The ultimate goal of the neurologic history and

History Taking
examination is:
APPROACH TO A PATIENT WITH NEUROLOGICAL 1. General information
I. To find out WHERE is the lesion?
DISEASE - name, age, sex, place of origin, handedness, status,
A. Levelize the lesion along the neuraxis
occupation.
B. Lateralize the lesion
- some diseases have a predilection for a particular
C. Localize the lesion age, sex or place of origin
Greg David V. Dayrit, M.D., FPCP,FPNA
Assistant Professor in Internal Medicine-Neurology II. To figure out the Pathophysiology of the lesion – 2. Chief complaint
disturbance in function 3. History of present illness
III. To discover the Pathology of the lesion – WHAT is
the lesion?

Neurologic Examination Temporal and Spatial Features of Major Disease

History of Present Illness Categories
Temporal Profile is very important !
• Congenital • Neoplastic Acute Subacute Chronic
• Hereditary • Degenerative
1. Acute – cerebrovascular disease, seizures
• Acquired • Vascular Focal Vascular Inflammatory Neoplasm
2. Gradual – brain tumors or abscess (infarct, (abscess,
3. Periodic – after an attack, there is improvement • Infectious • Trauma hemorrhage) myelitis)
Ex. familial hypokalemic periodic paralysiS • Immunologic • Demyelinating
4. Progressive – Malignant tumors Diffuse Vascular Inflammatory Degenerative
(Subarachnoid (meningitis,
hemorrhage) encephalitis)

Systems Affected by Neurologic Disorders Neurologic Disorders Occur at these Levels: Neurologic History

1. Consciousness system 1. Supratentorial level • “If one were to choose between history,
2. Sensory system 2. Posterior Fossa level examination and laboratory testing to arrive at
3. Motor System 3. Spinal level a correct diagnosis, the safest wager would be
4. Internal Regulation System on history.”
4. Peripheral Level (Peripheral nerve, NMJ, Muscle)
5. Homoestasis A.J.Dale, MD
6. Vascular System
 Neurologic History Historical Dissection: Chronological Episodes Neurologic Examination

• “If I don’t know what the patient has after I have 1. Symptoms (HPI) • Stethoscope • Pin
taken the history, I am in serious trouble.” • Sphygmomanometer • Aromatic Substance
2. Evaluation (PE/NE)
Alan Yudell, MD • Ophthalmoscope • Coin/Key
3. Diagnosis (DDx)
• Otoscope • Tuning Fork
• “Listen to the patient. He is trying to tell you what is 4. Treatment
• Neurological Hammer • Calorics testing
wrong with him.” 5. Outcome/Prognosis • Tongue Depressor • Tape Measure
Sir William Osler • Wisp of cotton • Visual Acuity Charts
• Sugar/Salt Crystals

Neurologic Examination
Mental Status Examination Neurologic Examination
1. Mental status exam/language (MMSE)
2. Vital signs (including BMI) • Orientation Mental Status/Language
3. Neurovascular • Attention – seven digits A) Comprehension
4. Cranial Nerves (12) • Learning- 3 objects – Listening
5. Muscle Strength (4) • Calculation – Reading
6. Sensation • Abstraction
B) Expression
7. Reflexes • Construction – draw a clock, cube
- Speaking
• Fund of information
8. General Motor Survey - Writing
• Recall - 3 objects from learning
9. Spine survey
10. Meningeal signs

Cranial Nerves
Neurologic Examination Neurologic Examination
I. Olfactory – camphor, perfume
2. Vital Signs 3. Neurovascular II. Optic
A. Height A. Cardiac Auscultation – fields: single eye finger counting in 4
B. Weight B. Neck/Orbit/Cranium Auscultation quadrants
C. Temperature C. Pulse Examination – Acuity: hand-held card, test eye separately
D. Blood Pressure (lying and standing) Radial – Color plates: test eye separately
E. Pulse (lying and standing) Temporal – Fundoscopy: disk margins, macula, vessels
F. Respiratory Rate Carotid
– Pupils: size, shape, reactivity
Dorsalis pedis (direct/consensual)
Posterior tibial
 Cranial Nerves
III Oculomotor, IV Trochlear, VI Abducens
- test 9 cardinal positions of gaze in both eyes
simultaneously if there are no complaints of
diplopia. Otherwise, test each eye separately
- Maddox rod test: for subtle diplopia and
localization of peripheral causes of diplopia
Cranial Nerves Cranial Nerves
VII. Facial
V. Trigeminal - Strength: tested during manual muscle testing
- tested during other portions of the exam: - Taste: rarely assessed unless with peripheral VII
- strength : manual muscle testing nerve palsies. Use tongue depressor with single
- sensation: during sensory exam substances applied to one side of the tongue.
- corneal reflex: during test for reflexes Instruct patient to protrude the tongue for
application, then raise the hand once they have
decided what the taste is.

Cranial Nerve Cranial Nerves Neurologic Examination

IX Glossopharyngeal MUSCLE STRENGTH : 41 groups of muscles on each
VIII Vestibulocochlear
side
- Hearing: finger rub testing. Rub your own X Vagus
1. Bulbar
thumb and index finger beginning 50 cm from 1. Pharyngeal “gag” reflex
the test ear, bringing the stimulus closer to the 2. Neck
2. Palatal elevation with phonation
patient’s head. Note the distance at which the 3. Upper limb
3. Heart rate response to deep breathing
stimulus is reliably perceived. 4. Abdomen
5. Lower limb
XI Spinal Accessory Nerve
- Vestibular function: Nylen manuever, Romberg 6. Anal Sphincter
testing XII Hypoglossal

Neurologic Examination
Neurologic Examination Neurologic Examination
SENSATION
REFLEXES GENERAL MOTOR SURVEY
1. Vibration
2. Joint Position Sense • Bulbar • 1. Watch patient walk down the hall unobserved
3. Light Touch • Frontal release • 2. Walk across the room
4. Pinprick • Upper limb • 3. Walk on toes then on heels
5. Two-point Discrimination • 4. Squat and rise without use of upper limbs
• Abdominal
6. Stereognosis • 5. Finger to nose (E/O, E/C)
• Lower Limb
7. Double simultaneous stimulation • 6. Alternation/motion rates
• Perineal • 7. Muscle Tone
8. Temperature
9. Deep Pain - comatose • Plantar Responses
 Neurological Examination Neurologic Examination
SPINE OBSERVATIONS

1. Nuchal signs • “ Normally developed, well-nourished, Filipino

2. Spinal Percussion tenderness male, no acute distress”
3. Palpation of Paraspinal muscles for spasm • Mood
4. Passive straight leg raise • State of mind
5. Flexion-abduction-external rotation of the hip • Skin and scleral pigmentation
6. Cervical and lumbar range of motion • Skin lesions, scars, birth marks
7. Observations: scoliosis, lordosis • Nerves (enlargement, tenderness, Tinel’s)
8. Manuevers: chin-chest, axial loading, rotation • Feet and Toes (Pes cavus)
• Abnormal masses

Principles of the Neurologic Examination Principles of the Neurologic Examination Principles of the Neurologic Examination

1. If you do not know what the patient has after a
thorough history, the exam will not likely give you
the answer, much less a battery of sophisticated
and costly tests.
2. Each neurologic examination must be tailored to
the patient at hand, the presenting problem, and
the diagnostic clues gleaned from the history.
3. Careful documentation is invaluable for assessing
severity, making judgments on the course
(whether the patient is better or worse), and
evaluating response to treatment.
4. Quantitation is a powerful tool in the neurologic
examination.
5. One of the greatest builders of confidence
between the patient and the physician is the ability
to convey what one knows, and what one does not
know. It is far less dangerous to admit ignorance
than to “pull a diagnosis out of the air” simply
because it is expected.

The ultimate goal of the neurologic history Steps in the Diagnosis of Neurologic
and examination is: Disease

I. To find out WHERE is the lesion? 1. Data Gathering

ANATOMIC LOCALIZATION
A. Levelize the lesion along the neuraxis 2. Anatomic Localization
B. Lateralize the lesion 3. Etiologic Diagnosis
C. Localize the lesion
Greg David V. Dayrit, MD, FPCP,FPNA
Internal Medicine-Neurology
Core Faculty
 Benefits of Localization Steps in Localization Signs and Symptoms in Neurologic Disease

1. Directs Diagnostic Work-up
2. Estimates the extent of the lesion
3. Limits the Differential Diagnosis
1. List down all abnormal neurologic signs
2. Determine all possible neuro-anatomic correlates
per sign
3. Look for “intersections” – the point where all signs
can be explained. If not, consider two or more
lesions.
Neurologic diagnosis depends on answers to two
questions that are considered separately and in
sequence:
1. Where is the Lesion? (3 L’s)
2. What is the nature of the disease?

Signs and Symptoms in Neurologic Disease

•Patient age Dictum in Neurology

•Sex REVIEW OF ABNORMAL
•Ethnicity NEUROLOGIC FINDINGS AND
“Try to explain all THEIR SIGNIFICANCE
•Socioeconomic considerations
neurological signs on the
•Tempo of disease basis of one lesion”
•Duration of symptoms
•Medical history
•Physical & neurological examination

Abnormal Cerebral Function

VISION & EOM’s Visual Field Defects
Diffuse or focal
1. Aphasia 1. Monocular Blindness
2. Apraxia 2. Visual Field Defects
3. Agraphia 3. Extraocular Muscle Disorders
4. Acalculia 4. Ptosis
5. Memory Impairment
6. Alexia
7. Personality Changes
8. Loss of Insight and Judgment
9. Right-Left Disorientation
10. Anomia
 Conductive vs Sensorineural Hearing Loss

DEAFNESS Weber Rinne Test

Lateralizes
1. Conductive-type Conductive Loss
2. Sensorineural type
Good ear No AC > BC
3. Mixed type
Bad Ear Yes BC > AC
Sensorineural Loss
Good ear Yes AC > BC
Bad ear No AC > BC

NASOPHARYNGEAL SYMPTOMS SPEECH DIFFICULTY MOTOR WEAKNESS

1. Dysphagia 1. Dysphasia 1. Hemiparesis

2. Impaired Gag reflex 2. Dysarthria 2. Paraparesis
3. Nasal Twang 3. Tongue Deviation 3. Quadriparesis
4. Hoarseness 4. Monoparesis

VII. SENSORY LOSS SENSORY LOSS ATAXIA

A. Crude vs. Cortical Sensation B. Distribution A. Sensory ataxia: 2’ to impaired sensory input (as in
1. Crude - pain, temperature, pressure, vibration 1. Hemisensory Loss peripheral neuropathies), worsened by darkness,
sense 2. Sensory Level eye closure, or rapid head movements
2. Cortical 3. Specific Dermatomal Distribution
A) astereognosis 4. Distal > Proximal Neuropathy B. Cerebellar ataxia: unsteadiness associated with
B) agraphesthesia hypotonia, intention tremor and truncal instability
5. Sensory Dissociation
C) sensory extinction
 MOVEMENT DISORDERS GAIT DISTURBANCE GAIT DISTURBANCE

Positive signs: Negative signs a. Steppage gait – foot extensor weakness d. Ataxic gait – wide-based gait with unsteady
• Rigidity • Akinesia b. Spastic gait – due to corticospinal tract damage, movement and abrupt irregular placement of
feet drag with little knee movement, leg internally feet and swaying of trunk
• Hypertonicity • Bradykinesia rotated
• Chorea • Abnormal postural e. Paretic gait – due to quadriceps paralysis,
c. Parkinsonian gait – stiff, slow movement with necessitates locking of knee (hyperextension)
• Ballismus movements flexed posture and small steps on supporting leg to prevent collapse.
• Athetosis
• Tics

PRINCIPLES OF LOCALIZATION HEMISYNDROMES BEHAVIORAL SYNDROMES

• Each nervous system area has specific functions
and circumscribed nervous system lesions
produce characteristic clinical signs and
symptoms:
• Symptoms confined to only one side of the body
are produced by disorders of cerebral hemispheric
motor and sensory pathways
Disorders involving “higher cortical functions”
• Aphasias: inability to understand or express words
• Apraxias: failure to execute voluntary acts
• Agnosias: failure to understand meaning of
stimulus

FRONTAL LOBE SYNDROMES PARIETAL LOBE SYNDROMES TEMPORAL LOBE SYNDROMES

• Localized contralateral paralysis • Contralateral homonymous visual field defects

• Contralateral sensory hemisyndromes
• Focal motor epileptic seizures • Repetitive language disorders (Wernicke’s
• Agnosia/inattention aphasia)
• Reappearance of primitive reflexes
• Apraxia • Memory disturbances
• Perseveration
• Abnormal tactile discrimation • Epileptic seizures (Complex Partial type)
• Apathy
• Neglect
• Motor aphasia
• R to L disorentation
• Uninhibited social behavior
 OCCIPITAL LOBE SYNDROMES BASAL GANGLIA SYNDROMES THALAMIC SYNDROMES

• Contralateral visual field defects
• Alexia
• Color recognition disturbances
• Loss of neurons in substancia nigra or globus
pallidus – hypokinesia (reduced movement),lack
of associated movement
• Loss of neurons in striatum – hyperkinesia
(increased involuntary movements),
choreoathetosis
• Impairment of contralateral sensation
• Delayed sensation/unpleasant sensation
• Abnormal contralateral posturing (particularly
of hands)

HYPOTHALAMIC SYNDROMES BRAINSTEM SYNDROMES CEREBELLAR SYNDROMES

• Impaired regulation of temperature • “Crossed deficits” • Ataxia, Dysmetria, Dysdiadochokinesia

• Salt and water metabolism • Altered consciousness • Intention tremor
• Feeding • Cranial nerve deficits • Hypotonia
• Sleep-wake cycle • Impaired ocular motility • Sustained nystagmus
• Altered sexual functioning • Vertigo, ataxia, nystagmus
• Endocrine disturbances

SPINAL CORD SYNDROMES SPINAL CORD SYNDROMES SPINAL CORD SYNDROMES

I. Transection II. Brown-Sequard syndrome (Spinal cord hemisyndrome) III. Anterior Spinal Artery Syndrome
• spastic paralysis of extremities below level of • Ipsilateral spastic weakness • Paralysis and dissociated sensory loss (loss of
lesion pain and temperature sense, but preservation
• Ipsilateral loss of proprioception
• loss of sensation below level of lesion (sensory of proprioception) below level of lesion
level) • Contralateral loss of pain and temperature below
• paralysis of rectal sphincter function, abnormal level of lesion
bladder function
• disturbed sexual function
 Neuroanatomic Structure Routine Neurologic
SPINAL CORD SYNDROMES PERIPHERAL NERVE SYNDROMES Examination
Cortex Cerebral Function Test
IV. Central cord syndrome • Dermatomal sensory loss or radicular distribution
• Loss of all sensations and voluntary motor of pain or numbness Cranial Nerves Cranial Nerve Test
control except in sacral dermatomes • Flaccid paralysis/weakness Cerebellum Cerebellar Function Test
• Hyporeflexia
Pyramidal Tract Motor Function Test

Spinothalamic Tract Sensory Test

Spinal Cord & its Nerves Reflexes

SUMMARY

• Review the basic neuroanatomical structures and its

functional correlates
• Review important neurological signs and its
anatomical basis
• Read Demeyer book