror of #4. Everything flipped to the left side. Still LEG > arm weakness."

DIAGNOSIS 6: Brainstem Stroke (Recovery) + Left Temporal Lobe Syndrome

Recovery period = things are better but not normal

Left temporal lobe = understanding spoken language

• Patient speaks FLUENTLY but says the WRONG words (paraphasias)
• Cannot understand what you say to them
• Speech sounds like a foreign language - grammatically fluent but meaningless
• This is called Wernicke's aphasia or "fluent aphasia"

What you find:

Memory trick:

"Left temporal = speaks but talks nonsense (Wernicke). Brainstem recovery = mild leftover deficits. Patient sounds like they know what they're saying but they don't."

SECTION 2: SPINAL / RADICULAR CONDITIONS

Diagnoses 7-11

• Pain that TRAVELS (radiates) down the arm or leg
• Weakness in specific muscles (the ones that root controls)
• Reduced reflexes at that level (always LMN here - no Babinski)
• Numbness in specific skin territories (dermatomes)

DIAGNOSIS 7: Cervical Disc Herniation C6-C7, Left Radiculopathy

Remember C6 and C7 like this:

What you find:

Memory trick:

"C6 = THUMB (six is thumbs up!). C7 = MIDDLE FINGER. Pain shoots where the finger is."

DIAGNOSIS 8: Cervical Disc Herniation C6-C7, BILATERAL Radiculopathy

• Legs become stiff and weak (spastic)
• Babinski appears in the feet
• Bladder problems develop This is called myelopathy and is a surgical emergency.

Memory trick:

"Both arms = same as one arm but times two. If legs involved too = cord compression = alarm."

DIAGNOSIS 9: Lumbar Disc Herniation L5-S1, Left Radiculopathy

Remember L5 and S1 like this:

What you find:

• L5: Cannot lift left foot up properly - "foot drop." Cannot lift big toe. Walks with a slapping steppage gait.
• S1: Cannot stand on left tiptoe. Pushes off weakly when walking.

Memory trick:

"Sciatica = electric pain from back to foot. S1 = no ankle jerk. L5 = foot drop. Lasègue = testing the guitar string."

DIAGNOSIS 10: Spinal Cord Injury C7-T1 (Recovery Period) + Pelvic Dysfunction

The two-level rule (most important concept for cord injuries):

• AT the dam = broken pipe (LMN)
• BELOW the dam = flooded (UMN - signals piling up with no brake)

C7-T1 level specifically affects:

• Triceps weak and wasted (C7) - LMN
• Hand intrinsic muscles wasted (T1) - interossei, thenar - "claw hand" tendency
• Triceps reflex absent

• Both legs spastic and stiff - UMN
• Hyperreflexia in both legs
• Babinski in both feet
• Clonus (rhythmic beating at ankle)

• Droopy eyelid (ptosis)
• Small pupil (miosis)
• Sunken eye (enophthalmos) Why? The sympathetic nerve to the eye runs down through T1 and gets cut here.

Pelvic dysfunction:

Memory trick:

"C7-T1 cord damage: Hand muscles wasted and floppy (LMN at level), legs stiff and brisk (UMN below). Horner's eye = sympathetic T1 cut."

DIAGNOSIS 11: Spinal Cord Injury L1-L2 (Recovery Period) + Pelvic Dysfunction

The conus is where the cord ends - it contains the sacral segments S2-S5 that control the bladder, bowel, and genitals.

The SADDLE area:

What you find:

• Knee jerk: variable
• Ankle jerk: reduced/absent
• Anal reflex ABSENT (cannot wink perianal skin)
• Bulbocavernosus reflex ABSENT

Pelvic dysfunction (ATONIC type - opposite of C7-T1!):

• Bladder is FLOPPY (atonic) - no sensation of fullness. Overflows and dribbles.
• Cannot empty voluntarily - needs catheter or manual pressure.
• Bowel incontinence.
• No reflex erection.
• No voluntary anal squeeze.

• C7-T1 = SPASTIC bladder (too much tone - urgency)
• L1-L2 = ATONIC bladder (no tone - overflow)

Memory trick:

"L1-L2 = CONUS. Saddle numb. Floppy bladder dribbles like a leaky tap. C7-T1 = spastic bladder squeezes unexpectedly."

SECTION 3: CHRONIC CEREBRAL ISCHEMIA

Diagnoses 12-13

DIAGNOSIS 12: Chronic Cerebral Ischemia Stage 2 + HYPERKINETIC Syndrome

Hyperkinetic = TOO MUCH movement

• Tremor in hands when holding them out
• Chorea - brief random jerky movements (looks like they're always fidgeting)
• Myoclonus - sudden single jerks

What you find:

Memory trick:

"Stage 2 = moderate. Hyperkinetic = too much movement. Like an old car where everything rattles. Can still drive (mostly), but barely."

DIAGNOSIS 13: Chronic Cerebral Ischemia Stage 3 + HYPOKINETIC-RIGID (Akinetic-Rigid) Syndrome

Akinetic-Rigid = TOO LITTLE movement

• Akinesia - cannot initiate movement
• Bradykinesia - every movement is extremely slow
• Rigidity - arms and legs stiff like lead pipes throughout entire range of movement

The KEY exam difference from Parkinson's disease:

• Bilateral Babinski signs (BOTH feet) - vascular damage to corticospinal tracts
• Bilateral hyperreflexia
• Bilateral frontal release signs

What you find:

Memory trick:

"Stage 3 = statue + dementia. Like Parkinson's but WORSE + Babinski present (brain also damaged). Car won't start AND the driver has forgotten where they're going."

SECTION 4: BRAINSTEM SYNDROMES

Diagnoses 14-15

DIAGNOSIS 14: Jackson's Syndrome

1. The hypoglossal nerve (CN XII) nucleus on ONE side
2. The motor tract (corticospinal) as it passes through

The crossed pattern (why it's famous):

How to tell peripheral CN XII from central CN XII:

Memory trick:

"Jackson's = like a tilted seesaw. Tongue falls toward the bad side (ipsilateral, peripheral). Body is paralyzed on the opposite side (contralateral, UMN). ATROPHY of tongue = peripheral."

DIAGNOSIS 15: Brown-Séquard Syndrome C7-T1

Why is it counterintuitive?

1. Motor tract (corticospinal) - already crossed in the medulla. So a RIGHT cord lesion causes RIGHT-sided paralysis (same side as lesion at spinal level).
2. Posterior column (proprioception/vibration) - crosses in the medulla. So RIGHT cord lesion = RIGHT proprioception lost (same side).
3. Spinothalamic tract (pain/temperature) - crosses within 1-2 levels of entry in the spinal cord. So RIGHT cord lesion = LEFT pain/temperature lost (opposite side).

The CLASSIC pattern (left cord hemisection for example):

• UMN paralysis of left leg (below lesion)
• LMN weakness at C7-T1 level in left arm (at level)
• Loss of proprioception and vibration left leg (posterior column)
• Horner's syndrome left eye (sympathetic pathway cut at T1)

• Normal strength (can walk)
• Loss of pain and temperature (spinothalamic crossed below lesion)

Memory trick:

"Brown-Séquard = PARADOX. Paralyzed leg still feels hot/cold. Walking leg cannot feel hot/cold. Half cord = half each. Horner's eye on same side as lesion."

SECTION 5: INFLAMMATORY / VASCULAR

Diagnoses 16-18

DIAGNOSIS 16: Chronic Meningitis + Cerebral + Meningeal Syndromes

The meninges are like 3 layers of cling wrap around the brain

The 4 meningeal signs - and WHY they happen:

Cerebral syndrome (raised pressure):

Memory trick:

"Meningitis = brain in a painful straitjacket. Cannot move neck. Cannot straighten leg. Hates light and sound. Like a severe hangover that never stops."

DIAGNOSIS 17: Subarachnoid Hemorrhage + Pseudobulbar Syndrome + Dislocation Syndrome

The classic presentation:

Pseudobulbar syndrome - what it means:

• Dysarthria - strained, nasal, strangled speech (not flaccid/breathy)
• Dysphagia - trouble swallowing
• Pathological affect - forced crying or laughing that patient CANNOT stop or control, unrelated to actual emotion
• Jaw jerk increased (both sides of corticobulbar tract cut)
• Gag reflex PRESERVED (unlike true bulbar palsy where gag is absent)

Dislocation syndrome = brain herniation:

• Pupil on one side dilates and stops reacting to light (CN III squeezed)
• Consciousness progressively drops
• Eventually decerebrate posturing (rigid extension of all limbs)

Memory trick:

"SAH = THUNDERCLAP headache. Pseudobulbar = both sides of brain = puppet with both strings cut = pathological crying/laughing. Herniation = brain being squeezed through a hole = emergency."

DIAGNOSIS 18: Severe TBI Consequences + Bulbar Syndrome + Marked Cognitive Decline

TRUE Bulbar palsy = LOWER brainstem damage

• Wasted (smaller than normal)
• Fasciculating (twitching under the skin)
• Cannot stick out properly
• This is pathognomonic of TRUE bulbar palsy

• Speech is breathy, very quiet, nasal - like someone speaking with no air (flaccid dysarthria)
• Cannot swallow safely - food and liquid go into lungs → pneumonia → often needs a feeding tube (PEG)
• Gag reflex absent

Cognitive decline:

Memory trick:

"TRUE Bulbar = tongue shrinks and twitches + no gag + flaccid speech. Think of it as the brainstem machinery actually broken down vs. pseudobulbar where the remote control (cortex) is broken but the machinery still works."

SECTION 6: EPILEPSY

Diagnosis 19

DIAGNOSIS 19: Epilepsy

Think of it like a circuit that occasionally short-circuits

Key exam concepts:

1. Sudden loss of consciousness
2. Tonic phase (rigid stiffening, stops breathing, turns blue) ~20-30 seconds
3. Clonic phase (rhythmic jerking) ~1-2 minutes
4. Post-ictal phase (deep sleep, confusion, headache) - minutes to hours

1. Tongue bite - biting the tongue = almost diagnostic of GTC seizure
2. Urinary incontinence during seizure = very suggestive
3. Post-ictal Todd's paresis = temporary weakness in one limb after a focal seizure

Todd's paresis is the most important exam concept:

During the seizure - eye deviation:

Memory trick:

"Epilepsy = electrical storm that passes. Normal between storms. Todd's paresis = brain's hangover in one limb. Eyes go AWAY from the trouble during the storm."

SECTION 7: PERIPHERAL NEUROPATHIES

Diagnoses 20-25

• LMN ONLY - floppy, wasted, no Babinski, reduced reflexes
• Pain/numbness in EXACTLY that nerve's territory (not the whole side of body)
• Motor loss in EXACTLY that nerve's muscles

DIAGNOSIS 20: Ulnar Nerve Compression - Left (Cubital Tunnel)

The ulnar nerve controls small hand muscles and the 4th-5th fingers

1. Froment's sign: Ask patient to hold a piece of paper between thumb and index finger. Normal = adductor pollicis holds it flat. Ulnar damage = adductor pollicis weak, so thumb compensates by flexing its IP joint (FPL takes over). The bent thumb = positive Froment.
2. Wartenberg's sign: Little finger spontaneously abducts (sticks out sideways) at rest because the opposing muscle (3rd palmar interosseous) is weak.
3. Tinel's at medial epicondyle: Tapping the inside of the elbow → electric shock to ring and little fingers.

Memory trick:

"Ulnar = FUNNY BONE nerve. Ring + little finger claw. Froment = bent thumb trying to compensate. Tinel at elbow. 4th + 5th fingers are the ulnar fingers."

DIAGNOSIS 21: Radial Nerve Compression - Left (Spiral Groove)

The radial nerve controls ALL extension in the arm

• Cannot extend fingers at knuckles (finger drop)
• Cannot extend thumb
• Cannot supinate forearm (supinator muscle)

Memory trick:

"Radial = EXTENSION. Wrist drop = cannot extend. Saturday night arm over chair back → wake up with floppy wrist. Motor much worse than sensory."

DIAGNOSIS 22: Median Nerve Compression - Left (Carpal Tunnel)

The median nerve controls the thenar muscles (base of thumb) and lateral 3.5 fingers' sensation

1. Phalen's test: Hold wrists maximally flexed for 60 seconds → reproduces the tingling
2. Tinel's test: Tap at the wrist over the carpal tunnel → electric tingling in the median fingers

Memory trick:

"Median = THENAR. Ape hand at base of thumb. Wakes up at night, shakes hand. Phalen + Tinel at wrist. Thenar skin spared = carpal tunnel confirmed."

DIAGNOSIS 23: Femoral Nerve Neuropathy - Right (Post-traumatic)

The femoral nerve controls the QUADRICEPS (biggest muscle in the body)

Memory trick:

"Femoral = QUAD = knee extension. No knee jerk. Knee buckles walking. Atrophy of front of thigh. Think of it as the knee's 'lock' mechanism being broken."

DIAGNOSIS 24: Facial Nerve Neuropathy - Left (Bell's Palsy)

THE critical distinction: Peripheral vs. Central facial palsy

Why is this?

• Forehead motor neurons in the brainstem receive input from BOTH hemispheres
• Peripheral lesion = the actual nerve is cut = EVERYTHING it supplies is paralyzed
• Stroke (upper motor neuron) = only contralateral hemisphere = forehead compensated by ipsilateral hemisphere

The branches tell you how high the lesion is:

• Taste loss (chorda tympani branch)
• Hyperacusis (stapedius branch - sounds too loud)
• Dry eye (greater petrosal nerve)

The eye is dangerous:

Memory trick:

"Bell's palsy = whole left face frozen. FOREHEAD INVOLVED = peripheral. Forehead SPARED = stroke. Cannot close eye = cornea danger. Pain behind ear precedes the palsy."

DIAGNOSIS 25: Trigeminal Neuralgia - Right (Tic Douloureux)

The most dramatic pain in medicine

• Electric shock, lightning strike, knife stab quality
• Lasts only seconds to 2 minutes then completely stops
• Triggered by the lightest touch: eating, talking, a breeze, toothbrushing
• Completely FREE OF PAIN between attacks

The trigger zone:

The critical exam finding:

Memory trick:

"TGN = lightning bolt in the face that disappears completely. Normal exam between bolts. Touch triggers the bolt. If sensory deficit found = secondary cause."

SECTION 8: MOVEMENT DISORDERS

Diagnosis 26

DIAGNOSIS 26: Parkinson's Disease

Think of dopamine as the oil in a car engine

• Everything moves TOO SLOWLY (bradykinesia)
• Everything stays in one position (rigidity)
• Parts tremble when not in use (resting tremor)
• Cannot keep balance (postural instability)

The 4 cardinal features (need 2 for diagnosis):

The FACE tells you in 3 seconds:

• Mask face - expressionless, no spontaneous smiling
• Reduced blinking - stare
• Quiet, monotone speech
• Drooling (not excess saliva - they just don't swallow enough because movements are reduced)
• Glabellar sign - tap their forehead repeatedly - normal people stop blinking; PD patients keep blinking every tap (cannot habituate)

The early warning signs (before motor features, often years earlier!):

1. Loss of smell (hyposmia)
2. REM sleep behavior disorder (acts out dreams - partner gets kicked/hit)
3. Constipation
4. Depression

The GAIT is almost diagnostic:

The one critical exam distinguisher from vascular Parkinsonism:

• TRUE Parkinson's: NO Babinski, NORMAL reflexes
• Vascular Parkinsonism: Babinski PRESENT, hyperreflexia

Memory trick:

"Parkinson's = no oil in brain engine. Stiff, slow, trembles at rest. Asymmetric start. Mask face, pill roll, penguin walk. Normal reflexes! No Babinski! Smell and sleep problems come first."

SECTION 9: INFECTIOUS / IMMUNE

Diagnoses 27-28

DIAGNOSIS 27: Encephalitis - Recovery Period

Encephalitis = brain ON FIRE

• Attacks the temporal lobes and frontal lobes preferentially
• Patient in acute phase: confused, aggressive, having seizures, feverish, amnestic

What's left in recovery:

1. Severe amnesia - cannot form new memories. Hippo campus (the brain's filing system) is destroyed. Patient lives in a permanent "present" - cannot remember what happened 5 minutes ago.
2. Behavioral change - aggression, hypersexuality, putting objects in mouth (Kluver-Bucy elements)
3. Epilepsy - the scarred temporal lobe becomes a seizure focus (very common residual)
4. Aphasia if dominant temporal affected

• Usually young women
• Starts as PSYCHIATRIC illness (psychosis, catatonia)
• Then seizures + movement disorder (orofacial dyskinesias - strange mouth/tongue movements)
• Often associated with ovarian teratoma (benign ovarian tumor acts as trigger)
• Key: always search for the tumor if anti-NMDAR antibodies found

Memory trick:

"HSV = destroys temporal lobe = patient remembers NOTHING new (amnesia) + has seizures + behaves strangely. Anti-NMDAR = young woman + 'psychiatric' encephalitis + check for ovarian tumor."

DIAGNOSIS 28: Multiple Sclerosis

The golden rule: Disseminated in TIME and SPACE

• Space = lesions in MULTIPLE different places in the CNS
• Time = attacks happen at DIFFERENT times (relapse-remission pattern)

The five hallmark features for viva:

The sensory pattern:

The Charcot triad (classic teaching, less common in practice):

Memory trick:

"MS = random wires stripped of insulation in young adults. Optic neuritis first. INO = hallmark. Lhermitte = electric shock when looking down. Uhthoff = worsens in heat. Bilateral Babinski + absent abdominal reflexes + posterior column loss."

SECTION 10: SPACE-OCCUPYING LESIONS

Diagnoses 29-30

DIAGNOSIS 29: Brain Tumor

Think of the skull as a rigid box

Two simultaneous effects:

• Morning headache: You lie flat all night → pressure builds (gravity isn't helping drain) → worst headache on waking
• Projectile vomiting: Pressure stimulates vomiting center directly → vomiting without nausea first
• Papilledema: Pressure transmitted back along optic nerve sheath → optic disc swells (visible on fundoscopy as blurred disc margins)
• Cushing's triad (very late/emergency): High blood pressure + slow heart rate + irregular breathing = brain about to herniate

Seizures:

False localizing sign:

Memory trick:

"Brain tumor = EXPANDING in a rigid box. Morning headache + projectile vomit + papilledema = ICP up. Where it hurts + what fails = where the tumor is. New adult seizures = tumor until proven otherwise."

DIAGNOSIS 30: Spinal Cord Tumor

The THREE-LEVEL RULE (the key to understanding any cord lesion):

• ABOVE the blockage: normal (pipe flows fine above)
• AT the blockage: broken pipe (LMN - floppy, wasted, absent reflexes)
• BELOW the blockage: backed up, overpressured (UMN - spastic, hyperreflexic, Babinski)

The two types of spinal cord tumors:

• First symptom: RADICULAR PAIN (girdle pain at the level)
• Classically worse at NIGHT (unlike disc disease which worsens with movement)
• Then Brown-Séquard pattern develops
• Then complete paraplegia

• Starts centrally → damages crossing spinothalamic fibers first
• DISSOCIATED sensory loss: pain and temperature lost in a "cape" or "suspended" pattern (level where crossing fibers are damaged), BUT vibration and proprioception PRESERVED (posterior columns not yet touched)
• Picture: patient can feel a pin on their hand but cannot feel if it's a hot pin

The sensory level - the most useful physical sign:

Progressive pelvic dysfunction:

1. First: urgency, frequency
2. Then: incomplete emptying (post-void residual)
3. Then: retention OR overflow incontinence
4. Finally: full bowel and bladder incontinence

Lhermitte's sign (cervical cord tumor):

Memory trick:

"Cord tumor = PROGRESSIVE squeezing of a pipe. AT level = LMN (floppy), BELOW = UMN (stiff). Intramedullary = dissociated sensory loss (cape pattern - feels touch but not heat). Extramedullary = night pain first. Bladder fails progressively."

MASTER QUICK-REFERENCE SUMMARY

The 10 Most Tested Clinical Rules

The "First Symptom" Memory Chain

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