Short summary of Neurological History and Examination

Neurological History

Recognizing that history is the key to the neurologic evaluation, perform a competent history noting the following key factors:

A. Establish the onset, progression (temporal profile) and character of the disorder identifying all related symptoms and exacerbating/relieving factors

B. Perform a standard neurological review of symptoms with regard to personality, memory, headaches, pain, seizures, impairments of consciousness, vision, hearing, language function, swallowing, coordination, gait, weakness, sensory alterations, sphincter disturbance and involuntary movements, etc. (See more complete listing below.)

C. Perform the components of the general exam relevant to the neurologic evaluation to include the following:

1. Skin examination

2. Cardiovascular system examination including blood pressure and auscultation for bruits

3. Examine for meningismus

4. Straight-leg-raising maneuver

Neurological Review of Systems

Mental Status and Specific Cortical Functions:

Loss of consciousness, memory loss, forgetfulness, periods of confusion, difficulty concentrating, seizures, change in intellect (decline), change in personality, nervousness, anxiety, emotional instability, irritability, crying spells, mental disease, family history, under the care of a psychiatrist or psychologist, previous psychiatric hospitalization or outpatient therapy, violence, trouble with the law, insomnia, sleep disturbances, difficulty with work, social withdrawal, drug or alcohol problems, trouble with speech) aphasia vs. dysarthria)

Local Examination:

Trauma to the head, neck or back, tenderness, degenerative disc disease, herniated disc, bone lesions, infections, headache, neck pain, back pain, sciatica, sighing hyperventilating

Cranial Nerves:

Loss of smell, loss of vision, visual blurring, double vision, loss of taste, facial numbness, facial droop/palsy, drooling, ringing in the ears (tinnitus), deafness, dizziness (vertigo), slurred speech (dysarthria), difficulty swallowing (dysphagia)

Motor:

Wasting, tremors, abnormal movements, stiffness, weakness, gait disturbances, loss of balance, strokes, tics, paralysis, dyskinesias

Sensory:

Dysesthesia, paresthesia, burns, trauma

Autonomic:

Change in bladder function, change in bowel function, impotence, other sexual problems, sweating changes

Neurological Examination

Mental Status Exam:

Level of consciousness - awake, confused, lethargic, obtunded, stupor, coma

Cognitive Function:

Orientation

a. time (day of week, day of month, month, season, year)

b. place (state, country, city, building, floor of building)

c. person (who, occupation, relationships, age, place of birth, date of birth)

Attention and attention span

Serial 7s, subtraction, digit retention

(nl: Concentration forward-7; backwards-4)

Memory

a. immediate (digit span forward and back)

b. recent (three objects at 5 minutes)

c. remote (history, presidents)

Intellectual

a. education, calculations, information (political, geographical)

b. functioning vocabulary (retarded, dull normal, normal, bright),

c. abstraction (proverbs, similarities/differences)

d. judgement

Behavioral Observations:

Appearance - dress, disordered, average, neat, bizarre, grooming, personal hygiene

Behavior (Affect) - labile, appropriate, flat, exaggerated, bizarre

Mood (Attitude) - detached, sad, suspicious, hostile, demanding, obstinate, anxious, friendly, cooperative, uncooperative, helpless, persistent, spontaneous, seductive, confused

Thought Processes - concrete, functional, abstract

Thought Content and Perceptions - delusions, phobias, interpretations, abnormal beliefs, morbid thoughts, preoccupations, illusions, hallucinations (visual vs. auditory; formed-temporal, unformed-assoc. cortex)

Insight/Judgement - none, little, average, good

Depression/Mania

Suicide/Homicide - none, ideation, threat, attempts, no information

Specific Cognitive Function:

Dominance - hand, foot, eye

Speech (Motor Aspects) - slurring, dysarthria, aphasia, spontaneous (fluent, paraphasia), distinction of articulation, testing of rapid labial and lingual sounds, rhythm of speech

Content of Speech - comprehension (ability to follow commands); naming (objects, colors, fingers, word finding problems), repetition (no ifs ands buts or maybes); reading (aloud, comprehension, dysphonia), writing (dictation, copying, handwriting)

Praxis - commands, imitation with a real object, sequential acts, e.g., dressing

Right/Left disorientation

Neglect and Hemineglect - double simultaneous stimulation (visual, tactile, auditory)

Visual-spacial Topographical Function - draw the face of a clock, set a time; copying, cube

Cranial Nerves:

I - unilateral, bilateral odors (tobacco, coffee)

II - light perception O.D. O.S.

confrontation fields

acuity (Jaeger, Snellen)

visual inattention

local exam of orbit

funduscopy

III, IV, and VI - eye position at rest (strabismus), extraocular movements, individual and conjugate eye movements, deviation, conjugate gaze, individual muscles, diplopia on extremes of gaze, ptosis, optokinetic response, nystagmus, pursuit, saccades

Pupillary response

size shape direct consensual convergence

Right

Left

V - corneal reflex, jaw reflex

sensory - 3 divisions; pin, touch (ophthalmic, maxillary, mandibular)

motor - masseters and temporalis; jaws open, bite, clench teeth

VII - brow, mouth, nasolabial fold, taste anterior, hyperacusis, lacrimation, palpebral fissures

volitional motor - raise eyebrows, wrinkle brow (upper nucleus); smile and frown (lower nucleus) close eyes tight, show teeth, frown, smile, puff cheeks, whistle

emotional motor - joke

VIII - acuity, Weber, Rinne

Cold Calorics L R

Positional Nystagmus

IX - swallowing, uvula, gag reflex L vs. R, phonation; taste in the posterior _ of tongue

X - yawn, say "ah", elevation of palate

XI - sternocleidomastoid, trapezius; shrug shoulders, rotate head against resistance

XII - tongue protrusion, tremor, fasiculations, atrophy, asymmetry, deviations of the tongue to the right, left, or midline, tongue-rapid alternation

Motor Exam:

Inspection - fasiculations, myokymia, tics, asterixis, contractures, abnormal movements, chorea, athetosis, dystonia, myoclonus, tremors (note amplitude and rate; resting, action, terminal, or postural) size, bulk, atrophy of muscle groups

Palpation - myoedema, myotonia, consistency, tenderness, induration

Tone - cogwheeling rigidity, flaccidity, hypotonia, clasp knife spasticity, spasm, peritonea

Strength, Power - distal weakness vs. proximal weakness, hemiparesis/hemiplegia, push/pull testing; functional hop in place, knee bends, posture, drift (pronator or tibial)

Coordination:

Slow RAM (rapid alternating motion), e.g., FN, FNF, HS; rebound

Rapid RAM; rapid alternation of tongue

Station - standing, one foot, Romberg, sitting

Gait - spastic, ataxic, myopathic, neuropathic, shuffling, apraxic, painful. Observe varus of feet, balance, arm swinging, turning tandem heel to toe walk, walk on toes, walk on heels, hopping, running

Reflexes:

Deep tendon reflexes Superficial

(phasic stretch reflexes) (polysynaptic flexor reflexes)

jaw jerk snout

biceps (C56) upper abdominals (T8910)

brachioradialis (C56) lower abdominals (T101112)

pectoral (C678) cremasteric (L12)

triceps (C678) anal (S34)

finger flexors (C78T1) deep abdominals

suprapatellar (L234) plantar response (L45S12)

quadriceps (L234)

hamstrings (L45S1)

ankle/gastrocnemius (S12)

Clonus - ankle, patellar

Frontal Release Signs - glabellar, palmomental, rooting, grasp, snout, suck

Sensory Exam:

Compare sides left to right

Compare proximal vs. distal

Dermatomes vs. peripheral nerve

Pain/pinprick (spinothalamic, contralateral)

Temperature (spinothalamic)

Crude touch (spinothalamic)

Fine touch (multiple places in cord)

Vibration (dorsal columns)

Position sense (dorsal columns)

Discriminative sensations

two point discrimination (dorsal column)

object identification - stereognosis

dermatographia/graphesthesia

extinction of double simultaneous stimulation

tactile inattention

localization

Autonomic/Trophic Changes - blood pressure, abnormal or absent sweating, cutaneous ulcerations, hair loss, poor circulation

Peripheral Nerve Status - enlargement, tenderness