Neurological History Taking and Physical Examination Dr. M. A. Sofi MD; FRCP (London); FRCPEdin; FRCSEdin

Neurological History: Taking the patient's history is traditionally the first step in virtually every clinical encounter. Pain should be further defined: Location (Ask the patient to point with one finger, if possible.) Radiation (Pay attention to any dermatomal relationship.) Quality (stabbing, stinging, lightning like, pounding, etc) Severity or quantity Precipitating factors (stress, periods, allergens, sleep deprivation, etc) Relieving factors (sleep, stress management, etc) Diurnal or seasonal variation The history of the presenting illness or chief complaint should include the following: Symptom onset (eg, acute, subacute, chronic, insidious) Duration Course of the condition (eg, static, progressive, or relapsing and remitting) Associated symptoms, such as pain, headache, nausea, vomiting, vertigo, numbness, weakness, and seizures

“Red flag” symptoms in headache Explanation Sudden onset (Maximal immediately or within minutes) Subarachnoid hemorrhage Cerebral venous thrombosis Pituitary apoplexy Meningitis Focal neurological symptoms (other than for typically migraines) Intracranial mass lesion Vascular Neoplastic Infection Constitutional symptoms Weight loss Fever Meningism General malaise Rash Meninencephalitis Neoplastic (Lymphoma or metastasis) Inflammatory (Vasculitic) Raised intracranial pressure (Worse on wakening/lying down associated vomiting) New onset ˃ 40 years age Temporal arteritis

Fainting Also called syncope, is a sudden, brief loss of consciousness and posture caused by decreased blood flow to the brain. Fainting can be triggered by a number of factors, including: Fear or other emotional trauma. Severe pain. A sudden drop in blood pressure. Low blood sugar due to diabetes or from going too long without eating. Hyperventilation (rapid, shallow breathing) Dehydration. Standing in one position for too long.

History, physical exam, ECG, basic lab tests Syncope Alarming symptoms Sudden without preceding symptoms History of heart disease History of sudden death in family Syncope with chest pain Seizure disorder Syncope with weakness and or speech problems No alarming symptoms Young age Feeling dizzy warm or nauseated Syncope with urination or defecation Syncope with pain or sight of blood No history of heart disease History, physical exam, ECG, basic lab tests No No No No Suspected cardiac cause Suspected neurologic cause Light headedness on standing Reflex mediated Unexplained recurrent syncope Yes Yes Yes Yes Yes Echocardiogram Stress test Holter monitoring Electrophysiology Drugs Electroencephalo-grm (EEG) Brain imaging (CT, MRI/MRA) Vital signs BP in sitting & standing position Tilt table test Carotid massage Implantable loop monitor Endocrine study Electrophysiology study

Alteration of consciousness Seizure Loss of consciousness Yes Yes Generalized seizure Partial seizure Alteration of consciousness No Yes Simple partial Complex partial

Transient loss of consciousness Precipitants e.g. micturition History and physical Witness account Light headed Light headedness Sweating Prolonged standing Precipitants e.g. micturition Chest pain Palpitations Slow heart rate Low blood pressure Déjà vu Jamais vu Aphasia Olfactory aura Epigastric sensation Tongue biting Post event delirium Focal neurology Pallor Sweating Slow pulse Low blood pressure Myoclonus or convulsion after : Pallor sweating after collapse Aphasia Delirium Head turn Automatism Posturing Convulsions Postictal delirium Syncope Seizure Syncope Convulsive Syncope Seizure

Dizziness Malaise Near syncope/Light headedness Vertigo Dysrhythmias Myocardial infarction Hypovolemia Vasovagal Sepsis Panic disorder Drug side effects Near syncope/Light headedness Malaise Anemia Infection Depression Dizziness Vertigo Peripheral Attacks : sudden , severe, usually seconds or minutes Nystagmus: horizontorotatory, worsened by head position No neurologic findings Central Attacks: gradual, mild usually continuous for weeks and months but can be sudden, severe and seconds or minutes with vascular causes Nystagmus: Usually vertical and downbeat Little change with head position Neurologic findings usually present No auditory findings Cerebellar hemorrhage BVP Short livid, positional caused by stray otoconial particles Positive Hallpike test Meniere’s Tennitus Hearing loss Attacks in clusters Long symptom free intervals Vestibular neuronotis Severe vertigo for days Mild persistant positional vertigo No auditory symptoms Positive head thrust test Acoustic neuroma Peripheral cause that can become central vertigo hearing loss Tennitus Hypoglycemia Head trauma Multiple sclerosis Labyrinthitis Vertebrobasilar migraine Vertebrobasilar insufficiency Associated with neurological abnormalities Acute suppurative Toxic patient Severe vertigo Serous: Inflammatory response to nearby infections Toxic Hearing loss Tennitus Chronic Symptoms secondary to fistula

ATAXIA Acute onset Types Cerebellar Sensory Vestibular COMMON CAUSES: Labyrinthitis/MS/stroke/NPH/ C2H5OH/Spinal cord disorders/ Multisensory loss Acute onset TIA STROKE ACUTE C2H5OH INTOXICATION POSTVIRAL STATUS INFECTION ACUTE METABOLIC SYNDROME MUSCLE WEAKNESS MEDICATIONS TENNITUS VERTIGO &/OR HEARING LOSS

ATAXIA Gradual onset Labyrinthitis/MS/stroke/NPH/ COMMON CAUSES: Labyrinthitis/MS/stroke/NPH/ C2H5OH/Spinal cord disorders/ Multisensory loss Gradual onset Toxic exposure No toxic exposure Mercury Lead Thallium Carbon Tetrachloride Tououne Family history No Family history Friedreich ataxia Ataxia telangiectasia Sensory loss in extremities No Sensory loss Peripheral neuropathy Syphilis Spinal cord tumor or injury Vitamin B12 deficiency Multiple sclerosis HIV infection Posterior fossa lesions Multiple sclerosis Hypothyroidism Syphilis Normal pressure hydrocephalus

Nerve conduction EMG testing Sensory Examination Pattern of involvement Symmetrical distal neuropathy Symmetrical proximal neuropathy Asymmetrical proximal neuropathy Possible neurological screening and consultation for possible underlying cause Motor Sensorimotor Sensory Small fiber/AF Look for feet Perception of pain Temperature Vibration Touch Small muscle atrophy Imbalance of power between flexors and extensors of muscle, clawed toes and prominent metatarsal heads Callus Decreased sweating or dry skin Fissures Oedema Vibration dorsum of great toe bilaterally Pressure on planter side bilaterally Ankle reflex bilaterally Dorsiflexors/ planter flexors Diminished/Absent pressure response Diminished/Absent reflexes Reduced/ week Diminished/ Absent vibration Nerve conduction EMG testing

Examination of the Higher Functions Components of Higher Functions Higher functions include gait, speech, and mental status. Gait is the attitude of a person in the upright position. Hemiparetic gait: The shoulder is adducted; the elbow is flexed; the forearm is pronated, and the wrist and fingers are flexed. Ataxic gait: Patient spreads his or her legs apart to widen the base of support to compensate for the imbalance while standing or walking The heel-to-toe or tandem walking maneuvers and standing on 1 leg uncover subtle forms of ataxia Shuffling gait: The individual takes short steps and appears to shuffle his or her legs rather than put them forward. Steppage gait: Individual takes high steps as if climbing a flight of stairs while walking on a level surface. Spastic or scissor gait: The legs are held in adduction at the hip and the thighs rub against each other as the patient walks. Antalgic gait: Patient favors the affected painful (usually lower) extremity and walks, putting weight on the normal leg. The hand held over hip on the affected side is typical in patients with radicular pain.

Category Tests Example of write up Cerebellum Cerebellar testing Dysmetria Finger-to-nose test Ankle-over-tibia test Dysdiadochokinesis Rapid pronation-supination Ataxia Nystagmus Intention tremor Staccato speech "intact finger-to-nose” Gait Gait is an attitude of a person in upright position. Abnormal types are: Gait WNL H E M I P L G C P R O U L S I V E S C I O R S T E P A G W A D L I N G

Mini–mental state examination Category Possible points Description Orientation to time 5 From broadest to most narrow. Orientation to time has been correlated with future decline. Orientation to place From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor. Registration 3 Repeating named prompts Attention and calculation Serial sevens, or spelling "world" backwards. It is more appropriate in a population where English is not the first language. Recall Registration recall Language 2 Naming a pencil and a watch Repetition 1 Speaking back a phrase Complex commands 6 Varies. Can involve drawing figure shown Total score 30

Examination of the Higher Functions Speech Speech is communication between individuals. Abnormalities include dysphonia, dysarthria, and dysphasia or aphasia. Dysphonia or aphonia Dysphonia is the impairment or inability to phonate. The voice becomes hoarse. In extreme cases, it is absent, and the patient is mute. Dysarthria or anarthria Dysarthria is the inability to articulate spoken words. The quality of oration is impaired, but the content remains intact (e.g., slurred speech). Ability to understand and synthesize speech remains intact. Dysphasia or aphasia: In dysphasia, the ability to process language is impaired, resulting in Inability to understand or comprehend Wernicke aphasia Transfer signals from the Wernicke to the Broca area conduction aphasia Properly execute speech expressive, motor, or Broca aphasia). The combination of Broca and Wernicke aphasias is referred to as global aphasia.

Essential Features of Common Dysphasias Type of Dysplasia Fluency Comprehension Naming Localization Broca Non-fluent Intact Impaired Broca area Wernicke Fluent Wernicke area Conduction Arcuate fasciculus Global Nonfluent Broca and Wernicke areas

Steps in the neurologic examination In examining a patient, abnormalities of function lead to localization and, eventually, to the pathophysiology. These steps include the following: General Appearance, including posture, motor activity, vital signs and perhaps meningeal signs if indicated. Mini Mental Status Exam, including speech observation. Cranial Nerves, I through XII. Motor System, including muscle atrophy, tone and power. Sensory System, including vibration, position, pin prick, temperature, light touch and higher sensory functions. Reflexes, including deep tendon reflexes, clonus, Hoffman's response and plantar reflex. Coordination, gait and Romberg's Test Examining the comatose patient

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