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Oxford Handbook of Clinical Medicine > Neurological history and examination > Flashcards

Neurological history and examination Flashcards

1
Q

Neurological history: presenting symptoms

A 
Headache.
Muscle weakness.
Change in other senses (hearing, smell, taste).
Dizziness.
Speech disturbance.
Dysphagia.
Fits/faints/funny turns/involuntary movements.
Abnormal sensations.
Tremor.
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2
Q

Neurological history: What questions should you ask someone presenting with headache?

A 
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.
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3
Q

Neurological history: What questions should you ask someone presenting with muscle weakness?

A 
Speed of onset?
Muscle groups affected?
Sensory loss?
Any sphincter disturbance?
Loss of balance?
Associated spinal/root pain?
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4
Q

Neurological history: What questions should you ask someone presenting with visual disturbance?

A 
Blurring?
Double vision (diplopia)?
Photophobia?
Visual loss?
Speed of onset?
Any preceding symptoms?
Pain in eye?
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5
Q

Neurological history: What questions should you ask someone presenting with dizziness?

A

Illusion of surroundings moving (vertigo)?
Hearing loss/tinnitus?
Any loss of consciousness?
Positional?

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6
Q

Neurological history: What questions should you ask someone presenting with speech disturbance?

A

Difficulty in expression, articulation, or comprehension (can be difficult to determine)?
Sudden onset or gradual?

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7
Q

Neurological history: What questions should you ask someone presenting with dysphagia?

A

Solids and/or liquids?
Intermittent or constant?
Difficulty in coordination?
Painful (odynophagia)?

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8
Q

Neurological history: What questions should you ask someone presenting with fits/faints/funny turns/involuntary movements?

A 
Frequency?
Duration?
Mode of onset?
Preceding aura?
Loss of consciousness?
Tongue biting?
Incontinence?
Any residual weakness/confusion?
Family history?
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9
Q

Neurological history: What questions should you ask someone presenting with abnormal sensations e.g. numbness, pins and needles, pain, odd sensations?

A

Distribution?
Speed of onset?
Associated weakness?

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10
Q

Neurological history: What questions should you ask someone presenting with tremor?

A 
Rapid or slow?
Present at rest?
Worse on deliberate movement?
Taking beta agonists?
Any thyroid problems?
Any family history?
Fasciculations?
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11
Q

Neurological history: abbreviated mental test score (AMTS)

A

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.

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12
Q

Neurological history: past medical history

A

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?

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13
Q

Neurological history: drug history

A

Any anticonvulsant/antipsychotic/antidepressant medication?
Any psychotropic drugs, e.g. ecstasy?
Any medication with neurological side effects? e.g. isoniazid can cause peripheral neuropathy.

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14
Q

Neurological history: social and family history

A

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.

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15
Q

Neurological history: cramp

A

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.

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16
Q

Neurological history: paraesthesia

A

Pins and needles, numbness/tingling, which can hurt or ‘‘burn’ (dysaesthesia).

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17
Q

Neurological history: paraesthesia, causes

A

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.

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18
Q

Neurological history: resting tremor

A

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.

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19
Q

Neurological history: postural tremor

A

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.

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20
Q

Neurological history: intention tremor

A

Worst on movement, seen in cerebellar disease, with past-pointing and dysdiadochokinesis.
No effective drug has been found.

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21
Q

Neurological history: facial pain, CNS causes

A

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.

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22
Q

Neurological history: facial pain, vascular and non-neurological causes

A

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.

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23
Q

Neurological examination: upper limb, general inspection

A

Abnormal posturing
Asymmetry
Abnormal movements (fasciculations, tremor, dystonia, athetosis)
Muscle wasting- especially small muscles of the hand, symmetrical or asymmetrical? local or general?

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24
Q

Neurological examination: upper limb, overview

A 
General inspection.
Tone.
Power.
Coordination.
Reflexes.
Sensation.
25
Q

Neurological examination: upper limb, tone

A

Ask patient to relax/go floppy like a rag doll.
Ask if patient has any pain in hands/arm/shoulder before passively flexing and extending the limb whilst also pronating and supinating the forearm.
Any spasticity or rigidity?

26
Q

Neurological examination: upper limb, power

A

Direct patient to adopt each position and follow commands whilst you as the examiner stabilise the joint above and resist movements as appropriate to grade power.
Test each muscle group bilaterally before moving on to the next position.
‘Shrug your shoulders and don’t let me push down’, ‘push your arms out to the side against me, try to pull them back in’.
‘Hold your arm up like this and pull me towards you, now push me away’.
‘Hold your hand out flat, don’t let me push it down, now don’t let me push it up’.
Offer the patient 2 fingers of yours and ask them to squeeze them.
Ask patient to ‘spread your fingers and stop me pushing them back together’, then ‘make an ok sign and stop me breaking the circle’ or ‘hold this bit of paper between fingers and don’t let me pull it out’.

27
Q

Neurological examination: upper limb, reflexes

A

For each reflex, test right then left and compare.
If absent, attempt to elicit with reinforcement by asking patient to clench their teeth on 3.
Are reflexes absent/present? normal/brisk/exaggerated?
Biceps: C5,6.
Triceps: C7.
Supinator: C6.

28
Q

Neurological examination: upper limb, coordination

A

Holding your finger in front of the patient, instruct ‘touch my finger then your nose, as fast as you can’.
Look for intention tremor and ‘past-pointing’.
Test for dysdiadochokinesia: ask patient to repeatedly pronate and supinate forearm, tapping hands each time.
Test both limbs, you may have to demonstrate.
Failure to perform rapidly alternating movements is dysdiadochokinesis.
Test for pronator drift: with patient’s eyes closed and arms outstretched, tap down on their up-facing palms and look for a failure to maintain supination.

29
Q

Neurological examination: limbs, sensation, light touch, pin prick, temperature

A

Use cotton wool, touch it to sternum first, ‘this is what it should feel like, say ‘yes’ when you feel it and if it feels the same on both sides’.
Proceed to test with cotton wool in all dermatomes, comparing left and right.
Repeat as above using a neurological pin, asking patient to tell you if it feels sharp or dull- dispose of in sharps bin.
Repeat as above, alternating hot and cold probes- can the patient tell the difference?

30
Q

Neurological examination: limbs, sensation, vibration

A

With the patient’s eyes closed, using a 128Hz tuning fork, confirm with patient that they can feel a ‘buzzing’ when you place the tuning fork on their sternum, and can tell when it stops.
Proceed to test the most distal bony prominence and move proximally by placing the buzzing fork on the bony prominence then stopping it with your fingers.
Ask the patient to tell you ‘yes’ when they feel buzzing and ‘stopped’ when it’s stopped.

31
Q

Neurological examination: limbs, sensation, proprioception

A

With the patient’s eyes closed, grasp distal phalanx of thumb/toe or index finger at the sides (not on top).
Stabilised the rest of the finger/toe.
‘This is up, this is down, keep your eyes closed and tell me which direction I’m moving it’.
Flex and extend the joint, stopping at intervals to ask whether the finger/toe tip is up or down.

32
Q

Neurological examination: lower limb, general inspection

A

Abnormal posturing
Muscle wasting
Fasciculations (LMN lesion?)
Deformities of the foot e.g. pes cavus of Friedrich’s ataxia or Charcot-Marie-Tooth disease.
Is one leg smaller than the other (old polio, infantile hemiplegia)?

33
Q

Neurological examination: lower limb, gait

A

Ask patient to walk a few metres, turn, and walk back to you.
Note use of walking aids, symmetry, size of paces, arm swing.
Ask patient to walk ‘heel to toe as if on a tightrope’ to exaggerate any instability.
Ask patient to walk on tiptoes, then on heels.
Inability to walk on tiptoes indicates S1 or gastrocnemius lesion.
Inability to walk on heels indicates L4,5 lesion or foot drop.

34
Q

Neurological examination: lower limb, Romberg’s test

A

Ask patient to stand unaided with arms by their sides and close their eyes (be ready to support them).
If they sway/lose balance the test is positive and indicates posterior column disease/sensory ataxia.

35
Q

Neurological examination: lower limb, tone

A

Ask patient to relax/go floppy like a rag doll.
Ask if patient has any pain in feet/legs/hips before passively flexing and extending the limb whilst also internally and externally rotating.
Hold the patient’s knee and roll it from side to side.
Put your hand behind the knee and flex it quickly.
The heel should lift slightly from the bed if tone is normal.
Any spasticity or rigidity?
Clonus: plantar flex the foot then quickly dorsiflex and hold- more than 3 beats of plantar flexion is sustained clonus and abnormal.
Hypertonia and clonus suggest UMN lesion.

36
Q

Neurological examination: lower limb, reflexes

A

For each reflex, test right then left and compare.
If absent, attempt to elicit with reinforcement.
Decide whether reflexes are absent/present. normal/brisk/exaggerated?
Knee: L3,4. Strike on patellar tendon, just below the patella.
Ankle: L5,S1. Ask the patient to slightly bend their knee and drop it laterally, grasp the foot and dorsiflex, then strike Achilles’ tendon. If hip pain limits mobility, dorsiflex foot with straight leg and strike hand, feel for ankle jerk.
Plantar reflexes: L5,S1,2. Stroke the patient’s sole with an orange stick or similar- normal reflex is downward movement of the big toe.
Babinski sign is positive if upgoing plantar reflex, dorsiflexion of big toe (UMN lesion) >6 months old.

37
Q

Neurological examination: lower limb, power

A

Direct patient to adopt position and follow commands while you as the examiner resist movements as appropriate to grade power.
Test each muscle group bilaterally before moving on to the next position.
Hip flexion: ‘keep your leg straight and lift it off the bed, don’t let me push it down’.
Hip extension: ‘and now push my hand down into the bed’.
Hip abduction: position your hands on outer thighs, ‘push your legs out to the sides’.
Hip adduction: position your hands on inner thighs, ‘and push your legs together’.
Knee flexion and extension: ‘bend your knee and bring your heel in towards your bottom, don’t let me pull it away, and now kick out against me and push me away’.
Ankle plantar flexion: with your hand on the underside of the patient’s foot, ask them to ‘bend your foot down to push my hand away’.
Ankle dorsiflexion: put your hand on the dorsal of the foot and ask them to ‘lift up your foot, point your toes at the ceiling, and don’t let me push your foot down’.

38
Q

Neurological examination: lower limb, coordination

A

Heel-shin test: using your finger on the patient’s shin to demonstrate, instruct patient to ‘put your heel just below your knee then run it smoothly down your shin, lift it up to kick my hand and place it back on your knee, repeat as fast as you can’. Repeat on the other side.
Fast alternate foot tapping onto examiner’s hands with patient lying down.

39
Q

Neurological examination: cranial nerves, CNI olfactory

A

Have you noticed any changes in your sense of smell recently?
Can test ability of each nostril separately to distinguish familiar smells, e.g. coffee.

40
Q

Neurological examination: cranial nerves, CNII optic

A

Acuity: test each eye separately, and its correctability with glasses or pinhole. Use a Snellen chart to test acuity.
Visual fields: compare with your own fields or formally via perimetry testing- any losses/inattention? ‘Point to the side you see my fingers wiggling’, ‘say ‘now’ when you can see my fingers’.
Pupils: size, shape, symmetry, reaction to light (direct and consensual) or accommodation, swinging torch test for RAPD.
Ophthalmoscopy: darken the room, warn the patient you will need to get close to their face, focus the lens on the optic disc (pale? swollen?) and follow vessels outwards to view each quadrant; examine red reflex for cataract.

41
Q

Neurological examination: cranial nerves, CNIII oculomotor, CNIV trochlear, CNVI abducens

A

Eye movements.
Ask the patient to keep their head still and follow your finger as you trace an imaginary ‘H’.
3rd nerve palsy = ptosis, large pupil, eye down and out.
4th nerve palsy = diplopia on looking down and in, head tilting compensates for this, often noticed going downstairs.
6th nerve palsy: horizontal diplopia on looking out.
Nystagmus: involuntary jerky eye oscillations.

42
Q

Neurological examination: cranial nerves, CNV trigeminal

A

Motor palsy- ‘open your mouth’, jaw deviates to side of lesion, muscles of mastication (temporalis, masseter, and pterygoids). Feel sides of face for muscles of mastication. Open jaw against resistance.
Sensory: check all 3 divisions with cotton wool, consider corneal reflex (lost first).

43
Q

Neurological examination: cranial nerves, CNVII facial

A

Facial nerve lesions cause droop and weakness.
As the forehead has bilateral representation in the brain, only the lower 2/3 is affected in UMN lesions, but all of one side of the face in LMN lesions.
Ask patient to pull some funny faces: ‘raise your eyebrows’, ‘shut your eyes as tight as you can and stop me opening them’, ‘puff out your cheeks’, ‘purse your lips as if you’re whistling’, ‘show me your teeth’.
Could also test taste sensation with salt/sweet solutions (anterior 2/3 of tongue).

44
Q

Neurological examination: cranial nerves, CNVIII vestibulocochlear

A

Hearing- point to the side you’re making a noise on.
Perform Weber’s and Rinne’s tests.
Balance/vertigo.

45
Q

Neurological examination: cranial nerves, CNIX glossopharyngeal, CNX vagus

A

Ask to say ‘aahhh’. 10th nerve lesions also cause the palate to be pulled to the normal side on saying ‘ah’, uvula deviates away.
Ask them to swallow a sip of water.
Consider gag reflex- touch the back of the soft palate with an orange stick- the afferent arm of the reflex involves CNIX, the efferent is CNX.

46
Q

Neurological examination: cranial nerves, CNXI accessory

A

Trapezii: shrug your shoulders, don’t let me push them down.
Sternocleidomastoid: turn your head to the left/right, don’t let me turn it back.

47
Q

Neurological examination: cranial nerves, CNXII hypoglossal

A

Tongue movement: stick out your tongue, deviates to side of lesion.

48
Q

Neurological examination: cranial nerves, types and causes of nystagmus

A

Horizontal nystagmus is often due to vestibular lesion (acute = nystagmus away from lesion, chronic = nystagmus towards lesion), or cerebellar lesion (unilateral lesions cause nystagmus towards the affected side).
If it is more in whichever eye is abducting, MS may be the cause (internuclear ophthalmoplegia).
If also deafness/tinnitus, suspect a peripheral cause, e.g. 8th nerve lesion, barotrauma, Meniere’s).
If it varies with head position, suspect benign positional vertigo.
If it is up and down, ask a neurologist to review- upbeat nystagmus classically occurs with lesions in the midbrain or at the base of the 4th ventricle, downbeat nystagmus in foramen magnum lesions.
Nystagmus lasting ≤2 beats is normal, as is nystagmus at the extremes of gaze.

49
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, general

A 
Any cranial nerve may be affected by diabetes mellitus, stroke, MS, tumours, sarcoidosis, vasculitis e.g. PAN or SLE, syphilis.
Chronic meningitis (malignant, TB, fungal) tend to pick off the lower cranial nerves 1 by 1.
50
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNI

A

Trauma
Respiratory tract infection
Meningitis
Frontal lobe tumour

51
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNII

A

Field defects may start as small areas of visual loss (scotomas, e.g. in glaucoma).
Monocular blindness: lesions of 1 eye or optic nerve, e.g. MS, giant cell arteritis.
Bilateral blindness: any cause of mononeuritis, e.g. diabetes, MS, rarely methanol, neurosyphilis.
Field defects, bitemporal hemianopia: optic chiasm compression, e.g. pituitary adenoma, craniopharyngioma, internal carotid artery aneurysm.
Homonymous hemianopia: affects half of the visual field contralateral to the lesion in each eye; lesions lie beyond the chiasm in the tracts, radiation, or occipital cortex, e.g. stroke, abscess, tumour.
Optic neuritis (pain on moving eye, loss of central vision, relative afferent pupillary defect, disc swelling from papillitis): demyelination e.g. MS, rarely sinusitis, syphilis, collagen vascular disorders.
Ischaemic papillopathy: swelling of optic disc due to stenosis of the posterior ciliary artery, e.g. in giant cell arteritis.
Papilloedema: bilaterally swollen discs, most commonly raised ICP (tumour, abscess, encephalitis, hydrocephalus, idiopathic intracranial hypertension), rarer = retro-orbital lesion, e.g. cavernous sinus thrombosis.
Optic atrophy: pale optic discs and reduced acuity, caused by MS, frontal tumours, Friedreich’s ataxia, retinitis pigments, syphilis, glaucoma, Leber’s optic atrophy, chronic optic nerve compression.

52
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNIII

A

Alone, medical causes (pupillary sparing): diabetes, HTN, giant cell arteritis, syphilis, idiopathic.
Alone, surgical causes (early pupil involvement due to external compression of nerve damaging parasympathetic fibres): posterior communicating artery aneurysm (+ surgery), raised ICP (if uncal herniation through the tentorium compresses the nerve), tumours.

53
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNIV

A

Alone: rare and usually due to trauma of the orbit.

54
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNV

A

Sensory: trigeminal neuralgia (pain but no sensory loss), herpes zoster, nasopharyngeal cancer, acoustic neuroma.
Motor: rare.

55
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNVI

A

Alone: MS, Wernicke’s encephalopathy, false localising sign in raised ICP, pontine stroke (presents with fixed small pupils ± quadriparesis).

56
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNVII

A

LMN: Bell’s palsy, polio, otitis media, skull fracture, cerebellopontine angle tumours e.g. acoustic neuroma, malignant parotid tumours, herpes zoster (Ramsay Hunt syndrome).
UMN: stroke, tumour. Spares the forehead, because of its bilateral cortical representation.

57
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNVIII

A 
Noise damage
Paget's disease
Meniere's disease
Herpes zoster
Acoustic neuroma
Brainstem CVA
Drugs, e.g. aminoglycosides.
58
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNIX, CNX, CNXI

A

Trauma
Brainstem lesions
Neck tumours

59
Q

Neurological examination: cranial nerves, causes of cranial nerve lesions, CNXII

A 
Rare.
Polio
Syringomyelia 
Tumour
Stroke
Bulbar palsy
Trauma
TB

Oxford Handbook of Clinical Medicine (22 decks)

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