1. Neurological History Taking and Physical Examination
Dr. M. A. Sofi MD; FRCP (London); FRCPEdin; FRCSEdin

2. Neurological History: Taking the patient's history is traditionally the first step in virtually every clinical encounter.
Pain should be further defined:
Location (Ask the patient to point with one finger, if possible.)
Radiation (Pay attention to any dermatomal relationship.)
Quality (stabbing, stinging, lightning like, pounding, etc)
Severity or quantity
Precipitating factors (stress, periods, allergens, sleep deprivation, etc)
Relieving factors (sleep, stress management, etc)
Diurnal or seasonal variation
The history of the presenting illness or chief complaint should include the following:
Symptom onset (eg, acute, subacute, chronic, insidious)
Duration
Course of the condition (eg, static, progressive, or relapsing and remitting)
Associated symptoms, such as pain, headache, nausea, vomiting, vertigo, numbness, weakness, and seizures

5. Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery.
This definition excludes seizures, coma, shock, or other states of altered consciousness. Although most causes of syncope are benign, this symptom presages a life-threatening event in a small subset of patients.
Signs and symptoms
History and physical examination are the most specific and sensitive ways of evaluating syncope.
Precipitant factors
Activity the patient was involved in before the event
Position the patient was in when the event occurred
Presyncopal symptoms :
Prior faintness, dizziness, or light-headedness (70% of cases of true syncope)
Prior vertigo, weakness, diaphoresis, epigastric discomfort, nausea, blurred or faded vision, pallor, or paresthesias

8. A seizure
Also known as a fit, is caused by a disturbance in the electrical activity of the brain, which can be due to conditions such as epilepsy. There are 2 main types of seizure:
Generalised seizures involve both sides of the brain from the start of the attack. Common subtypes include
Tonic-clonic and
Absence seizures.
Partial (or focal) seizures begin in a specific area of the brain and may be contained there. Or they may spread to the entire brain.
Simple partial seizures, the person remains conscious.
Complex partial seizures involve impaired consciousness

11. D I P L O A S E M N T

13. These steps include the following:
Steps in the neurologic examination
In examining a patient, abnormalities of function lead to localization and, eventually, to the pathophysiology.
These steps include the following:
General Appearance, including posture, motor activity, vital signs and perhaps meningeal signs if indicated.
Mini Mental Status Exam, including speech observation.
Cranial Nerves, I through XII.
Motor System, including muscle atrophy, tone and power.
Sensory System, including vibration, position, pin prick, temperature, light touch and higher sensory functions.
Reflexes, including deep tendon reflexes, clonus, Hoffman'sresponse and plantar reflex.
Coordination, gait and Rhomberg's Test Examining the comatose patient

14. Examination of the Higher Functions
Components of Higher Functions
Higher functions include gait, speech, and mental status.
Gait is the attitude of a person in the upright position. Abnormal types are described below.
Hemiparetic gait: The shoulder is adducted; the elbow is flexed; the forearm is pronated, and the wrist and fingers are flexed.
Ataxic gait: Patient spreads his or her legs apart to widen the base of support to compensate for the imbalance while standing or walking
The heel-to-toe or tandem walking maneuvers and standing on 1 leg uncover subtle forms of ataxia
Shuffling gait: The individual takes short steps and appears to shuffle his or her legs rather than put them forward.
Steppage gait: Individual takes high steps as if climbing a flight of stairs while walking on a level surface.
Spastic or scissor gait: The legs are held in adduction at the hip and the thighs rub against each other as the patient walks.
Antalgic gait: Patient favors the affected painful (usually lower) extremity and walks, putting weight on the normal leg. The hand held over hip on the affected side is typical in patients with radicular pain.

16. Examination of the Higher Functions
Speech
Speech is communication between individuals. Abnormalities include dysphonia, dysarthria, and dysphasia or aphasia.
Dysphonia or aphonia
Dysphonia is the impairment or inability to phonate. The voice becomes hoarse. In extreme cases, it is absent, and the patient is mute.
Dysarthria or anarthria
Dysarthria is the inability to articulate spoken words. The quality of oration is impaired, but the content remains intact (e.g., slurred speech).
Ability to understand and synthesize speech remains intact.
Dysphasia or aphasia: In dysphasia, the ability to process language is impaired, resulting in
Inability to understand or comprehend Wernicke aphasia
Transfer signals from the Wernicke to the Broca area conduction aphasia
Properly execute speech expressive, motor, or Broca aphasia).
The combination of Broca and Wernicke aphasias is referred to as global aphasia.

17. Essential Features of Common Dysphasias
Type of Dysplasia
Fluency
Comprehension
Naming
Localization
Broca
Non-fluent
Intact
Impaired
Broca area
Wernicke
Fluent
Wernicke area
Conduction
Arcuate fasciculus
Global
Nonfluent
Broca and Wernicke areas

18. Mini–mental state examination
Category
Possible points
Description
Orientation to time 5
From broadest to most narrow. Orientation to time has been correlated with future decline.
Orientation to place
From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor.
Registration 3
Repeating named prompts
Attention and calculation
Serial sevens, or spelling "world" backwards. It is more appropriate in a population where English is not the first language.
Recall
Registration recall
Language 2
Naming a pencil and a watch
Repetition 1
Speaking back a phrase
Complex commands 6
Varies. Can involve drawing figure shown
Total score

19. Category
Tests
Example of writeup
Cranial nerve examination
Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart
CNII-XII grossly intact
Motor system
Muscle strength, often graded on the MRC scale 0 to 5 (i.e., 0 = Complete Paralysis to 5 = Normal Power).
grades 4−, 4 and 4+ maybe used to indicate movement against slight, moderate and strong resistance respectively.
Muscle tone and signs of rigidity.
Examination of posture
Decerebrate
Decorticate
Hemiparetic
Resting tremors
Abnormal movements
Seizure
Fasciculations
Tone
Spasticity
Pronator drift
Rigidity
Cogwheeling (abnormal tone suggestive of Parkinson's disease)
Gegenhalten – is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia
"strength 5/5 throughout, tone WNL"

20. Category
Tests
Example of writeup
Deep tendon reflexes
Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e., Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate A reflex hammer is used for this testing.
"2+ symmetric, downgoing plantar reflex"
Sensation
Sensory system testing involves provoking sensations of fine touch, pain and temperature. Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception.
Sensory
Light touch
Pain
Temperature
Vibration
Position sense
Graphesthesia
Stereognosis, and
Two-point discrimination (for discriminative sense)
Extinction
Romberg test – 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. epicritic sensation
"intact to sharp and dull throughout
Cerebellum
Cerebellar testing
Dysmetria Dysdiadochokinesis
Finger-to-nose test Rapid pronation-supination
Ankle-over-tibia test
Ataxia
Assessment of gait
Nystagmus
Intention tremor
Staccato speech
"intact finger-to-nose, gait WNL

21. Interpretation
The results of the examination are taken together to anatomically identify the lesion. This may be diffuse (e.g., neuromuscular diseases, encephalopathy) or highly specific (e.g., abnormal sensation in one dermatome due to compression of a specific spinal nerve by a tumor deposit).
General principles
Looking for side to side symmetry:
Determining if there is focal asymmetry.
Determining whether the process involves:
(PNS),(CNS), or both.
If the finding can be explained by a single lesion or whether it requires a multifocal process.
Lesion's location.
If the process involves the CNS, clarifying if it is cortical, subcortical, or multifocal.
Subcortical, clarifying whether it is white matter, basal ganglia, brainstem, or spinal cord.
PNS then determining whether it localizes to the nerve root, plexus, peripheral nerve, neuromuscular junction, muscle or whether it is multifocal.
Differential diagnosis may then be constructed that takes into account the patient's background

22. Reflex-Grading System Score Reflexes Absent 1
Muscles and Spinal Roots
Muscle
Spinal Roots
Biceps
C5, 6
Brachioradialis C6
Triceps C7
Patellar
L2-4
Achilles S1
Reflex-Grading System
Score
Reflexes
Absent 1
Hypoactive or present only with reinforcement 2
Readily elicited with a normal response 3
Brisk with or without evidence of spread to the neighboring roots 4
Associated with a few beats of unsustained clonus 5
Sustained clonus

23. Muscle-Strength Scale
Score
Description
Absent voluntary contraction 1
Feeble contractions that are unable to move a joint 2
Movement with gravity eliminated 3
Movement against gravity 4
Movement against partial resistance 5
Full strength