[01.25a] Overview of the Neurological Examination (Part 1) V2

Medical specialty concerned with the treatment and diagnosis of disorders of the nervous system

What is Neurology?

Brain and spinal cord

What are the components of the Central Nervous System?

Motor neurons, peripheral nerves, neuromuscular junction, and muscle

What are the components of the Peripheral Nervous System?

Is there a lesion? What is the lesion? Where is the lesion?

What are the first three questions to ask when approaching a neurological patient?

Localization

What principle is fundamental to obtaining a neurological diagnosis?

A good background in neuroanatomy

What is essential for localizing a lesion in a neurological patient?

Elicit clinical facts through history taking/neurologic examination

What is the first step in diagnosing a neurological disease?

Interpret signs and symptoms in terms of physiology and anatomy

What is the second step in diagnosing a neurological disease?

Syndromic formulation and localization of lesion (anatomic diagnosis)

What is the third step in diagnosing a neurological disease?

Integrate mode of onset and course with other medical data and appropriate lab tests (pathologic/etiologic diagnosis)

What is the fourth step in diagnosing a neurological disease?

Sequence of Neurological Examination
Mental Status Exam and Higher Cortical Function Tests

What is the first step in the sequence of a neurological examination?

Cranial Nerve Testing

What is the second step in the sequence of a neurological examination?

Motor Examination (Muscle Strength Testing, Cerebellar Exam, Reflexes)

What is the third step in the sequence of a neurological examination?

Sensory Exam

What is the fourth step in the sequence of a neurological examination?

Meningeal Exam

What is the fifth step in the sequence of a neurological examination?

Autonomic Nervous System Exam (if needed)

What is the sixth step in the sequence of a neurological examination?

Both sides

On which sides of the patient must neurological examinations be performed?

Be presentable and professional, keep patient comfortable, ask permission if you will examine, be respectful and sensitive to patients’ needs and privacy

What are the key reminders before history taking?

Maintain an attentive position (lean forward 10°, straight head, back and shoulders up), maintain eye contact, minimize distractions, give time to answer in their own words, facilitate and clarify

What are the key reminders during history taking regarding position, eye contact, and patient interaction?

Introduce and identify yourself, know and use the patient’s name, state your purpose, ensure comfort and privacy, show empathy and genuine interest, talk in a language they are comfortable with, use open-ended questions, allow patients to talk, encourage with silence, focus by paraphrasing and summarizing, avoid body language suggesting disinterest, say thank you

What are the key reminders during and after history taking regarding introduction, patient comfort, communication style, and closing?

Introduction, Name, Age, Handedness, Civil Status, Occupation, Religion, Residence, Province, Assurance of confidentiality

What are the components of General Data in history taking?

To establish the dominant hemisphere

Why is handedness important to note in general data?

What brings you in for consultation?

What is the typical question to elicit the Chief Complaint?

When did it start? Was it sudden or gradual?

What questions are asked to determine the Onset and How it started?

Show me exactly where it is on you (ask patient to point)

What question is asked to determine the Location of the complaint?

Does it go or shoot anywhere?

What question is asked to determine the Radiation of the complaint?

How does it feel? (Sharp? Stabbing? Dull? Tight? Cramps? Squeezing? Burning?)

What questions are asked to determine the Quality and Character of the complaint?

How bad is it, on a scale from 1-10?

What question is asked to determine the Severity of the complaint?

How long has it stayed? Is it continuous or pabugso-bugso (in bursts)?

What questions are asked to determine the Duration of the complaint?

How frequent does it come? Is it worse at a particular time of day?

What questions are asked to determine the Frequency and Timing of the complaint?

What brings it on?

What question is asked to determine Precipitation Factors?

What makes it worse?

What question is asked to determine Aggravating Factors?

What do you do to lessen the pain/condition?

What question is asked to determine Palliating Factors?

Is it getting worse, better, or is it just the same? How does it start and end? Abruptly or sudden? Does it slowly get worse as the day goes by?

What questions are asked to determine the Progression and Course of the complaint?

Have you noticed anything else that occurs with it? Do you have any warning if the pain or condition will be coming?

What questions are asked to determine Associated and Accompanying Symptoms?

Does it interfere with your daily activities? Have you missed work because of this?

What questions are asked to determine the Impact on Work/Daily Life?

Have you taken any medication to handle the symptoms?

What question is asked about Medication(s) for the current complaint?

Have you had any tests done for the complaint? Did you consult any doctor for this problem?

What questions are asked about Consultation and Diagnostic Tests for the current complaint?

Everything not related to the chief complaint (e.g., weight loss, fever, blurring of vision, other body aches, chest pain, abdominal pain)

What does the Review of Systems cover?

Medication, current, and past illnesses (e.g., relapse of symptoms like multiple sclerosis, hypertension, diabetes, last hospital visit)

What does Past Medical History include?

Heredo-familial diseases of interest (e.g., stroke, aneurysms, diabetes, tuberculosis)

What does Family History focus on in a neurological context?

Substance use (smoke, alcohol, drugs) and reproductive status for females (pregnancy, birth, OCP use)

What might be included in Personal and Social History?

Reflex hammer, tuning fork (128 Hz or 256 Hz), pocket vision chart, pen light, cotton or tissue paper, wooden tongue depressors, 4 opaque small containers (for coffee, cigarette, sugar, and salt), stethoscope, ophthalmoscope

What are the basic tools needed for a neurological examination?

Engage in light conversation and ask the patient to talk about themselves further

What is done to set preliminary conditions and make the patient comfortable before MSE?

General behavior and appearance (quiet, calm, hyperactive, grooming, hygiene), speech/stream of thought/language function (rapid, pressured, normal, slow, non-spontaneous), emotional status/mood/affect (euphoric, agitated, silent, weeping, angry, anxious)

What aspects of the patient are observed during the preliminary conditions of MSE?

Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA)

What are two common formal tests for mental status and cognitive function?

Stream of talk, language functions, appearance, attitude, behavior, emotional status

What specific aspects are observed during the Mental Status Examination Proper?

Do you see things that others might interpret differently?

What question checks for Illusion?

Can you see or hear things that I might not be able to see?

What question checks for Hallucinations?

Do you have any persistent beliefs that might be quite different? Do you feel that there are people who want to harm you?

What questions check for Delusion?

Time, person, and place

What three components are assessed for Orientation?

Can you memorize three words? “Mango, table, coin”, keep them in mind as I will ask you again later what they are.

What question checks for Recent memory?

When is your birthday? What was the last school you attended?

What questions check for Remote memory?

Can you give me any recent relevant news? Can you name some past presidents of our country?

What questions check for Fund of information?

What do you think of your illness?

What question checks for Insight?

What will you do after this consultation? What are your plans for the future?

What questions check for Planning?

What should you do if you suddenly wake up to find a small fire in the corner of your room?

What question checks for Judgment?

What does the proverb “People who live in glass houses shouldn't throw stones” mean to you?

What question checks for Abstract thinking?

Can you subtract 7 from 100 and continue subtracting from each answer until I tell you to stop?

What question checks for Calculation (serial subtraction)?

When asking the patient simple questions or to follow commands

How is comprehension assessed in the HCF exam?

Receptive aphasia

What condition is suggested if a patient cannot understand commands and instructions very well?

When the patient is able to elaborate extensively their response to the examiner's queries

How is speech fluency assessed?

Expressive aphasia

What condition is suggested if a patient cannot speak fluently and convey what they want to say properly?

Paraphasic errors, substitutions, neologisms, and errors in grammar

What specific speech errors should be noted during HCF examination?

Ask the patient to name objects and repeat a phrase or sentence

What are two ways to test for aphasia?

Cannot understand commands and instructions very well

What characterizes Receptive Aphasia?

Cannot speak fluently and convey what they want to say properly

What characterizes Expressive Aphasia?

Agraphia, Finger agnosia, Right-left orientation, Acalculia

What are the four components of Gerstmann Syndrome?

Ask the patient to write any sentence on a piece of paper

How is Agraphia tested?

Ask the patient to name the different fingers on their hand

How is Finger Agnosia tested?

Ask the patient to point to their left ear, right eye, left hand, etc.

How is Right-left orientation tested?

Similar to the calculation test (serial subtraction) in checking for sensorium

How is Acalculia tested?

Dominant parietal lobe lesion

What does failing any of the Gerstmann Syndrome tests suggest?

Tongue apraxia, Hand apraxia, Ideomotor apraxia, Constructional apraxia

What are the four types of Apraxia mentioned?

Ask the patient to stick out their tongue

How is Tongue apraxia tested?

Ask the patient to form a fist with their hand

How is Hand apraxia tested?

Ask the patient to perform a certain daily activity (e.g., show me how to brush your teeth?)

How is Ideomotor apraxia tested?

Ask the patient to copy a drawing that is shown to them

How is Constructional apraxia tested?

Clock drawing test

What test assesses Executive Function and Visuospatial Ability?

Ask the patient to draw a clock complete with numbers and hands at a specific time (e.g., ten past eleven)

How is the Clock drawing test performed?

Sensory inattention

What specific test is mentioned under Agnosia?

Patient places arms palms down, examiner lightly brushes one arm, then both simultaneously, and asks patient to identify stimulation side

How is Sensory Inattention tested?

Non-fluent aphasia with word finding difficulty

What was observed about the speech of patient GA in Case #1?

Left brain

Given patient GA is right-handed, which hemisphere is her dominant lobe?

Intact memory but difficulty expressing self (no dysarthria)

What was noted about patient GA's memory?

Music function located on the unaffected non-dominant right brain

Why was patient GA more fluent singing than speaking?

Intact comprehension, can follow commands (no motor apraxia)

What was noted about patient GA's comprehension?

Right-left confusion and acalculia

What other Higher Cortical Function findings were present in patient GA besides aphasia?

No finger agnosia and able to repeat phrases and sentences

What HCF findings were intact in patient GA?

Transcortical Motor aphasia

What was the final impression for patient GA's aphasia?

No

Can a patient with Transcortical Motor aphasia speak fluently?

Yes

Can a patient with Transcortical Motor aphasia comprehend?

Yes

Can a patient with Transcortical Motor aphasia repeat?

3-5 minutes

How long should a properly done cranial nerve examination last?

Systematic and orderly

What is important about the approach to cranial nerve examination?

Always inform the patient of what you are about to do before performing any tests

What should always be done before performing any cranial nerve tests?

Selection of substances with identifiable smells in similar bottles or vials (e.g., coffee, soap, garlic, cigarette, peppermint)

What materials are needed for testing CN I?

Noxious stimuli (e.g., ammonia, perfume)

What type of substances should not be used to test CN I because they can also test CN V for pain?

Check for nasal obstruction (e.g., colds)

What preliminary check is necessary before testing CN I?

Inform patient to raise hand if they smell something; ask them to close their eyes and close one nostril; bring substance close to open nostril; ask what the smell is; repeat for both nostrils

What is the procedure for testing CN I?