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

2. 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

3. “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

4. 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.

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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.

16. 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

17. 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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