Neurological History and Exam

1. Neurological History and Exam DrSadik Al- Ghazzawi MRCP. FRCP UK 07 9775 1663

2. Where is the lesion=localization What is the lesion=differential diagnosis What is the etiology of the lesion

3. 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

4. Past HistoryFamily HistorySocial History

5. Headache Changes in the level of consciousness Weakness Sensory changes Abnormal movements Memory and behavioral changes Falls Neurological Symptoms

6. Description and history taking Checklist for pain Possible etiologies Primary Secondary Red flags in the history of headache Headache

7. Level of Consciousness Seizures Classification Temporal progression Possible etiologies Syncope Breath holding spells Mass effect and increased intracranial pressure

8. Weakness / Sensory Change Onset Distribution Progression Associated symptoms Etiologies

9. Shaking movements of the hands Slow writhing movements Ballistic proximal movements Sudden jerks Abnormal Movements

10. 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

11. 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.

12. Neurological Exam

13. Neurologic Exam General observations Neck and cervical spine Cranial nerves Motor system Sensory system Coordination Cortical function

14. General Observations Level of consciousness Facial appearance Gait Speech Language Involuntary movements Hand writing Neck and spine movements

16. Gait Hemiparetic Spastic Foot drop Parkinsonian Cerebellar Apraxic

17. Speech Disorder of articulation, motor weakness myasthenia gravis motor neuron disease multiple lacunes parkinsonism cerebellar lesions Recurrent laryngeal nerve palsy

18. Language (Aphasia( Broca’s Wernicke’s Conduction aphasia Global aphasia

19. Language Spontaneous speech Naming objects Comprehension Repetition of spoken words Reading aloud Handwriting

20. Involuntary movements - Tremor Chorea: Athetosis Dystonia Myoclonus Hemiballismus Orofacial-lingual dyskinesia Tics

21. 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

22. Athetosis a continuous stream of slow, flowing, writhing involuntary movements.

23. Hemiballismus a type of chorea, usually involving violent, involuntary flinging of one arm and/or one leg.

24. 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.

25. Neurologic Exam General observations Neck and cervical spine Cranial nerves Motor system Sensory system Coordination Cortical function

26. Cranial Nerves Olfactory nerve Optic Nerve visual acuity pupillary reflexes visual fields color vision fundoscopy

27. Cranial Nerves Oculomotor, Trochlear, Abducent nerves Trigeminal nerve sensory motor corneal reflex jaw jerk

28. Cranial Nerves Facial nerve Vestibulocochlear nerve Glossopharyngeal and Vagus nerves Accessory nerve Hypoglossal nerve

30. Neurologic Exam General observations Neck and cervical spine Cranial nerves Motor system Sensory system Coordination Cortical function

31. Motor System Inspection and palpation of muscle groups Assessment of tone Testing of power Deep tendon reflexes and plantar responses Superficial and Pathological reflexes

34. Neurologic Exam General observations Neck and cervical spine Cranial nerves Motor system Sensory system Coordination Cortical function

35. Sensory System Pattern and distribution peripheral neuropathy mononeuropathy radiculopathy myelopathy hemispheric

36. Sensory System Modalties pain temperature light touch vibration positin

37. Neurologic Exam General observations Neck and cervical spine Cranial nerves Motor system Sensory system Coordination Cortical function

38. Coordination Finger-Nose-Finger test Heel-Shin test Rapid alternating movements Stance and gait

39. Problem Solving in Neurology Problem Solving in Neurology Problem Solving in Neurology

40. Cortical Function Point localization Streiognosis Graphaesthesia Sensory inattention Calculating skills Constructional apraxia

41. Problem solving in Neurology

42. 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)

43. 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.

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

45. 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)

46. 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.

47. 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.

48. 3-internal capsule. 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.

49. 4- Brain stem. 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 contralateralhemiplegia Pons lesion, epsilateral 6TH Cr N plus contralateralhemiplegia

50. Also in the brain stem the Reticular nuclei which deals with conscious 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