Neurologic history & physical examination

Desalegn Yayeh (MD, Neurologist)

Arsi University

June 2022
 Outline of the presentation
• Brief clinical neuro-anatomy

• Neurological history taking

• Neurological physical examination

• References
The levels of the nervous system
 The Neuraxis

N-M
Muscle Nerve Plexus Root
junction

Ant
Post Supra-
Horn Cord
Fossa Tentor
Cell
Right half of the brain, medial view
 Anatomy and Physiology
• Central Nervous System

• The Brain:

• Has four regions:

• The cerebrum

• The diencephalon

• The brainstem, and

• the cerebellum.

• Each cerebral hemisphere is subdivided into frontal, parietal, temporal, and occipital lobes.
The decussation of the pyramids in the lower medulla

.
• The 31 segments of spinal cord

• Cervical Cord ...8 segments

• Thoracic Cord ...12 segments

• Lumbar Cord ...5 segments

• Sacral Cord ...5 segments

• Coccyx …1 segment
 Neurologic history
• The neurological history should be a focused, goal-directed exercise which
seeks to answer the following questions:

Where in the nervous system is the lesion?

What is the pathological process?

(e.g. inflammatory, vascular, infectious)?

Is this a purely neurological problem or a neurological manifestation of a systemic disease?

 Components of neurological history

Identification
Past illness
Age
Family history
Gender

Address Personal & Social history

Handedness
Marital status
Source of history
Occupation
Presenting complaint

Hx of Present illness Review of systems

 Common Neurological Presentations
• Headache

• Seizures

• Weakness (generalized, proximal, or distal)

• Tremors or involuntary movements

• Disturbance of Balance & Dizziness or vertigo

• Numbness, abnormal or absent sensation

• Headache types: 1° & 2°

• 1. Primary headaches:
• Migraine headaches

• Tension headaches

• Cluster headaches

• Trigeminal autonomic cephalagias

• 2. Secondary headaches:

• Arise from underlying structural, systemic, or infectious causes and may be life threatening.
• Migraine headache:

• Is often preceded by an aura or prodrome, and is highly likely if three of the five
“POUND” features are present:

• Pulsatile or throbbing;

• One day duration, or lasts 4 to 72 hours if untreated;

• Unilateral;

• Nausea or vomiting;

• Disabling or intensity causing interruption of daily activity

• Seizures:

• May be symptomatic, with an identifiable cause, or idiopathic.

• Tremors or invountary Movements.

• Tremor, “a rhythmic oscillatory movement of a body part resulting from the contraction
of opposing muscle groups,” is the most common movement disorder.

• Does the tremor occur at rest?

• Does it get worse with voluntary intentional movement or with sustained postures?
 Past medical history:
• Past medical illnesses and accidents including hospitalizations and operations.

• History of infections

• Seizures

• Head injuries

• Birth and childhood development

• Diabetes, hypertension and stroke.

• Past history of neurological episodes similar to the presenting

• Complaint and outline any investigations, their results and

• Treatments received, and any persisting disabilities.

 Family History:
• Some neurological disorders are inherited.

• Enquire if there is anyone else in the family with the same illness.

• Document the patient’s first degree relatives .

• i.e. parents, siblings and children including their ages, sex and health.

• Pay particular attention to the age of onset of any neurological

conditions and family members who have died young.

• Any deaths and their causes if known.

 Personal & Social History:
• Home environment, caregivers, community and financial circumstances.

• Occupation

• Employment

• Travel

• Alcohol

• Smoking

• How the current illness has affected work and social life including time lost from
work.
 Drug History
• complete list is important (prescribed
& OTC).

• Intravenous drug can cause

neurological effects from either a
direct pharmacological effect or
infection.

• Substances of abuse are always

significant.

• Peripheral neuropathy is a
particularly common problem.
The temporal profile of different pathological processes.
 Physical Examination
• Components :

• Mental Status

• Cranial Nerves

• Motor Exam

• Reflexes

• Coordination and Gait

• Sensory Exam (primary and cortical sensation; Extinction)

 Components of Mental State Exam
1) LEVEL OF ALERTNESS, ATTENTION, AND Attention
COOPERATION
Spelling a short word forward & backward
Name months forward & backward.
Depends on language, memory & some logic functions as well.

Level of consciousness
2) Orientation Tests recent & long term memory
 Cont….
• 3) Memory • Recent Memory :
• Ask patient to recall 3 items or brief story after delay of 3-5 min.
• Signifies damage to the limbic memory structures located in the medial temporal lobes and medial
diencephalon.
• Anterograde amnesia:
• Difficulty remembering new facts and events occurring after lesion onset.
• Retrograde amnesia:
• Impaired memory of events for a period of time immediately before lesion onset, with relative sparing of
earlier memories.
• Remote Memory:
• Ask about historical or verifiable personal events.

• 4) Language
• Spontaneous speech – fluency, phrase length, rate, abundance, neologism.

• Comprehension – can the patient understand simple questions & commands?

• Naming

• Repetition - (a standard is “no ifs, ands, or buts”)?

• Reading

• Writing – name, sentence.

 Cont….
5)CALCULATIONS, RIGHT–LEFT CONFUSION, FINGER • Often tested as part of language assessment.
AGNOSIA, AGRAPHIA Abnormalities of all 4 disproportionate to other cognitive deficit
•
usually suggest lesion in dominant parietal lobe.

6)Apraxia • Ask to do complex tasks.

 eg. Pretend to comb hair.
• Inability to follow motor command.
• Can be 2° to lesions at d/t locations.
• Not due to primary motor deficit or language impairment.
• Commonly present in lesions affecting the language areas and
adjacent structures of the dominant hemisphere.

7)Neglect and Constructions • Test for extiction on double stimulation.

• visual, auditory, somatosensory, and motor exams.
Hemineglect is an abnormality in attention to one side of the Draw complex figures.
universe that is not due to a primary sensory or motor •
disturbance. • In lesions of nondominant parietal lobe.

• *occasionally in right frontal, thalamic, basal ganglia lesions.

Cranial Nerves
Olfactory Nerve (CN I)

• Responsible for smell.

• Usually not tested unless there is a complaint

or suspicion of frontal lobe pathology.

• Nasal passage should be clear.

• use orange peel, coffee, and soap.

• Do not use noxious odors, since they may

stimulate pain fibers from CN V.
 Optic Nerve (CN II)
• Components

• Visual acuity

• Visual field

• Color vision

• Fundoscopic exam

• Pupillary reaction & accommodation reflex.

Visual Field Pathway and Visual Field Defects
Pupillary light reflex
Fundoscopic Exam
• Right with right eye and vise-versa.

• Identify red reflex and follow beam of light

into eye looking for a normal pale pink disc.

• Main sign of papilledema is swelling of the

optic disc with blurring of the disc margins.

• Main sign of optic atrophy is a pale white

optic disc.
CN III, IV, VI
Eye movements & Nystagmus
Levator palpabrae
Trigeminal Nerve (CN V)
Facial palsy
Branches and distribution of the facial nerve.
Glossopharyngeal & Vagus Nerve (CN IX + X)

Voluntary Gag reflex

• watch the soft palate and uvula move upwards in the

midline in response to the patient saying “aah”.
• Tests efferent.

Involuntary Gag reflex

• Gently touch each side of the soft palate with tongue

depressor and asking the patient if the sensation was
the same on both sides and watching the palate rise
involuntarily.

• Tests afferent + efferent.

Spinal Accessory Nerve (CN XI)

• Supplies sternoclediomastoid and trapezius

muscles.

• Weakness of these muscles is unusual in

clinical practice but does occur mostly in
muscle disease and myasthenia gravis.
Hypoglossal Nerve ( CN XII)

• Purely motor nerve.

• Done by inspecting the tongue at rest and on

protrusion & movement.

• First inspected in the floor of the mouth checking for

evidence of wasting or fasciculation.

• A unilateral LMN weakness results in atrophy and

fasciculations on the affected side & deviation towards
the same side of the lesion.

• A unilateral UMN lesion will result in tongue deviation

away from affected side.
Motor Exam
Inspection

Inspection
 Muscle tone
• Tested by moving the limbs passively as the examiner feels the degree of resistance.
• Categorized as normal, decreased or increased.

Causes
Decreased tone LMN ; Muscle d/s; Cerebellar disease
 Pyramidal (UMNL)

• Clasp knife rigidity

Increased tone • Initial resistance and the sudden give away or release.
• Best appreciated just at the start of flexion at the knee and extension at the elbow.

Extrapyramidal (parkinson’s disease)

• Lead pipe or cogwheel in type.

• rigidity is equally stiff throughout both flexion and extension.

• Best appreciated by slowly fully flexing and extending the elbow and knee and by
pronating and supinating the wrist.
•
• Cog wheeling represents intrusion of rest tremor into lead pipe rigidity.
Power
Test for pronator drift
Medical Research Council Grading
 Power cont.…
• Normal strength varies widely, so your standard of normal should
allow for factors like age, sex, and muscular training.

• The patient’s dominant side is usually slightly stronger than the

nondominant side, though differences can be hard to detect.

• Keep this difference in mind as you compare sides

• Impaired strength or weakness is called paresis.

• Absent strength is paralysis, or plegia.

• Hemiparesis refers to weakness of one half of the body;

• Hemiplegia refers to paralysis of one half of the body.

• Paraplegia means paralysis of the legs;

• Quadriplegia means paralysis of all four limbs.

Summary of localization
Reflex
Reinforcement (Jendrassik maneuver).
Reflexes
Sensitivity – 50%; specificity – 99% of lesion in corticospinal tract
Sensitivity – 59% ; specificity – 49%
Coordination Tests

past pointing
Overshoot
 dysdiadochokinesia
 Romberg test:
Tests propioceptive function
Ataxia:
 Abnormal movements seen in
coordination disorders.

 There are medium- to large amplitude

involuntary movements with an irregular
oscillatory quality superimposed on and
interfering with the normal smooth
trajectory of movement

Truncal Ataxia
*Stability Needs Vision; propioception &
vestibular sense in addition to motor strength.
 Tests for gait & balance

Hoping on either foot Tandem walking

Sensory Exam
 *The most difficult part of the exam to interpret with certainty.

• Performed in all extremities, as well as on the face and trunk, with the patient’s eyes
closed.
Dermatomes
Patterns Of Sensory Deficit
Cortical Sensations Normally <5 mm on finger pads;
Differs depending on location
 Cutaneous Reflexes (superficial stimulation reflex)
Present in healthy persons but are absent in an UMNL.

The abdominal reflexes may also be absent in obese persons and after pregnancy and after
abdominal surgery.
 Meningeal signs

Nuchal rigidity
• The most sensitive.
• 84% -acute meningitis ; 21-86%-SAH

Brudzinski’s sign
• Sensitive in young children than adults.

Kernig’s sign
• Positive on both sides in meningeal inflammation.
• pain & resistance in lumbar area due to stretching of
inflamed nerve roots.
 References
• Bates’ guide to physical examination & history taking: 12th edition, Chapter
17, the nervous system

• Blumenfeld Neuroanatomy – 2nd edition

• Neurology in Africa – clinical skills & neurologic disorders

• Mayo-Clinic essential Neurology

• Dejong’s the neurologic examination

• Bates guide to physical examination 12th edition

Time to do it wrong several times to get it
right.

Thank you!