Neurology history and examination Flashcards
What things can exacerbate a headache?
Noise Stress Bending Standing up Coughing Sneezing Blowing nose Eating Combing hair Bright/flashing lights Certain foods/drugs Dehydration
What is important to ask about in an altered consciousness history?
What were they doing at the time? Pain? Injections? Hot, crowded rooms? Stress? Prolonged standing? How they felt before? Associated symptoms? Recovery? Witness?
What is important to know in neurological histories?
Sudden onset?
How long did it take to reach the peak of symptoms?
Getting better/worse?
Static/progressive/relapsing/remitting?
What risk factors need to be asked about in the past medical history?
Head/spinal trauma Metabolic/endocrine disorders Cancer Epilepsy Hypertension AF Heart diseases
What drugs need to be asked about in the drug history?
Anti-convulsants Drugs interacting with anti-convulsants or lower seizure threshold Analgesics Anti-hypertensives Anti-depressants Insulin Recreational drugs
What drugs can interact with AEDs?
Alcohol
Interact with each other
NOACs
What drugs an lower the seizure threshold?
Anti-depressants Amphetamines Cocaine Lithium Anti-histamines
What should you ask about in social history?
Alcohol Smoking Recreational drugs Occupation Social activities/hobbies Home circumstances/level of independence
What should you ask about in family history?
Diabetes Cerebral haemorrhage Cerebrovascular disease/stroke IHD Migraine Epilepsy
What are the steps in a neuro examination?
Inspection Tone Power Reflexes Co-ordination Sensory
What should you ask before beginning an upper limb examination?
Any pain?
Right or left handed?
What should you inspect? Upper limb
Posture Wasting Tremor Fasciculations Involuntary movements Pronator drift
How do you assess tone? Upper limb
Passively move each joint
How do you assess power? Upper limb
Get the patient to perform each movement against resistance
What movements do you need to assess? Upper limb
Shoulders - flexion, extension, abduction, adduction
Elbows - flexion, extension, pronation, supination
Wrists - flexion, extension
Fingers - flexion, extension, abduction
Thumb - palmar abduction, adduction, opposition
What reflexes need to be assessed? Upper limb
Biceps
Triceps
Supinator/brachioradialis
How do you assess co-ordination? Upper limb
Finger to examiners finger then own nose
Finger to own nose with eyes closed
Fine movements - fingers to thumb
Dysdiadochokinesis
How do you assess sensation?
Soft touch Pain Temperature Proprioception Vibration
Where are the dermatomes in the upper limb?
C5 - regimental badge C6 - palmar side of thumb C7 - palmar side of middle finger C8 - palmar side of little finger T1 - medial aspect of antecubital fossa
What myotome and muscles are assessed in shoulder abduction?
C5 (axillary nerve)
Deltoid
What myotome and muscles are assessed in shoulder aduction?
C6/7 (thoracodorsal)
Teres major, latissimus dorsi, pectoralis major
What myotome and muscles are assessed in elbow flexion?
C5/6 (musculocutaneous and radial)
Biceps brachii, coracobrachialis, brachialis
What myotome and muscles are assessed in elbow extension?
C7 (radial)
Triceps brachii
What myotome and muscles are assessed in wrist extension?
C6 (radial)
Extensors of wrist
What myotome and muscles are assessed in wrist flexion?
C6/7 (median)
Flexors of wrist
What myotome and muscles are assessed in finger extension?
C7 (radial)
Extensor digitorum
What myotome and muscles are assessed in finger abduction?
T1 (ulnar)
First dorsal interosseous
Abductor digiti minimi
What myotome and muscles are assessed in thumb abduction?
T1 (median)
Abductor pollicis brevis
How do you assess for tone? Lower limb
Passively move each joint
Ankle clonus
What do you inspect? Lower limb
Posture Wasting Tremor Fasciculations Involuntary movements Gait - normal and heel-to-toe Romberg's test
How do you assess power? Lower limb
Check movements against resistance
What movements should you do? Lower limb
Hip - abduction, adduction, flexion, extension
Knee - flexion, extension
Ankle - dorsiflexion, plantarflexion
Big toe - plantarflexion, dorsiflexion
What reflexes should you assess? Lower limb
Knee
Ankle
Babinski
Ankle clonus
How do you assess co-ordination?
Heel-shin test
What are the dermatomes in the lower limb?
L1 - inguinal region and very top of medial thigh
L2 - middle and lateral aspect of anterior thigh
L3 - medial aspect of knee
L4 - medial aspect of lower leg and ankle
L5 - dorsum and medial aspect of big toe
S1 - dorsum and lateral aspect of little toe
What myotome and muscles are assessed in hip flexion?
L1/2 (iliofemoral)
Iliopsoas
What myotome and muscles are assessed in hip extension?
L5/S1 (sciatic)
Gluteus maximus
What myotome and muscles are assessed in knee flexion?
S1 (sciatic)
Hamstrings
What myotome and muscles are assessed in knee extension?
L3/4 (femoral)
Quadriceps
What myotome and muscles are assessed in ankle dorsiflexion?
L4/5 (deep peroneal)
Tibialis anterior
What myotome and muscles are assessed in ankle plantarflexion?
S1/2 (tibial nerve)
Gastrocnemius
Soleus
What myotome and muscles are assessed in big toe extension?
L5 (deep peroneal)
Extensor hallucis longus
What nerves are activated in knee-jerk reflex?
L3/4
What nerves are activated in ankle-jerk reflex?
S1
What nerves are activated in babinski reflex?
L5/S1
What nerves are activated in biceps reflex?
C5/6
What nerves are activated in supinator reflex?
C5/6
What nerves are activated in triceps reflex?
C7
What does an MRC grading of 5 mean?
Movement against gravity with full power against resistance
What does an MRC grading of 4 mean?
Movement against gravity with reduced power against resistance
What does an MRC grading of 3 mean?
Movement against gravity only without applied resistance
What does an MRC grading of 2 mean?
Muscle contraction seen, no movement
What does an MRC grading of 1 mean?
Flicker of muscle contraction seen, no movement
What does an MRC grading of 0 mean?
No muscle contraction
What are the signs of cerebellar dysfunction?
DANISH - Dysdiadochokinesia - Ataxia - Nystagmus - Intention tremor - Speech and stance - Heel-to-shin test positivity Gait abnormalities
