Neurological History and Exam

●Dr Sadik Al- Ghazzawi

●MRCP. FRCP UK

07 9775 1663

● Where is the lesion=localization

● What is the lesion=differential diagnosis

● What is the etiology of the lesion

Chief Complaint

● Time factor - Time of onset

- Mode of onset

- Change over time (progression)

- If episodic: duration, recurrence

● Location factor - Right/left, Upper/lower, Crossed

● Associations

Past History

Family History

Social History

● Headache ● Changes in the level of consciousness ● Weakness ● Sensory changes ● Abnormal movements ● Memory and behavioral changes ● Falls

Neurological Symptoms

● Description and history taking

- Checklist for pain

● Possible etiologies - Primary - Secondary

● Red flags in the history of headache

Headache

Level of Consciousness

● Seizures - Classification - Temporal progression - Possible etiologies

● Syncope ● Breath holding spells ● Mass effect and increased intracranial pressure

Weakness / Sensory Change

● Onset

● Distribution

● Progression

● Associated symptoms

● Etiologies

● Shaking movements of the hands

● Slow writhing movements

● Ballistic proximal movements

● Sudden jerks

Abnormal Movements

Memory and Confusion

● Baseline of the patient ● History of trauma, incontinence, gait problem,

anticoagulation, abnormal movements, language deficit, systemic disease.

● Onset of the change ● Specific manifestation ● Living environment ● Possible etiologies

Falls

● Loss of consciousness: seizure, syncope ● Transient ischemic attacks ● Third ventricular and posterior fossa tumors ● Motor and sensory impairment of the lower limbs: neuromuscular disorders - myelopathy - cerebral and cerebellar disorders - basal ganglionic diseases - Neuropathy.

Neurological Exam

Neurologic Exam

● General observations

● Neck and cervical spine

● Cranial nerves

● Motor system

● Sensory system

● Coordination

● Cortical function

General Observations

● Level of consciousness

● Facial appearance

● Gait

● Speech

● Language

● Involuntary movements

● Hand writing

● Neck and spine movements

Gait

● Hemiparetic

● Spastic

● Foot drop

● Parkinsonian

● Cerebellar

● Apraxic

Speech

● Disorder of articulation, motor weakness - myasthenia gravis - motor neuron disease - multiple lacunes - parkinsonism - cerebellar lesions - Recurrent laryngeal nerve palsy

Language (Aphasia(

● Broca’s

● Wernicke’s

● Conduction aphasia

● Global aphasia

Language

● Spontaneous speech

● Naming objects

● Comprehension

● Repetition of spoken words

● Reading aloud

● Handwriting

Involuntary movements

- Tremor ● Chorea: ● Athetosis ● Dystonia ● Myoclonus ● Hemiballismus ● Orofacial-lingual dyskinesia ● Tics

Chorea

repetitive, brief, irregular, somewhat rapid involuntary movements that start in one part of the body and move abruptly, unpredictably, and often continuously to another

part

Athetosis

● a continuous stream of slow, flowing, writhing involuntary movements.

Hemiballismus

a type of chorea, usually involving violent, involuntary flinging of one

arm and/or one leg.

Dystonia

characterized by long-lasting (sustained) involuntary muscle contractions that may force into abnormal positions—for example, causing the entire

body, the trunk, limbs, or neck to twist.

Neurologic Exam

● General observations

● Neck and cervical spine

● Cranial nerves

● Motor system

● Sensory system

● Coordination

● Cortical function

Cranial Nerves

● Olfactory nerve

● Optic Nerve - visual acuity

- pupillary reflexes

- visual fields

- color vision

- fundoscopy

Cranial Nerves

● Oculomotor, Trochlear, Abducent nerves

● Trigeminal nerve - sensory

- motor

- corneal reflex

- jaw jerk

Cranial Nerves

● Facial nerve

● Vestibulocochlear nerve

● Glossopharyngeal and Vagus nerves

● Accessory nerve

● Hypoglossal nerve

Neurologic Exam

● General observations

● Neck and cervical spine

● Cranial nerves

● Motor system

● Sensory system

● Coordination

● Cortical function

Motor System

● Inspection and palpation of muscle groups

● Assessment of tone

● Testing of power

● Deep tendon reflexes and plantar responses

● Superficial and Pathological reflexes

Neurologic Exam

● General observations

● Neck and cervical spine

● Cranial nerves

● Motor system

● Sensory system

● Coordination

● Cortical function

Sensory System

● Pattern and distribution - peripheral neuropathy

- mononeuropathy

- radiculopathy

- myelopathy

- hemispheric

Sensory System

● Modalties - pain

- temperature

- light touch

- vibration

- positin

Neurologic Exam

● General observations

● Neck and cervical spine

● Cranial nerves

● Motor system

● Sensory system

● Coordination

● Cortical function

Coordination

● Finger-Nose-Finger test

● Heel-Shin test

● Rapid alternating movements

● Stance and gait

Problem Solving in Neurology

Problem Solving in Neurology

Problem Solving in Neurology

Cortical Function

● Point localization

● Streiognosis

● Graphaesthesia

● Sensory inattention

● Calculating skills

● Constructional apraxia

Problem solving in Neurology

Problem solving in Neurology Diagnosis problem To make diagnosis easy, it is better to divide the diagnosis in to five stages Step one The functional diagnosis Which mean the loss functional ability?

e.g

monoplegia or hemiplegia ,it mean loss of power function

This is the easiest step because the patient or the family complain of (chief complain)

Step tow

Etiological diagnosis Very important because on this step you can plan your management. There are important hints for making etiology possible, a-onset of the problem, e.g. sudden onset-Vascular. B-progression of the problem. e.g. remitting-relapsing in MS.

Step three

Anatomical diagnosis. Need basic knowledge of neuroanatomy and neurophysiology. There are multiple system in the brain which have multiple function

e.g. A- (pyramidal system)(PS)( primary motor system). B-extra-pyramidal system (EPS) (basal ganglia). C-cerebellum (cerebellar system). Both these systems help the pyramidal system to perform Coordinated movement (cerebellum) and smooth movement (extra- pyrademal system)(EPS)

cerebellum

PS----------------------------smooth and coordinated movement EPS

Motor system pathway. 1-motor area (precentral area (PCG). In which all body area are represented in very small compact area. So lesion in this area will give very localized defect. E.g. monoplegia on the opposite side.

2-motor tract (pyramidal tract. Because of wide distribution of the motor fibers, Lesion at this area lead to wide deficit (hemiplegia) on the opposite side e.g. hemiplegia.

internal capsule.-3

Because in the internal capsule other fibers passes ( sensory&visual fiber ) in addition to the motor fibers . So lesion at that area led to a-hemiplegia b-hemianasthesia c-hemianopia So there are (motor ,sensory, visual deficits) at the opposite side.

Brain stem. -4 In the brain stem there nuclei , 3rd,4th in the mid brain. 6th 7th in the pons. When the motor tract passes in the brain stem, it is join by fibers from these nuclei. So, lesion at the brain stem result in; 1-Contra-lateral (opposite )side hemiplegia, 2-Epsi-lateral (same side) cranial nerve paralysis. Eg Midbrain lesion Epsilateral 3TH Cr N plus contralateral hemiplegia Pons lesion, epsilateral 6TH Cr N plus contralateral hemiplegia

which deals with conscious Reticular nucleiAlso in the brain stem the

level, So, lesion in the brain stem specially at the pons lead to disturbance in conscious level (may be coma). Then after that, some of the motor fibers crosses to the opposite side in the medulla (in direct cortico-spinal tract) and some do not cross

Reticular activating system. Dells with 1-a wakefulness and sleep cycle (physiologically). 2-Coma and consciousness (pathologically).

Step four Pathological Diagnosis That’s need the, Combination of the previous steps as well as neuro-investigations, Eg, Routine investigations, Neuro-Imiging eg CT,MRI As well as Neuro-physiological study e.g NC,EMG. Some time we need CSF analysis, biopsy, advanced investigation and immunological investigations.

Step five Final Diagnosis Final step is the final diagnosis which is done by, 1- combination of the previous steps. 2-logical interpretation of the results. . 3-analysis of the history, examination ,investigations.