Motor System Examination Case Sheet PDF

CASE SHEET – EXAMINATION OF MOTOR SYSTEM NAME: AGE: SEX: ADDRESS: OCCUPATION: GENERAL EXAMINATION: Posture and attitude: Normal Body build and nourishment: Moderately built and moderately nourished Pallor: No Pallor Icterus/ Jaundice: No icterus Cyanosis: No cyanos...

CASE SHEET – EXAMINATION OF MOTOR SYSTEM NAME: AGE: SEX: ADDRESS: OCCUPATION: GENERAL EXAMINATION: Posture and attitude: Normal Body build and nourishment: Moderately built and moderately nourished Pallor: No Pallor Icterus/ Jaundice: No icterus Cyanosis: No cyanosis Clubbing: No clubbing Lymphadenopathy: No lymphadenopathy Edema: No edema Skin, hair and nails: Normal Other features: Gait: Normal Thyroid swelling: No thyroid swelling Varicosity of veins: No varicosity of veins VITAL SIGNS: ARTERIAL PULSE: 1. RATE: /min 2. RHYTHM : Regular 3. VOLUME: Normal 4. CHARACTER: Normal 5. CONDITION OF VESSEL WALL: No vessel wall thickening  6. RADIOFEMORAL DELAY: No radiofemoral delay 7. Other peripheral pulsations: All peripheral pulsations are normal and equally felton both sides BLOOD PRESSURE: / mm Hg in Right arm in sitting position RESPIRATION: Rate: /min Rhythm: Type: TEMPERATURE: Afebrile EXAMINATION OF HIGHER FUNCTIONS: 1. Appearance and behavior : Normal 2. Level of consciousness: Fully conscious 3. Mental and emotional state: Normal 4. Orientation in place, time and person: Well oriented 5. Delusion and hallucination: no delusion and hallucination 6. Memory: Normal 7. General intelligence: Normal 8. Speech: Normal Examination Of Motor Part Of Cranial Nerves: 1. III, IV, VI. (OCULOMOTOR, TROCHLEAR AND ABDUCENT NERVE): a) Movement of eyeball RIGHT LEFT Adduction Normal Normal Abduction Normal Normal  Elevation Normal Normal Depression Normal Normal b) Squint No squint No squint c) Ptosis No ptosis No ptosis d) Pupil Size Normal Normal Shape Round and regular Round and regular Reaction to light Direct light reflex Present and Normal Present and Normal (constriction of pupil (constriction of on same side) pupil on same side) Indirect light reflex Present and Normal Present and Normal (constriction of pupil on opposite side) e) Accomodation reflex Present and Normal (convergence of eye balls and constriction of pupils) 2. V. (TRIGEMINAL NERVE): Clenching of teeth (Temporalis, Masseter) – Equally prominent on both sides Opening of mouth (Lateral pterygoid) - No deviation of jaw 3. VII. (FACIAL NERVE): RIGHT LEFT 1. Wrinkling of forehead Present Present 2. Closure of eyelids Unable to make eyes open with normal effort while subject keeps them closed 3. Nasolabial fold Present Present 4. Deviation of Angle of mouth No deviation of angle of mouth 5. Whistling Able to whistle 6. Inflating mouth and blowing Able to inflate mouth and blowout the cheeks against resistance without leakage of air 7. History of hyperacusis No h/o hyperacusis 4. IX. (GLOSSOPHARYNGEAL NERVE): Gag/ Pharyngeal reflex - Present and normal (Reflex contraction of pharyngeal muscle)  Palatal reflex - Present and normal (Reflex contraction of palate) 5. X. (VAGUS NERVE): History of nasal regurgitation - No h/o nasal regurgitation History of dysphagia - No h/o dysphagia Nasal tone of voice - No nasal tone Position of uvula - Central Movement of palate - Normal (Equal on both sides) Gag reflex - Present and normal (Reflex contraction of pharyngeal muscle) Palatal reflex - Present and normal (Reflex contraction of palate) 6. XI. (SPINAL ACCESSORY NERVE): Trapezius - Able to shrug the shoulder against resistance Sternocleidomastoid - Sternocleidomastoid stands out prominently while turning face to the opposite side against resistance 7. XII.(HYPOGLOSSAL NERVE): Protusion of tongue as far as possible – No deviation of tongue Movement of tongue from side to side and pushing cheek against resistance – Can move tongue equally to both sides and pushing cheek against resistance Wasting of tongue - No wasting of tongue Fibrillation / Fasciculation - No fibrillation or fasciculation of tongue EXAMINATION OF MOTOR SYSTEM RIGHT LEFT UL LL 1. Bulk of muscle UL LL NORMAL NORMAL NORMAL NORMAL 2. Tone of muscle NORMAL NORMAL NORMAL NORMAL 3.STRENGTH OF MUSCLE Upper limb muscles: S.No Muscle Right Left 1. Abductor pollicis brevis Grade 5 Grade 5 2. Opponens pollicis Grade 5 Grade 5 3. 1st Dorsal interossei Grade 5 Grade 5 4. Interossei and lumbricals Grade 5 Grade 5 5. Flexors of fingers Grade 5 Grade 5  6. Flexors of wrist Grade 5 Grade 5 7. Extensors of wrist Grade 5 Grade 5 8. Brachioradialis Grade 5 Grade 5 9. Biceps Grade 5 Grade 5 10. Triceps Grade 5 Grade 5 11. Supraspinatus Grade 5 Grade 5 12. Deltoid Grade 5 Grade 5 13. Infraspinatus Grade 5 Grade 5 14. Pectoralis Grade 5 Grade 5 15. Serratus anterior Grade 5 Grade 5 16. Latissimus dorsi Grade 5 Grade 5 Muscles Of Trunk: S.No Muscle Right Left 1. Abdominal Muscle Grade 5 Grade 5 2. Babinski’s rising up sign Negative 3. Beevor’s sign Negative 4. Errector spinae Grade 5 Grade 5 5. Trapezius Grade 5 Grade 5 Lower limb muscles: S.No Muscle Right Left 1. Dorsiflexors of foot Grade 5 Grade 5 2. Plantar Flexors of foot Grade 5 Grade 5 3. Extensors of the knee Grade 5 Grade 5 4. Flexors of the knee Grade 5 Grade 5 5. Flexors of the thigh Grade 5 Grade 5 6. Adductors of the thigh Grade 5 Grade 5 7. Abductors of the thigh Grade 5 Grade 5 8. Rotators of thigh Grade 5 Grade 5 9. Extensors of the hip Grade 5 Grade 5 TESTS FOR CO-ORDINATION: S.No Upper Limb: 1. Finger nose test Normal on both sides 2. Dysdiadochokinesia No dysdiadochokinesia Lower Limb: 3. Walking along a straight line Normal 4. Heel knee test Normal on both sides  Reflexes : Normal  Gait : Normal   Involuntary Movements : No involuntary movements REPORT: On examination, the motor system of given subject is found to be within normal limits.