Transcript Neurological History Taking and Physical

Neurological History Taking
and Physical Examination
Dr. M. A. Sofi MD; FRCP (London);
FRCPEdin; FRCSEdin
Neurological History: Taking the patient's history is
traditionally the first step in virtually every clinical encounter.
• 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
“Red flag” symptoms in headache
Symptom
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)
Intracranial mass lesion
New onset ˃ 40 years age
Temporal arteritis
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.
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
Suspected
cardiac cause
Yes
Echocardiogram
Stress test
Holter monitoring
Electrophysiology
Drugs
No
Suspected
neurologic cause
Yes
Electroencephalogram (EEG)
Brain imaging (CT,
MRI/MRA)
No
Light headedness
on standing
Yes
Vital signs
BP in sitting &
standing position
No
Reflex mediated
Yes
Tilt table test
Carotid massage
Unexplained
recurrent syncope
Yes
Implantable loop
monitor
Endocrine study
Electrophysiology
study
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
Seizure
Loss of consciousness
Yes
Yes
Generalized seizure
Partial seizure
Alteration of consciousness
No
Simple partial
Yes
Complex partial
Transient loss of consciousness
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
Syncope
Déjà vu
Jamais vu
Aphasia
Olfactory
aura
Epigastric
sensation
Tongue
biting
Post event
delirium
Focal
neurology
Seizure
Pallor
Sweating
Slow pulse
Low blood
pressure
Syncope
Myoclonus
or
convulsion
after :
Pallor
sweating
after
collapse
Convulsive
Syncope
Aphasia
Delirium
Head turn
Automatism
Posturing
Convulsions
Postictal
delirium
Seizure
Dysrhythmias
Myocardial infarction
Hypovolemia
Vasovagal
Sepsis
Panic disorder
Drug side effects
Near syncope/Light
headedness
Malaise
Dizziness
Anemia
Infection
Depression
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
Serous: Inflammatory
response to nearby
infections
Head trauma
Multiple
sclerosis
Vertebrobasilar
migraine
Labyrinthitis
Acute suppurative
Toxic patient
Severe vertigo
Hypoglycemia
Toxic
Hearing loss
Tennitus
Chronic
Symptoms
secondary to fistula
Vertebrobasilar
insufficiency
Associated with
neurological abnormalities
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Ataxia consists of lack of voluntary coordination of
muscle movements that includes gait abnormality.
Types
 Cerebellar
 Sensory
 Vestibular
The three types of ataxia have
overlapping causes and can
either coexist or occur in
isolation.
 Focal lesions
 Exogenous substances
(metabolic ataxia)
 Radiation poisoning
 Vitamin B12 deficiency
 Hypothyroidism
Causes of isolated sensory
ataxia:
Peripheral neuropathies may
cause generalized or localized
sensory ataxia.
Spinal disorders may cause
sensory ataxia when they involve
the dorsal columns


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

Non-hereditary cerebellar
degeneration
Hereditary ataxias
Arnold-Chiari malformation
(congenital ataxia)
Wilson's disease
Gluten ataxia
Sodium-potassium pump
Ataxia
Common causes:
Labyrinthitis, Multiple
sclerosis, NPH, Alcoholism
Spinal cord disorders
Multisensory loss
Acute onset
TIA
Stroke
Acute
alcoholic
intoxication
Encephalitis,
HIV infection
Any infection
Metabolic
disturbance
Medications
Gradual onset
Tennitus
Vertigo
and/or
Hearing loss
Toxic exposure
Mercury
Lead
Thallium
Toloune
No toxic exposure
F/H of ataxia
Friedreich
ataxia
Ataxia
Talangiectasia
No F/H of ataxia
Extremities
Sensory loss
Peripheral
neuropathy
Spinal cord
lesions
B12 deficiency
HIV infection
No sensory
loss
Posterior fossa
lesions
Multiple sclerosis
Hypothyroidism
NPH
Sensory Examination
Pattern of involvement
Symmetrical distal
neuropathy
Motor
Symmetrical proximal
neuropathy
Sensorimotor
Sensory
Asymmetrical proximal
neuropathy
Small fiber/AF
Possible neurological
screening and consultation
for possible underlying
cause
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
Vibration dorsum of
great toe bilaterally
Pressure on planter
side bilaterally
Diminished/ Absent
vibration
Diminished/Absent
pressure response
Decreased
sweating or dry
skin
Fissures
Oedema
Ankle reflex
bilaterally
Diminished/Absent
reflexes
Nerve conduction EMG testing
Dorsiflexors/
planter flexors
Reduced/ week
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's
response and plantar reflex.
VII.Coordination, gait and Romberg's Test
Examining the comatose patient
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.
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.
Essential Features of Common Dysphasias
Type of
Dysplasia
Fluency
Comprehension Naming
Localization
Broca
Non-fluent
Intact
Impaired
Broca area
Wernicke
Fluent
Impaired
Impaired
Wernicke area
Conduction
Fluent
Intact
Impaired
Arcuate
fasciculus
Global
Nonfluent
Impaired
Impaired
Broca and
Wernicke areas
Mini–mental state examination
Category
Possible
Description
points
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
3
Repeating 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
3
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
Orientation to time
Total score
30
Category
Tests
Example of
write up
• I (olfactory nerve): smell .
Cranial
Nerves
• II (optic nerve): visual acuity, visual fields and fundi.
All cranial
• II, III (optic nerve and oculomotor nerve): pupillary
nerves WNL
reactions.
• III, IV, VI (oculomotor, trochlear and abducent
nerves): extra-ocular movements, including opening
of the eyes.
• V (trigeminal nerve): facial sensation, movements of
the jaw, and corneal reflexes.
• VII (facial nerve): facial movements and gustation.
• VIII (vestibulocochlear nerve): hearing and balance.
• IX, X (glossopharyngeal and vagus nerves):
swallowing, elevation of the palate, gag reflex and
gustation.
• V, VII, X, XII (trigeminal, facial, vagus and
hypoglossal nerves): voice and speech.
• XI (accessory nerve): shrugging the shoulders and
turning the head.
• XII (hypoglossal nerve): movement and protrusion of
tongue.
Category
Tests
0
Absent voluntary contraction
1
Feeble contractions that are unable to move a joint
2
Movement with gravity eliminated
3
Movement against gravity
4
Movement against partial resistance
5
Full strength
Motor system
Muscle tone and signs of rigidity.
• Tone
• Spasticity
• Rigidity
• Cogwheel (abnormal tone suggestive of
Parkinson's disease).
Examination of posture
• Decerebrate
• Decorticate
• Hemiparetic
Abnormal movements
• Resting tremors
• Fasciculations
• Seizure
Example of
write up
"strength 5/5
throughout, tone
WNL“
Category
Cerebellum
Cerebellar testing
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Gait
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Example of
write up
Tests
• Rapid pronationsupination
• Ataxia
• Nystagmus
• Intention tremor
• Staccato speech
Dysmetria
Finger-to-nose test
Ankle-over-tibia test
Dysdiadochokinesis
Gait is an attitude of a person in upright position.
Abnormal types are:
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"intact finger-tonose”
Gait WNL
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Muscles and Spinal Roots
Muscle
Spinal Roots
Biceps
C5, 6
Brachioradialis
C6
Triceps
C7
Patellar
L2-4
Achilles
S1
Reflex-Grading System
Score
Reflexes
0
Absent
1
Hypoactive or present only with reinforcement
2
Readily elicited with a normal response
3
Brisk with or without evidence of spread to the neighboring roots
4
Associated with a few beats of un-sustained clonus
5
Sustained clonus
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).
General principles
• Subcortical, clarifying whether it is
white matter, basal ganglia,
• Looking for side to side
symmetry:
brainstem, or spinal cord.
• Determining if there is focal
• PNS then determining whether it
asymmetry.
localizes to the nerve root, plexus,
Determining whether the
peripheral nerve, neuromuscular
process involves:
junction, muscle or whether it is
multifocal.
• (PNS),(CNS), or both.
• If the finding can be explained • Differential diagnosis may then be
by a single lesion or whether it
constructed that takes into account
requires a multifocal process.
the patient's background
Lesion's location.
• If the process involves the
CNS, clarifying if it is cortical,
sub-cortical, or multifocal.