NEUROSURGICAL HISTORY & EXAMINATION Essam Elgamal FRCS(SN)

In conjunction with information from other systems, previous medical history, family and social history, current medications. Confirmation from relative or a friend.

History Headache Visual disorder Loss of consciousness Speech disorder Motor disorder Sensory disorder Sphincter disorder

History Lower cranial nerve disorder Mental disorder

HEADACHE Onset Course Duration Severity Character features Site Relieving factors Precipitating factors Timing Associated

VISUAL DISORDER Onset Course Duration Impairment Diplopia Hallucinations Precipitating factors

LOSS OF CONSCIOUSNESS Onset Course Duration Tongue biting Incontinence Limb twitching Alcohol/Drug Abuse Head injury Cardiovascular or Respiratory symptoms Precipitating factors

SPEECH DISORDER Onset Course Duration Articulation Expression Understanding

MOTOR DISORDER Onset Course Duration Coordination Weakness Involuntary movement Relieving factors Precipitating Factors

SENSORY DISORDER Onset Course Duration Pain Numbness Site Relieving factors Precipitating factors

SPHINCTER DISORDER Onset Course Duration Incontinence Or Retention Bladder Anal

LOWER CRANIAL NERVE DISORDER Onset Course Duration Deafness Tinnitus Vertigo Balance/staggering Swallowing Precipitating factors

MENTAL DISORDER Onset Course Duration Memory Intelligence Behaviour Personality

Examination General: Neurological disease systemic signs Systemic disease affect nervous system

Examination Temperature Blood pressure Neck stiffness Pulse irregularity Carotid bruit/murmer Cyanosis Weight loss Breast lump Lymphadenopathy Hepatosplenomegaly Prostatic irregularity Septic source Skin marks Anterior fontanelle Head circumference

Conscious level Higher functions: Cognitive skills Memory Reasoning Emotional status Cranial Nerves

Upper & Lower Limbs: Motor; Status Tone Power Reflexes Sensory; Pain Touch Temperature Proprioception Steriognosis Coordination

GCS Eye Opening: Spontaneous4 To speech3 To pain2 None1

GCS Verbal response: Orientated5 Confused4 Words3 Sounds2 None1

GCS Motor response: Obeys commands6 Localising to pain5 Flexing to pain4 Decorticated3 Decerebrated2 None1

Cognitive skills (Dominant Hemisphere) – Listen to language HesitantExpressive dysphasia FluentReceptive dysphasia – Doesn’t understand Receptive – Cannot name objectsNominal – Doesn’t readDyslexia – Doesn’t writeDysgraphia – Numerical calculationDyscalculia – Cannot recognise objectsAgnosia

Cognitive skills (Non-dominant Hemisphere) Doesn’t find his wayGeographical agnosia Cannot dress himselfDressing apraxia Copy geometric patternConstructional apraxia Minimental function test

Memory Test Immediate Recent Remote Verbal Visual Rretrograde amnesia Post-traumatic amnesia

Reasoning and problem solving Compare with expected abilities Emotional state Depressed Anxiety Apathy Uninhibited Slowness

Cranial nerves I Olfactory II Optic Acuity Field Fundus Pupils III, IV, VI Oculomotor, Trochlear, Abducent Ocular movement Diplopia Nystagmus

Cranial nerves V Trigeminal Sensory Motor VII Facial UMN weakness, LMN palsy VIII Auditory Cochlear component Weber’s test Conductive; louder in affected ear Neural; louder in normal ear Rinne’s test

Cranial nerves IX, X Glossopharyngeal & Vagus Gag reflex XI Accessory Sternomastoid Trapezius XII Hypoglossal

Motor system Asymmetry / deformity M. status M. tone Increased –Clasp-knife –Lead-pipe –Cog-wheal –Clonus

Motor system Power Grade 5Normal Grade 4 against some resistance Grade 3against gravity but not resistance Grade 2 elimination of gravity Grade 1 flickers Grade 0None

Reflexes Upper Limb Biceps C5,C6 Triceps C6,C7,C8 Hoffman sign Co-ordination Finger-nose test Finger-finger test Dysadiadocholinesia Arm bounce Rebound phenomenon

Reflexes Lower limb Knee Ankle Planter Coordination Romberg’s test Gait

Sensation Pain Touch Temperature Joint sensation Vibration Two point discrimination Sensory inattention (detect stimuli in both limbs) Streognosis Graphaesthesia

Sphincters Distended bladder Evidence of incontinence Anal reflex