Neurological history and examination Flashcards
Neurological history: presenting symptoms
Headache. Muscle weakness. Change in other senses (hearing, smell, taste). Dizziness. Speech disturbance. Dysphagia. Fits/faints/funny turns/involuntary movements. Abnormal sensations. Tremor.
Neurological history: What questions should you ask someone presenting with headache?
SOCRATES. Different to usual headaches? Acute/chronic? Speed of onset? Single/recurrent? Unilateral/bilateral? Associated symptoms e.g. aura with migraine? Any meningism? Worse on waking (raised ICP)? Decreased conscious level? Take a 'worst ever' headache seriously.
Neurological history: What questions should you ask someone presenting with muscle weakness?
Speed of onset? Muscle groups affected? Sensory loss? Any sphincter disturbance? Loss of balance? Associated spinal/root pain?
Neurological history: What questions should you ask someone presenting with visual disturbance?
Blurring? Double vision (diplopia)? Photophobia? Visual loss? Speed of onset? Any preceding symptoms? Pain in eye?
Neurological history: What questions should you ask someone presenting with dizziness?
Illusion of surroundings moving (vertigo)?
Hearing loss/tinnitus?
Any loss of consciousness?
Positional?
Neurological history: What questions should you ask someone presenting with speech disturbance?
Difficulty in expression, articulation, or comprehension (can be difficult to determine)?
Sudden onset or gradual?
Neurological history: What questions should you ask someone presenting with dysphagia?
Solids and/or liquids?
Intermittent or constant?
Difficulty in coordination?
Painful (odynophagia)?
Neurological history: What questions should you ask someone presenting with fits/faints/funny turns/involuntary movements?
Frequency? Duration? Mode of onset? Preceding aura? Loss of consciousness? Tongue biting? Incontinence? Any residual weakness/confusion? Family history?
Neurological history: What questions should you ask someone presenting with abnormal sensations e.g. numbness, pins and needles, pain, odd sensations?
Distribution?
Speed of onset?
Associated weakness?
Neurological history: What questions should you ask someone presenting with tremor?
Rapid or slow? Present at rest? Worse on deliberate movement? Taking beta agonists? Any thyroid problems? Any family history? Fasciculations?
Neurological history: abbreviated mental test score (AMTS)
Tell patient an address to recall at the end, e.g. 42 West Street.
Age.
Time (to nearest hour).
What year is it?
Recognise 2 people, e.g. doctor and nurse.
Date of birth.
Dates of WWII.
Name of current monarch/PM.
Where are you now?
Count backwards from 20 to 1.
A score of ≤6 suggests poor cognition, acute delirium, or chronic dementia.
AMTS correlates well with the more detailed MMSE.
Deaf, dysphasic, depressed, and uncooperative patients, as well as those who don’t speak English, will also get low scores.
Neurological history: past medical history
Meningitis/encephalitis.
Head/spine trauma.
Seizures.
Previous operations.
Risk factors for vascular disease (AF, HTN, hyperlipidaemia, diabetes, smoking).
Recent travel, especially exotic destinations.
Any chance you might be pregnant?- eclampsia?
Neurological history: drug history
Any anticonvulsant/antipsychotic/antidepressant medication?
Any psychotropic drugs, e.g. ecstasy?
Any medication with neurological side effects? e.g. isoniazid can cause peripheral neuropathy.
Neurological history: social and family history
What can the patient do/not do? i.e. activities of daily living, ADLs.
Barthel Index score?
Family history of neurological or psychiatric disease?
Consanguinity?
Consider sexual history, e.g. syphilis.
Neurological history: cramp
This is painful muscle spasm.
Leg cramps are common at night or after heavy exercise, and in patients with renal impairment or on dialysis.
Cramp can signify salt depletion, and rarely muscle ischaemia (claudication, DM), myopathy, or dystonia.
Forearm cramps suggest motor neuron disease.
May be caused by drugs: diuretics, domperidone, salbutamol, levothyroxine, etc.
Neurological history: paraesthesia
Pins and needles, numbness/tingling, which can hurt or ‘‘burn’ (dysaesthesia).
Neurological history: paraesthesia, causes
Metabolic: low Ca2+ (perioral), raised PaCO2, myxoedema, neurotoxins (tick bite, sting).
Vascular: arterial emboli, Raynaud’s, DVT, high plasma viscosity.
Infection: rare- Lyme, rabies.
Drugs: ACE inhibitors.
Brain: thalamic/parietal lesions.
Cord: MS, myelitis/HIV, B12 deficiency, lumbar fracture.
Plexopathy/mononeuropathy: cervical rib, carpal tunnel, sciatica.
Peripheral neuropathy: glove and stocking, e.g. DM, CKD.
If paroxysmal: migraine, epilepsy, phaeochromocytoma.
If wandering, take travel history, consider infection, e.g. strongyloides.
Neurological history: resting tremor
Worst at rest.
e.g. from parkinsonism (± bradykinesia and rigidity, more resistant to treatment than other symptoms).
Usually slow tremor, frequency 3-5Hz.
Typically ‘pill-rolling’ of the thumb over the finger.
Neurological history: postural tremor
Worst if arms are outstretched.
Typically rapid (8-12Hz).
May be exaggerated by physiological tremor, e.g. anxiety, hyperthyroidism, alcohol, drugs, or due to brain damage, e.g. Wilson’s disease, syphilis, or benign essential tremor.
Often familial (autosomal dominant) tremor of arms and head presenting at any age.
Cogwheeling may occur but there is no bradykinesia.
Suppressed by alcohol, and patients may self-medicate rather than admit their problems.
Rarely progressive (unless unilateral onset).
Propranolol can help some patients.
Neurological history: intention tremor
Worst on movement, seen in cerebellar disease, with past-pointing and dysdiadochokinesis.
No effective drug has been found.
Neurological history: facial pain, CNS causes
Migraine.
Trigeminal or glossopharyngeal neuralgia or from any other pain sensitive structure in the head or neck.
Post-herpetic neuralgia = nasty, burning and stabbing pain involving dermatomal areas affected by shingles, may affect CNV and CNVII in the face, may become chronic and intractable.
Always give strong psychological support.
Transcutaneous nerve stimulation, capsaicin ointment, and infiltrating local anaesthetic are tried.
Neuropathic pain agents e.g. amitriptyline or gabapentin may help.
Neurological history: facial pain, vascular and non-neurological causes
Neck: cervical disc pathology.
Bone/sinuses: sinusitis, neoplasia.
Eye: glaucoma, iritis, orbital cellulitis, eye strain, AVM.
Temporomandibular joint: arthritis or idiopathic dysfunction (common).
Teeth/gums: caries, broken teeth, abscess, malocclusion.
Ear: otitis media, otitis externa.
Vascular/vasculitis: arteriovenous fistula, aneurysm, or AVM at the cerebellopontine angle, giant cell arteritis, SLE.
Neurological examination: upper limb, general inspection
Abnormal posturing
Asymmetry
Abnormal movements (fasciculations, tremor, dystonia, athetosis)
Muscle wasting- especially small muscles of the hand, symmetrical or asymmetrical? local or general?