simplified full history taking & examination for neurological case

1. NEUROLOGICAL
EXAMINATION
Dr Ahmed Youssef
Lecturer of internal medicine & nephrology

2. History
• Personal H: • Past H:
– Handness 2T Trauma, TB
– Occupation (driver)
2S Syphilis, Similar attack
2H HTN, Heart disease
• C/O: 2D DM, Drugs
– Onset, course & duration
1E ENT
1F Fever
• Family H:
– Heredofamilial ataxia
– Familial periodic paralysis • HPI:
– Peroneal mus. atrophy
– 12 items

3. HPI
• Motor • Cranial n • Speech • Mental
• Sensory • ↑ ICT • Sphincter • Hypoth
• Trophic • Fits • Gait • Other

4. Motor
• Involuntary: extra ∆ , fasiculation
• State
• Tone •Dist or prox
•Stat or Kinetic
• Weakness •Disappear e sleep or Not
• Ataxia (cerebellum)
•UL or LL
•Drunken gait •Rt or Lt
•Intension tremors •Dist or Prox
•dysdidoko •Flexor or Extensor
•+ve romberge •Abductor or Adductor
•Improve on bed

5. Sensory
• Superficial: Pain, Temp, Touch
• Deep: Position, Mov., Vibr. If +ve : pattern
•Sensory level
• Cortical: Steriog, T. loc., T. discr. •hemihypoth
•Glove & stock
•Jacket loss
Trophic changes or deformities
• Ulcers: (N.B. : painless)

6. • ①: Cranial n
• Anosmia
• : • , :
• Sensory •
• ②: • Tast ant ⅔
Dysph (phar)
• Acuity • N. regur (palat)
• Motor
• Field • N. tone (palat)
• Eey clos.
• Mouth clos. • Hoarsn (lary)
• ③,④,⑥:
• Diplopia • : • :
• Ptosis • Deaf • Shoulder elev
• Squint • Tinitus • neck side mov
• Vertigo
• ⑤: • :
• Sensory • Tounge mov
• Pain,Temp
• Motor
• Masticat.

7. ↑ ICT
• Papilledema
• Headache
• Vomiting
Fits
• Aura
• Post effect
• Cons. Loss
• Gener. Or local
• March

8. Speech
• Aphasia: (higher neurolo. center lesion):
– Receptive(sensory):
• Spoken(Auditory)(aud recogn area lesion)
• Written(Visual)(visual recogn area lesion)
– Expressive(motor):
• Spoken (broca’s area lesion)
• Written(Agraphia)(exner’s area lesion)
• Dysarthria: (articul system lesion):
– ∆: bilateral→ slurred (psudobulbar)
– Extra ∆ → slow monotonus
– Cerebellar → stacatto
– Cr n → slurred (true bulbar)

9. Sphincters
Gait
Mental
• Consciousness
• Hallucination
• Memory

10. Hypothalamus
• D.I.
• Polyphagia
• Hypogonadal
• Hypersomnia
• Hyperpyrexia
Other systems affection

11. Examination
• General examination
• Neurological examination:
• Motor • Cranial n • Speech • Mental
• Sensory • ↑ ICT • Sphincter • Hypoth
• Trophic • Fits • Gait • Other

12. Mental
• Consciousness
• Memory
• Mode
• Orientation
• Behavior
• Intelligence

13. EXAMINATION – LEVEL OF
CONSCIOUSNESS (AROUSAL)
Level of Consciousness (Arousal): Techniques and Patient Response
Level Technique Abnormal Response
Alertness Speak to the patient in a normal tone of voice.
An alert patient opens the eyes, looks at you,
and responds fully and appropriately to stimuli
(arousal intact).
Lethargy Speak to the patient in a loud voice. For A lethargic patient appears drowsy but
example, call the patient’s name or ask, “How opens the eyes and looks at you, responds
are you?” to questions, and then falls asleep.
Obtundation Shake the patient gently, as if awakening a An obtunded patient opens the eyes and
sleeper. looks at you, but responds slowly and is
somewhat confused. Alertness and interest
in the environment are decreased.
Stupor Apply a painful stimulus. For example, pinch a A stuporous patient arouses from sleep
tendon, rub the sternum, or roll a pencil across only after painful stimuli. Verbal responses
a nail bed. (No stronger stimuli are needed.) are slow or even absent. The patient
lapses into an unresponsive state when
the stimulus ceases. There is minimal
awareness of self or the environment.
Coma Apply repeated painful stimuli. A comatose patient remains unarousable
with eyes closed. There is no evident
response to inner need or external stimuli.

14. Glasgow Coma Scale

15. Trophic changes or deformities
Speech
Read Sorat El Fateha
• Aphasia: (higher neurolo. center lesion):
• Dysarthria: (articul system or Cr n. lesion):

16. Motor
• Involuntary: extra ∆ , fasiculation
• State
• Tone •Dist or prox
•Stat or Kinetic
• Weakness •Disappear e sleep or Not
• Ataxia (cerebellum)
• Reflexes •UL or LL
•Rt or Lt
•Rapid alternating movem
•Drunken gait Sensory or •Dist or Prox
•Finger-to-Nose /Finger
•Intension tremors Cerebellar ataxia: •Flexor or Extensor
•Heel-to-Knee
•dysdidoko Test •Abductor or Adductor
•Romberg’s Test
•+ve romberge •-ve romberg
•Gait
•Improve on bed •Intension tremors

17. Tone
• 6 joints + don’t forget support before joint
• Tone is the resistance appreciated when
moving a limb passively
• “Normal Tone”
• Hypotonia
– “Central Hypotonia”:shock UMNL, cerebellar
– “Peripheral Hypotonia”: LMNL, myopathy
• Hypertonia
– Spasticity (Corticospinal Tract = ∆ )
– Rigidity (Basal Ganglia, Parkinson’s = extra ∆ )

18. Weakness: examine the following
Flexion at the elbow (C5, C6, biceps)
Extension at the elbow (C6, C7, C8, triceps)
Extension at the wrist (C6, C7, C8, radial nerve)
Squeeze 2 fingers as hard as possible ("grip," C7, C8, T1)
Finger abduction (C8, T1, ulnar nerve)
Oppostion of the thumb (C8, T1, median nerve)
Flexion at the hip (L2, L3, L4, iliopsoas)
Adduction at the hips (L2, L3, L4, adductors)
Abduction at the hips (L4, L5, S1, G. medius and minimus)
Extension at the hips (S1, gluteus maximus)
Extension at the knee (L2, L3, L4, quadriceps)
Flexion at the knee (L4, L5, S1, S2, hamstrings)
Dorsiflexion at the ankle (L4, L5)
Plantar flexion (S1)

19. Weakness: examine the following
Muscle(s) Function Primary Nerve Origin
DELTOID Shoulder abduction Axillary C5-C6
BICEPS Elbow flexion Musculocutaneous C5, C6
TRICEPS Elbow extension Radial C6, C7, C8
WRIST EXTENSORS Radial C6, C7, C8
WRIST FLEXION Median C6, C7
HAND GRIP Grasp Fingers Median C7, C8, T1
FINGER ADDUCTION Median C7-T1
FINGER ABDUCTION Ulnar C8, T1
THUMB OPPOSITION Median C8, T1
HIP FLEXION Iliopsoas L2, L3, L4
HIP EXTENSION Gluteus maximus S1
Quadriceps Knee extension L2, L3, L4
Hamstrings Knee flexion L4, L5, S1, S2
Tibialis anterior Foot dorsiflexion Deep peroneal L4, L5
Gastrocnemius Ankle plantar flex mainly S1
Ext hallicus longus Extens of great toe L5

20. Weakness: examine the following
Upper limb: C8 Lower limb:
C4
C5
Shoulder: T1 Hand Hip:
Adduction Thumb Flexion L1,2
Abduction Oppon pollicis L5, S1 Extension
Flexion Abd pollicis Adduction
Extension Add pollicis Abduction
Lat rotation
Med rotation
Flexor pollicis Knee:
Exte pollicis S1,2 Flexion
serratus ant.
C5 Other fingers: Extension L2,3,4
C6 Elbow: Abductors
C7
Flexion Ankle:
Adductors
Extension Dorsiflexion L4,5
Flexion S1,2 Planter flexion
C7
C8
Wrist: Extension
Flexion Lumbricalis
Extension
Abdom. mus: T7-
T12
Trunk mus:
Flexion extension

21. Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength

22. Reflexes & clonus
Deep (tendon jerks) Superficial reflexes
UL • Corneal
C5,6
• BICEPS • Grasp
• BRACHIORADIALIS • Gag (palatal)
C6,7 • TRICEPS S1,2 • Planter
Sure
LL signs of T6-12 • Abdominal
∆???? L1
L2,3,4 • KNEE + clonus • Cremastric
S1,2 • ANKLE + clonus S3,4,5 • Anal
Technique
Abnormal Deep reflexes Babiniski Scratsh From below up- lat to medial
Chaddock The skin under and around the lateral malleolus
• Jaw jerk is stroked in a circular fashion.
• Wartenberg Gonda’s
rd th
Flex 3 & 4 toes 7 release suddenly
Oppenheim press to the anterior surface of the tibia,
• Finger jerk stroking down to the ankle.
• Hofman Gordon Compressing the calf muscles
• Patelal jerk Schaefer Pinching the Achilles tendon enough to cause
pain.
• Adductor jerk

23. EXAMINATION – REFLEXES: SCALE
FOR GRADING
Reflexes are usually graded on a 0 to 4+ scale
4+ Very brisk, hyperactive, with clonus
3+ Brisker than average; possibly but not
necessarily indicative of disease (no clonus)
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response

24. Sensory
• Superficial: Pain, Temp, Touch (one ⅟2, Rt & Lt, derm)
• Deep: Position, Mov., Vibr., N & M If +ve : pattern
•Sensory level
• Cortical: Steriog, T. loc & discr., Graph. •hemihypoth
•Glove & stock
•Jacket loss

25. Cranial n
• ① - smell
• ② - Acuity: ( Snellen chart, Counting finger, Hand
mov., Light perception)
- Fields ( confrontation)
- Fundus
- Colour vision
• ③,④,⑥- Ocular mov.
Partial ptosis+ - Ptosis, Myosis or Mydriasis
Complete ptosis+
Miosis+ - Reflexes: Mydriasis+
Anhdrosis+
Enophthalm • Light: (direct & consensual) Diverg squint
• Accomodation =
=
??
?? • Ciliospinal

26. Cranial n
• ⑤ - Sensory: (ophth., maxillary, mandibular)
- Motor: (massiter, temporalis, tregoid)
- Reflexes:
→
• Corneal
→ • Jaw : if +ve = bilateral ∆ lesion above pons (above nc.)
• - Sensory: (Tast ant ⅔ of tounge)
- Motor: (frontalis, orbic occul., buccinator,
retractor angulii, orbic oris)
- Reflexes: Rapid phase toward
→ • glabellar occular pendular H
• ⑧ - Nystagmus cerebel fix i.e. (lesion) H
vestib Away from (norm) H
- Hearing
stem vertical V

27. Cranial n
• ⑨,⑩ -Say AHH = palatal movement
Move No movement
→
-Palat reflex
deviate to healthy =
Move up = normal
LMNL → -Pharyn reflex
Exag bilat= Lost bilateral=
Bilateral UMNL Bilateral LMNL

28. Cranial n
• ⑪ - Shoulder elev (trapezius)
- Neck side mov (sternomastoid)
• ⑫ - Observation ( atrophy, fascic)
- Midline protrusion (Deviation, invol. movem )
- Power
Sphincters
↑ ICT

29. Gait
Classical Patterns of Abnormal Gait
•Parkinsonism Gait
•Hemiparetic Gait
•Ataxia Gait
•Waddling Gait (Hip Girdle Weakness)
•High Stepping Gait
Other systems affection