Symptoms in Neurology

•Altered behavior
•Dizziness
•Fits or faints
•Disorder of balance
•Headache

•Disturbance of
vision
•Hearing,speech,
swallowing

•Weakness
•Disturbance of
sensation
•Sphincter
disturbances
Weakness
 Weakness- What a patient means..?

Increased
Fatigability

Apraxia Pain

Weakness
Hysteria

Severe
Slowness in
positional
activity
sensory loss
 Weakness
• Onset-
– Sudden - Stroke, Traumatic Compression radiculopathy
– Insidious -Brain tumors, Intracranial abscess

• Duration
– Acute- Stroke, GBS
– Subacute- CIDP
– Chronic-ALS

• Progression
– Progressively improving- Traumatic Compressive neuropathy, MS
– Static- Stroke , compressive neuropathy
– Progressively worsening- ALS,Polymyositis,Dermatomyositis
– Episodic –Multiple sclerosis
 Weakness
• Where is the weakness?
One limb
Symmetric
Proximal One side of body Bilateral
Asymmetric
– Upper limb or lower limb Distal
or trunk
Entrapment
Inability to get up from Stroke Inability to hold Cord
sitting pen, compression
mix food
GBS
neuropathy Stroke
or squatting
–Radiculopathy
U/l or B/l or one limb Hemiplegic migrain Myopathies
to climb stairs to button shirt
Myopathy
Multiple
to lift armsclerosis
above head forSOL in Brain
ALS Myasthenia
to hold the slippers with gripgravis
combing
– Proximal or distal
Stroke
Myasthenia
to gravis
lift bucket of water Mononeuritis
to stand on toes multiplex
– Symmetric or assymetric
 Weakness
You feel weakUMN
because? LMN

• Limb tightness , slowness in movement?

Limb tightness or stiffness Floppiness or heaviness
• Floppiness or heaviness of limb?

• No
Aremuscle
musclewasting
twitches(disuse)
present? Significant muscle wasting

• Wasting of muscle?
No muscle Muscle twitching present
twitching(fasciculation)
 Weakness
How much is the weakness?

- Indirect indicator of muscle power

- Climb stairs without support?

• Bed ridden?

• How much has the disability affected activities of daily living?

• Able to go for work?

History of Sensory disturbance
 Sensory symptoms

Positive symptoms Negative symptoms

• Paresthesia • Numbness- touch,

• Allodynia temperature

• Hyperalgesia • Worsening balance, gait

History in Sensory Cortexdisturbance
Contralateral hemineglect
Thalamus
Hemi-attention
Hemisensory disturbance from
head to foot
Dejerine roussy syndrome –
Shearing pain
Brain stem
Crossed pattern of sensory
loss

Spinal cord
Horizontal truncal sensory level
Band like sensation-At the level
Suspended Dissociated segmental sensory
Root
loss- Synringomyelia
Radicular pain
Bladder involvement
Saddle anesthesia-Cauda equina
Flexor spasm
Nerve
Sensory distribution along nerve
distribution
Glove and stocking
 History in Sensory disturbance
• Onset-
– Sudden- Stroke
– Insidious- Paraneolastic,CIDP

• Progression-

Acute Subacute Episodic

• Stroke • Nutritional • CIDP
• Porphyria • Malignancy • Porphyria
• Infections- • Paraneoplastic • HNPP
Diphtheria,lymes • Vasculitis
• Arsenic,dapsone,
thallium
 What is the character of sensory
abnormality?
Anterolateral tract, Small fibres Posterior column, Large fibres

• Walking on Pins and needles? • Cotton wools?

• Burning sensation? • Fine activities with precision?

• Sensation of clothes you • Slippage of slippers without

wear? knowing?

• Hot or cold? • Fall when closing eyes or in

dark room?

• Band like sensation?

 Pain as Sensory disturbance
• Site-
– Low back pain – Site of compression
– Proximal/distal(Glove and stocking pattern)
– Symmetric/Asymmetric/Single limb

• Onset
– Sudden-Radicular pain
– Insidious- Diabetic neuropathic

• Character
– Shooting type- Sciatica
– Electric shock like sensation- Lhermitte sign
– Band like sensation – Transverse myelitis
 History in Sensory disturbance
Features Neurogenic Vascular
• Radiation- claudication claudication
Localisation of pain
– Along the Back,buttock,legs,
nerve distribution in neuropathy Calf
Bilateral Unilateral
– Along the dermatomal distribution- Radiculopathy
Associated Paresthesia, None
• Associated symptoms
symptoms weakness,
• Aggravating factors incontinence
– On bending
Provoking factorsneck-Lhermitte
Prolonged
sign standing Walking
Walking downhill<uphill
– On exposure to heat- Uhthoff’s sign
downhill>uphill
– On prolonged standing- Neurogenic claudication
Relieving factors Sitting, lying down Stopping exertion
Disturbance of Balance and gait
 Disturbance in Balance and Gait
• First ask for H/o Pain in joints (arthritis), Impaired joint
mobility(contractures)
• Onset –
– Sudden- Stroke
– Gradual- Sensory ataxia
• Duration-
– Acute- Drug induced cerebellar ataxia
– Subacute- Sensory ataxia
– Chronic-Parkinsons
• Progression-
– Worsening- Parkinsons
– Improving- Drug induced, Stroke
– Episodic- NPH
 Disturbance in Balance and Gait
What is your difficulty? If yes?
• Difficulty in standing up from  Proximal muscle weakness
sitting?
• Sways while standing?  Cerebellar/ Vestibular

• Initiation of walk?
 Frontal lobe lesion

• Dragging of legs?
 Circumduction
 Scissoring – Spastic gait
 Disturbance in Balance and Gait
What is your difficulty? If yes?
• Sways or lurches to one side  U/L Cerebellar Lesion
• Waddle while walk?  Gluteal weakness
• Knee buckling while walk?  Quadriceps weakness
• Lift your feet higher each time for  Foot drop
next step?

• Slap feet down as you walk?  Sensory abnormality

• Gait worse with eyes closed?-  Dorsal column disease
 Disturbance in Balance and Gait

What is your difficulty? If yes?

• Difficult to take next step ?  Parkinsons

• Feet magnetically stuck to the

 NPH
ground?

• Difficult to stop suddenly? Fall

while turning?  Parkinsons

 Disturbance in Balance and Gait

Frontal ataxia Cerebellar ataxia Sensory ataxia

• Wide stance • Wide stance • Narrow

base base base,looks
• Start hesitation • Lateral down
• shuffling instability of • Regular with
trunk path deviation
• Difficulty • Falls on closing
maintaining eye
balance
Falls
 Falls
• Falls without loss of consciousness

• Event description:

– Give away of legs underneath?

– Fall as if collapsing in a heap? –

– DROP ATTACKS OR COLLAPSING FALLS

• Orthostatic hypotension
• Meniere’s disease

– Fall due to freezing of gait? PARKINSONS

– Fall when eyes closed or dark rooms? Posterior column

 Falls
– Fall like a tree trunk or a log of wood?

– Fall consistently in a particular direction?

TOPPLING FALL(muscle tone is retained)

• Cerebellar, vestibular lesion

• Fall over backward- PSP

 Falls with Loss of consciousness

Syncope Seizure
Complete flaccidity Tone normal or increased
Episode lasts seconds to
Episode lasts for minutes
minute
Tongue bite, frothing absent Tongue bite,frothing present

Usually prodrome present No Prodrome

Jerks are asynchronous,
small,non-rhythmic
No fecal incontinence
Post-episode confusion is
short
Jerks are coarse and
rhythmic
Fecal incontinence present
Post-ictal phase is long

Urinary incontinence is present in both

 Dizziness
World spin around you? If yes,
VERTIGO(Central/Peripheral)
No

Limbs shaking or spinning? If yes,

Posterior column involvement

No

Felt might loss consciousness but did not

Presyncope
 Peripheral and central vertigo
Features Peripheral Central

Imbalance Mild-moderate Severe

Nausea and Severe Variable, may be

vomiting minimal
Auditory symptoms Common Rare

Neurologic Rare Common

symptoms
Compensation Rapid Slow
 Vertigo

Symptoms Likely diagnosis

Persistent vertigo Vestibular neuronitis

Without
hearing loss
Intermittent vertigo Benign positional vertigo

Persistent vertigo Labyrinthitis

With
hearing loss
Intermittent vertigo Meniere’s disease