HISTORY TAKING AND NEUROLOGICAL EXAMINATION DR. M. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin 20/09/2016

The history of the presenting illness or chief complaint should include the following information: Symptom onset (e.g., 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 Pain should be further defined in terms of the following: Location (Ask the patient to point with one fing). Radiation (Pay attention to any dermatomal relationship.) Quality (stabbing, stinging, lightning like, pounding, etc) Severity or quantity (Estimate functional limitation.) 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 information: A patient's history is the most important part of a neurological examination[and must be performed before any other procedures unless impossible.  Important factors to be taken in the medical history include: Time of onset, duration and associated symptoms (e.g., is the complaint chronic or acute) Age, gender, and occupation of the patient Handedness (right- or left-handed) Past medical history Drug history Family and social history A complete history often defines the clinical problem and allows the examiner to proceed with a complete but focused neurologic examination. Handedness is important in establishing the area of the brain important for language. The interval of a complaint is important as it can help aid the diagnosis. For example vascular disorders (such as strokes) occur very frequently over minutes or hours, whereas chronic disorders (such as Alzheimer's disease) occur over a matter of years.

Specific tests in a neurological examination include the following: Category Tests Example of write up Mental status examination The assessment of consciousness, often using the Glasgow Coma Scale (EMV) Mental status examination, often including the abbreviated mental test score (AMTS) or mini mental state examination (MMSE) Global assessment of higher functions Intracranial pressure is roughly estimated by fundoscopy; this also enables assessment for microvascular disease. "A&O x 3, short andlong-term memoryintact" Cranial nerve examination Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart). "CNII-XII grossly intact"

Specific tests in a neurological examination include the following: Category Tests Example of write up Motor system Muscle strength, often graded on the MRC scale 0 to 5(i.e., 0 = Complete Paralysis to 5 = Normal Power). grades 4−, 4 and 4+ maybe used to indicate movement against slight, moderate and strong resistance respectively. Muscle tone and signs of rigidity. Examination of posture Decerebrate Decorticate Hemiparetic Resting tremors Abnormal movements Seizure Fasciculations Tone Spasticity Pronator drift Rigidity Cogwheeling (abnormal tone suggestive of Parkinson's disease) Gegenhalten – is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia. "strength 5/5 throughout, tone WNL"

Specific tests in a neurological examination include the following: Category Tests Example of write up Sensation Sensory system testing involves provoking sensations of fine touch, pain and temperature. Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception. Sensory Light touch Pain Temperature Vibration Position sense Graphesthesia Stereognosis, and Two-point discrimination (for discriminative sense) Extinction Romberg test – 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. epicritic sensation "intact to sharp and dull throughout"

Specific tests in a neurological examination include the following: Category Tests Example of write up Cerebellum Cerebellar testing Dysmetria Finger-to-nose test Ankle-over-tibia test Dysdiadochokinesis Rapid pronation-supination Ataxia Assessment of gait Nystagmus Intention tremor Staccato speech "intact finger-to-nose, gaitWNL" Interpretation The results of the examination are taken together to anatomically identify the lesion. This may be diffuse (e.g., neuromuscular diseases, encephalopathy) or highly specific (e.g., abnormal sensation in one dermatome due to compression of a specific spinal nerve by a tumor deposit).

Neurology History taking and examination General principles Looking for side to side symmetry: one side of the body serves as a control for the other. Determining if there is focal asymmetry. Determining whether the process involves the peripheral nervous system (PNS), central nervous system (CNS), or both. Considering if the finding (or findings) canbe explained by a single lesion or whether it requires a multifocal process. Establishing the lesion's location. If the process involves the CNS, clarifying if it iscortical, subcortical, or multifocal. If subcortical, clarifying whether it is white matter, basal ganglia, brainstem, or spinal cord. If the process involves the PNS then determining whether it localizes to the nerve root, plexus, peripheral nerve, neuromuscular junction, muscle or whether it is multifocal. A differential diagnosis may then be constructed that takes into account the patient's background (e.g., previous cancer, autoimmune diathesis) and present findings to include the most likely causes. Examinations are aimed at ruling out the most clinically significant causes (even if relatively rare, e.g., brain tumor in a patient with subtle word-finding abnormalities but no increased intracranial pressure) and ruling in the most likely causes