Neurological history and examination Flashcards
What does a medical history entail?
PC, HPC, PMH, DH and allergies, SH, FH, RoS
Parts to a neurological history
- Patient +/- relative
- Impact of consciousness, speech or memory
- Age, gender, headedness, profession
- Pattern of progression important
- Impact, function, QoL
- Expectations, understanding, information
PC headache questions
Acute/chronic
speed of onset
single/recurrent
unilateral/bilateral/worsening features [e.g. waking/coughing]
relivieng features [e.g. sleep/rest]
associated features [e.g. aura, LOC]
red flags: new headache, over 60 years old, thunderclap, infective Sx, Hx of malignancy, etc.
Give examples of red flag Sx for a headache
New headache, over 60 years, thunderclap, infective Sx, Hx of malignancy etc.
Questions for weakness
- Onset gradual or sudden
- Rate of progression
- Muscle groups affected.
- pattern: symmetrical, asymmetrical
- associated sensory loss
pain - red flags [sphincter control, sudden onset, progressive, resp/swalloing problems]
What are red flag Sx for weakness?
loss of sphincter control
sudden onset [stroke]
progressive
resp. or swallowing problems
Questions for visual disturbances
"blurring" visual loss [monocular vs binocular] double vision [diplopia] photophobia speed of onset pain [in the eye, eye movements?] any other Sx [e.g. headache and visual loss in older person, acute onset]
Speech problems questions
“confusion”
comprehension? [recpetive/Wernicke’s dysphasia]
speech production? [expressive/broa’s]
repetition [conductive dysphasia, arcuate fasciculus]
articulation/slurred speech [dysarthria]: cerebellar, bulbar, pseudo-bulbar [“Donald duck” speech]
Phonation [dysphonia] e.g. laryngeal pathology, resp. muscle weakness
Questions for dysphagia
Is it neurological or mechanical?
Solids, liquids, or both?
Pain [odynophagia], things getting stuck?
Nasal regurgitation
associated coughin
speed of onset
mechanical causes incl. stricture and achalasia
neuro causes: bulbar and pseudoulbar palsy [brainstem pathology, MG, MND, etc.]
Sensation questions
positive or negative [numbness, pins and needles, para-dysaesthesia]? Pain, odd sensations "squeezing"? Distribution? Speed of onsety Ass. weakness/clumsiness
Blackout/fits/faints/funny turns questions
Detailed history important The way the patient tells it Eye witness account was there loss of consciousness? 3 Ps: posture, provokation, prodome? Frequency, duration Tongue biting, incontinence, cyanosis, post-event confusion shaking chest pain, palpitation, FHx driving
Compare epilepsy/non-epileptic attack/vasovagal syncope/cardiac syncope for situation/before/recovery/additional features/incontinence
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Obsrevaiton in the Dx of dementia
how many people come? Who gives the history? head turn sign detail of events, account of Hx Sx of depression and anxiety fluctuating, stepwise, progressing
Functional neurological disorders
Do the Sx add up
Do they fit into an appropriate anaotmical patterna
How does the person tell the story
what other Sx do they have
What are their ideas, concerns, and expectations
… and past past psychaitric hsitor yand social hsitory
PMH important qs
Similar/related Sx in past
DM and other vascualr RFs
AF
DH questions
Focus depends on presentation Peripheral neruopathy, Parkinsonism Now and in the past OTC recreational drugs alleergies and intolerance
Sh questions
Alcohol [seizures, neuropahy, ataxia, Wernicke-Korsakoff syndrome] Smoking Activities of daily living Family support Accomodation Driving
Tools in neuro exam
Fundoscope, tendon hammer, tuning fork, other
Main parts to neuro exam
Gen app, arms, legs, tone/power/reflexes/coordination/sensation, CN, [cognition, movement disorder, cortical signs etc.]
Signs of movement disorder PD
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inspection elements
well or unwell, thin or fat walking into clinic, tranferring, getting dressed and undressed PEG, catheters weakness, wasting, fasciculations Abnormal movements: tremor, chorea, tics, hemiballismus speech cognition interaction
Ways of testing cognitive state
AVPU, AMT [10], MMSE [30], MOCA [better - 30], ACE-R [better still - 100], neurophysiology
AMT parts
- recall address
- age
- time [nearest hour]
- year
- recognize two people [doctor, nurse etc.]
- DOB
- Date WW2
- Name present monarch
- name of hospital
- Count backwards from 10
briefly summarise anatomically where the CNs come out from the brain
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Name the cranial nerves?
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Which nerve does COVID affect?
3rd
how to test olfactory nerve?
- first ask any change sense of smell
- test ability to distinguish different smells covering each nostril
- smell bottles rare ward
change olfactory nerve can be cuased by what?
skull fractures, infx, tumour, PD
how to test optic nerve
visual fields, pupil reflexes and accomodation, visual acuity, funcdoscopy
Go through visual field disturbances and why anatomically they prestent as such
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How to test pupils?
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Give examples of pupillary problems and how they may present?
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how will an optic nerve lesion affect the pupil?
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If ophthalmoscopy shows swollen disc, what is this sign of? What about a pale disc?
Swollen optic nerve: papilloedema
Pale: optic atrophy
Which movements of the eye is the abducens nerve responsible for?
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Which movements of the eye is the oculomotor nerve responsible for?
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Which movements of the eye is the trochlear nerve responsible for?
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What is ocular palsy?
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in hypertropia, which nerve is paralysed?
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Only one eye obeys command look to the left? Which CN affected?
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Which deficit is nystagmus a sign of?
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Which deficit is internuclear ophthalmoplegia a sign of?
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Sensation and motor componenent to the trigeminal nerve
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Give an example of animal that has a large trigeminal nerve
Crocodile!
how to test for the trigeminal nerve
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Example condition adn Sx with trigeminal nerve problems
look up
Questions for facial nerve VII
Raise eyebrows clsoe your eyes shows me your teeth/smile puff out cheeks LMN vs UMN
how would LMN/UMN present in facial nerve?
Look up
Commands for vestibulocochlear nerve VIIII
rubbing fingers, whispering numbers, Rinne’s test: in confuctive hearing loss bone conduction is louder
Weber’s test: sound is louder in affcted ear in conductive deafness
Commands for glossopharyngeal IX/vagus X nerve
slides
how to test for vagus X and accessory Xi nerves
power of SCM and trapezius
how to test hypoglossal
tongue out and fasciculations, also speech and jew jerk
Insepction part of the limbs
Wasting, fasciculations, scars, tremor
3 types of tremor seen UL
rest, posture, intention
which CNS part affected in when spastic tone in UL?
pyramidal tracts
which CNS part affected when rigidity in UL?
basal ganglia
all parts of the UL examination
slides
how to differentiate between rigidity and spasticity in tone?
Spasticity: amplitude and velocity dependent, “Clasp knife”
Rigidity: present thoughout movement independent of speed, present even at slow speeds, lead pipe, cogwheel [regidity and tremor]
How to test power UL?
test each muscle indivudally
compare L and R
SAb, EF, EE, WF, WE, 1st DI, FE, APB, FF
HF, KF, DF, PF, great toe exntesion
Reflexes tested arms and limbs
arms: supinator, biceps, triceps, finger jerks, Hoffman’s
legs: knee, ankle, plantar
What are brisk reflexes a sign of?
look up
how to test coordination in the examination?
DANISH Dysdiadokinesis Ataxia Nystagmus intention tremor speech [hypotonia]
What are the 4 sensory modalities?
Light touch, pin prock, vibration, proprioception
Dsecribe the course of the dorsal column system and compare to the spinothalamic tract . How does this relate tot eh sensory modalities?
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30 yo.F headache: questions, examination, red flags?
SOCARATES, medication and coffee PMH
Papilloedema, BP, CNs, reflexes
65 y/o with difficulty walking: history, examination, red flags, additoinal SHx
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75 y/o acute onset left arm and leg weakness: history, examination, red flags
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