History taking
And
Physical Examination
In neurology
Collected By:
Dr. Soran Mohamad Gharib
Reviewed By:
Dr.Hawar A. Mykhan
Neurologist
F.I.B.M.S ( Neurology ) , , M.B.CH.B
History Taking & Clinical Examination in neurology
During the history and clinical examination 2 points are important:
Where is the pathology?
What is the pathology?
History Taking
What is different in neurology is that the sequelae of events is more important than the more details regarding some symptoms.
Ask the following questions or the patient will present with one of the followings:
1) Weakness:
whether it is started from the proximal or distally i.e centrally or peripherally.
2) Numbness and parasthesia:
numbness is the tingling sensation which is due to excitation while the parasthesia is the loss of sensation and it is due to inhibition.
3) Headache:
ask about(site, bilateral or unilateral, aggravating and relieving factors as increase during sleep as in ICP or relief by sleep in HTN other factors as phototherapy, any associated features as N/V and weakness and loss of consciousness and any epileptic attack, can be relieve by taking certain medication, is it associated with blurred vision and any lacrimation and any hearing problems , then the onset of headache , is it intermittent or continuous , is there any previous attack, is it severe or not i.e can interfere with daily activity and make the patient to stay at home and remain in bed, is it relive by vomiting, at which time is more during the day time or night, is there any medical disease and HTN).
4)Visual disturbance:
as blurring vision and decrease visual acuity or any double vision.
5) Hearing disturbance:
as fluctuating deafness which is more after 50 years of age as the patient not hear well from short distance later it will be changed and can be found in Mienerer's disease;
6) Vertigo:
the followings are the features of true vertigo:
- Feeling of rotation.
-Sudden retro or propulsion
-Sinking and upward going of what is patient seeing.
7) Sphincteric disturbance:
ask about the followings:
* urinary incontinence( when the bladder is full dripping of urine occur).
* urgent incontinence (whenever there is urine in bladder even it is not full dripping of urine occur)
* frequency ( micturation daily more than 7 times)
* retention of urine.
8) Swallowing difficulties:
that associated with speech disturbance as nasal speech, aspiration, nasal regurgitation.
Note :
if there is dysphagia for solid meal only mean the organic cause, but for both solid and liquid mean neurological causes.
9) Loss of consciousness which is inhibitory.
10)Epilepsy which is excitation.
11)Then any other disease as (DM, HTN , cardiac disease , drugs)
Notes:
*Center of consciousness is located in reticular activating system that we have cerebral hemisphere, thalamus, midbrain-pons-medulla
oblongata.
* When there is sudden loss of consciousness mean brainstem lesion.
* Almost both thalamus should be affected in order loss of consciousness to occur and usually it is not sudden loss.
Clinical Examination
Include 2 main parts :
A) General examination
1. Consciousness.
2. orientation
3. memory
4. speech
5. GAIT.
B) Specific examination:
1. cranial nerve examination
2. meningeal signs
3. motor system examination
4. co-ordination
5. Sensory system examination.
Cranial nerve Examination
Remember we have 12 cranial nerves , and ( 1, 2,8 are sensory) and (4,6,7,11,12 are motor) and (3,5,9,10 are mixed).
(1st is central and arise from the nasal mucosa, 2nd is central from retina), (3rd and 4th from midbrain , 5th,6th,7th,8th are from pons , 9th, 10th , 11st, 12nd are from medulla oblongata).. from 3rd to 12nd are peripheral.
Olfactory nerve
It can be examined by asking the patient to close the eyes then we introduce certain but common and non irritable substance to each nostril that should be examined separately and then we ask the patient to name that substance.
Smell receptors are in the nasal cavity, the olfactory nerve is going under the frontal lobe through the cribriform plate under roof of nasal cavity and it is from the anterior part of brain . its function is smell.
The loss of smell is called ( anosmia) as may be due to head injury or tumor, while the perversion of smell is called paronosmia.
Optic nerve
Its function is vision. The nerve start from globe and passes through the optic canal of sphenoid bone then join with other nerve that form optic chiasma then optic tract that pass to geniculate body of thalamus then to area of 17 or visual cortex in occipital lobe.
The pupillary light reflex had efferent part by 3rd CN and the afferent part by 2nd CN.
The defect in this nerve can cause some abnormalities as blurring vision, hemianopia especially the homonimus hemianopia( the right eye-defect in nasal part of left and temporal part of right eye occur) which is loss of half of visual field in one or both eyes and this may be due to pituitary tumour that compress the optic tract or radiation or the bitemporal hemianopia due to defect in optic chiasma.
Scotoma means the presence of blind spot that surrounded by the normal visual field and the central scotoma is normal it is either relative or absolute scotoma.
The component of examination are:
Visual acuity:
this can be examined by using the Snellen chart that is 6/6,6/9, 6/12, 6/18, 6/24,6/36,6/60. if this not done then counting fingers from half meter that should be done for each eye separately by asking the if this not response then hand movement, then light perception as a last choice.
Visual field:
this can be tested by confrontation test that you as an examiner will sit in front of the patient but both of you should be at the same level then you cover one of your eye and ask the patient to cover
the reverse eye , then you use a subject better with red head and then move it to right, left, up, down infront of the patient but ask the patient to look to it only by his opened eye without using the head then repeat it to the other eye to see the field of vision.
Light reflex:
the light reflex is carried by optic nerve and then will be
return back by the 3rd CN that causing the constriction of pupil. This reflex is 2 types which is direct (the eye that you put the light on it) and the indirect (or called the consensual reflex) (mean the other eye). This test is done by using the torch from the lateral but should be as a brisk movement on the eye but avoid putting the light in 90 degree on the eye then look to the pupil whether constricted or not.
Color vision: by using ishihara test.
Fundoscopy:
the patient and you should be at the same level and should be at 45 degree position and the patient should look to the prime
position or straight forward then putting one of your hand on the head of patient and then using the scope laterally. The aim is to look to the optic disc to know whether there is optic atrophy (vessels are thin and margin is very white) or the papilledema (which indicate the old lesion in which there is decrease or absent margin, hyperemia and engorgement of vessels occur).
Oculomotor ,trochlear and abducent nerves
The rule is that SO4, LR6 and MIIS3(medial rectus, inferior oblique, inferior rectus , superior rectus).
Defect in 3rd make unable to look up,down,medially(dysconjugate gaze), ptosis , dilated pupil and loss of accommodation reflex and divergent squint occur.The cause maybe DM.
Defect in 4th CN the patient can not look downward,
and defect in 6th CN there is convergent squint.
The examination is as followings:
• Ask the patient to look straight forward then by inspection look for 3Ps( pupil to know regular,round , and then look for ptosis-lowset upper eye lid- then the proptosis by doing the Naffziger as stand from behind the patient and then tilt the head inward and look to the eye whether outside the imaginary anterior line or not).
* Then in first eye movement as putting one of your hand on the head of patient and then by your finger or a subject better with red head move it to the right, left, up, down and ask the patient to look to it only using the eyes without moving the head, at that time look for any nystagmus or squint or diplopia but this ask the patient do u see that subject in one or two.
*Accommodation reflex: the reflex is positive and god only if the followings occurred and this by sitting in front of the patient and using the same above directly between the both eyes and move it toward the patient by looking to it:
1. if both eyes are partially ptosed.
2. constriction of both pupils.
3. converging of both eye medially.
*Light reflex.
Trigeminal nerve
The nerve has 2 branches motor and sensory. The motor will supply the muscle of mastication which are (Masseter , Temporalis muscle ,lateral and medial pterygoid muscles).
The sensory has 3 branches which are ophthalmic, maxillary and mandibular branches and has the sensory function of pain and temperature of scalp, face, lip, mouth, eyes and the ant.2/3rd of the tongue.
The lesion of this nerve causing loss of sensation of the previous areas and wasting of temporalis and masseter muscles and called (trigeminal neuralgia- Tic Douloureux) that may be due to tumor, vascular spasm, MS.
The examination is done as the followings:
Motor examination:(almost done before sensory branch):
- Look to the masseter and temporalis for any wasting and then ask the patient to open the mouth for any jaw deviation.
- Ask the patient to clinch the teeth then palpate the masseter and temporalis muscles.
-Then put your hand under the chin and ask the patient to open it against the ur hand resistant as much as he or she can then move the chin to right and left against your hand beside that side.
- Reflex Examination: which is 2 reflexes
1. Corneal reflex:
use apiece of cotton then suddenly attached it to the lateral corner of eye. This reflex has the sensory by ophthalmic branch of 5th CN and the motor part of 7th CN.
2. Jaw jerk:
not found normally if +ve mean Bilateral UMNL, it is done by slight opening the mouth then put your index at the angle of jaw then hit your finger by the hammer but in 45 degrees. This reflex is supplied by C3
Sensory examination :
*Start up examination by using the special pin and move it as a strip like line for each branch.
Facial nerve
The nerve has the function of ( expression, motor part of corneal reflex, sensation of salivary and lacrimal gland, sensation of anterior 2/3 of tongueand taste by chorda tympani branch).
The paralysis of the nerve called the Bell's palsy that occur as:
1-UMNL:
There is lesion above the nucleus and characterized by:
1. Hypertonia occur as Spasticity of the limb
2. There is very mild or no wasting of muscle.
3. Reflexes are brisk or exaggerated.
4. The upper part of face not involved because the forehead has the dual nerve supply but the lower part will be affected.
5. plantar reflex is upgoing mean +ve Babiniski sign.
The causes may be CVA, Pyramidal system lesion.
2-LMNL:
This indicates the lesion in the anterior horn cells and the lesion occur inside the nucleus, it is characterized by:
1. Weakness and wasting of muscles.
2. Fasciculation
3. hypotonic
4. Loss of the reflexes.
Causes may be :
*Poliomyelitis
*Warding Hoffman syndrome
*Diabetic neuropathy
*Alcohol and trauma
*Drugs as INH and vincristine and metronidazole
* Infectios as diphtheria and Leprosy.
* Guillian-Barre syndrome.
* Motor neuron dis.
•*Vitamin Bi and B12 deficiency.
* Amyloidosis.
The most common cause for Bell's palsy is idiopathic others may be viral as mentioned above.
The effect of the UMNL is that the lower part of the face is more obvious and deviation occur toward the healthy side.
The effect of the LMNL is that the upper and lower part will be affected, there is loss of nasolabial fold on the affected side, and deviation of mouth to the normal side occur, the patient can not close the eyes properly, if the patient whistle there is leaking of the air through the affected side , and there is increase the space between the corner of mouth and the tongue of the affected side when the patient open the mouth. Some time the patient will have (Bell's Phenomena) in which the patient try to open the eyes but the sclera is still appear and the eyeball go up and medially.
Examination of this nerve is done as the followings:
1) Ask the patient to elevate the eye brows and then look to the creases in the forehead if lesion occur there is absence of these creases (Frowning test).