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

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 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 Neurological History: Taking the patient's history is traditionally the first step in virtually every clinical encounter.

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.

A seizure Also known as a fit, is caused by a disturbance in the electrical activity of the brain, which can be due to conditions such as epilepsy. There are 2 main types of seizure: I.Generalised seizures involve both sides of the brain from the start of the attack. Common subtypes include Tonic-clonic and Absence seizures. II.Partial (or focal) seizures begin in a specific area of the brain and may be contained there. Or they may spread to the entire brain. Simple partial seizures, the person remains conscious. Complex partial seizures involve impaired consciousness

DIPLOPIAASSESSMENTDIPLOPIAASSESSMENT

1.Types  Cerebellar  Sensory  Vestibular 2.Causes  Focal lesions  Exogenous substances (metabolic ataxia)  Radiation poisoning  Vitamin B 12 deficiency  Hypothyroidism  Causes of isolated sensory ataxia  Non-hereditary cerebellar degeneration  Hereditary ataxias  Arnold-Chiari malformation (congenital ataxia)  Wilson's disease  Gluten ataxia  Sodium-potassium pump Ataxia is a neurological sign consisting of lack of voluntary coordination of muscle movements that includes gait abnormality.

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: I.General Appearance, including posture, motor activity, vital signs and perhaps meningeal signs if indicated. II.Mini Mental Status Exam, including speech observation. III.Cranial Nerves, I through XII. IV.Motor System, including muscle atrophy, tone and power. V.Sensory System, including vibration, position, pin prick, temperature, light touch and higher sensory functions. VI.Reflexes, including deep tendon reflexes, clonus, Hoffman'sresponse and plantar reflex. VII.Coordination, gait and Rhomberg's Test Examining the comatose patient

Components of Higher Functions Higher functions include gait, speech, and mental status. Gait is the attitude of a person in the upright position. Abnormal types are described below. 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. 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. Examination of the Higher Functions

Type of Dysplasia FluencyComprehensionNamingLocalization BrocaNon-fluentIntactImpairedBroca area WernickeFluentImpaired Wernicke area ConductionFluentIntactImpaired Arcuate fasciculus GlobalNonfluentImpaired Broca and Wernicke areas Essential Features of Common Dysphasias

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 5 From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor. Registration 3Repeating named prompts Attention and calculation 5 Serial sevens, or spelling "world" backwards. It is more appropriate in a population where English is not the first language. Recall 3Registration recall Language 2Naming a pencil and a watch Repetition 1Speaking back a phrase Complex commands 6Varies. Can involve drawing figure shown Total score

CategoryTests Example of writeup 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 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"

CategoryTests Example of writeup Deep tendon reflexes Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e., Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate A reflex hammer is used for this testing. "2+ symmetric, downgoing plantar reflex" 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 Cerebellum Cerebellar testing Dysmetria Dysdiadochokinesis Finger-to-nose test Rapid pronation-supination Ankle-over-tibia test Ataxia Assessment of gait Nystagmus Intention tremor Staccato speech "intact finger-to- nose, gait WNL

General principles Looking for side to side symmetry: Determining if there is focal asymmetry. Determining whether the process involves: (PNS),(CNS), or both. If the finding can be explained by a single lesion or whether it requires a multifocal process. Lesion's location. If the process involves the CNS, clarifying if it is cortical, subcortical, or multifocal. Subcortical, clarifying whether it is white matter, basal ganglia, brainstem, or spinal cord. PNS then determining whether it localizes to the nerve root, plexus, peripheral nerve, neuromuscular junction, muscle or whether it is multifocal. Differential diagnosis may then be constructed that takes into account the patient's background 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).

ScoreReflexes 0Absent 1Hypoactive or present only with reinforcement 2Readily elicited with a normal response 3 Brisk with or without evidence of spread to the neighboring roots 4Associated with a few beats of unsustained clonus 5Sustained clonus Reflex-Grading System MuscleSpinal Roots BicepsC5, 6 BrachioradialisC6 TricepsC7 PatellarL2-4 AchillesS1 MuscleSpinal Roots Muscles and Spinal Roots

Muscle-Strength Scale ScoreDescription 0Absent voluntary contraction 1Feeble contractions that are unable to move a joint 2Movement with gravity eliminated 3Movement against gravity 4Movement against partial resistance 5Full strength