Review of Neurologic History and Examination, Correlative Neuroanatomy and Localization

What are the two main sources of objective data in the clinical method?

history and physical examination

• where Symptoms and signs are obtained

How are relevant symptoms and physical signs interpreted in the clinical method?

In terms of anatomy and physiology

What is the purpose of analyzing objective data in the clinical method?

To ease out unnecessary/irrelevant facts and correlate findings with basic neurosciences, especially neuroanatomy

What is the main goal of localizing findings in the clinical method?

• To identify if there is a lesion in the neuroaxis or nervous system

  • know if its a neurologic problem if localized

• determine its location

What type of diagnosis is made after localizing the lesion in the clinical method?

Anatomic or syndromic diagnosis

What is the next step after localizing the disease process in the clinical method?

Deduction of pathologic and etiologic diagnosis

What diagnostic workups follow localization in the clinical method?

Imaging studies and physiological studies

What additional assessment is done after determining anatomic, pathologic, and etiologic diagnoses in the clinical method?

Assessing the degree of disability (functional diagnosis) and prognostication

Summarize the 5 steps of the clinical method.

1) History and physical exam, 2) Interpretation with anatomy/physiology, 3) Localization of lesion, 4) Deduction of pathology/etiology, 5) Assess disability and prognosis

What are the important data to obtain in establishing a neurologic diagnosis?

Demographics, symptom onset and development, medical history and physical examination, family history, social history, incidence and prevalence of diseases

Why are demographics important in establishing a neurologic diagnosis?

They help correlate diseases with age, sex, and population-specific risks

Why is symptom onset and development important in diagnosis?

It provides the temporal profile and helps differentiate between acute, subacute, and chronic neurologic conditions

Why is medical history and physical examination important?

They reveal comorbidities and past conditions that may influence the current neurologic illness

Why is family history important in neurologic diagnosis?

It helps identify hereditary and genetic neurological disorders

Why is social history important in neurologic diagnosis?

It provides context such as occupation, environment, lifestyle, and exposures that may predispose to disease

Why is incidence and prevalence data important in neurologic diagnosis?

Some neurologic diseases are region-specific or more common in certain populations

What is an example of a neurologic disease unique to a particular region?

Lubag or Dystonia of Panay, a movement disorder seen in Panay, Philippines

What is the typical age group most affected by stroke?

Usually between 55 to 60 years old

Why is stroke in younger patients clinically important?

It may occur without the usual risk factors like diabetes, dyslipidemia, and hypertension, so further workup is needed

List the 11 major categories of neurologic disease.

Infections, genetic/congenital, traumatic, degenerative, vascular, toxic, metabolic (inherited or acquired), neoplastic, inflammatory-immune, psychogenic, iatrogenic

Why is classifying neurologic diseases into categories important?

It helps determine the primary working impression or diagnosis together with differential diagnoses

How many differential diagnoses are recommended in neurology?

At least 2–3 differential diagnoses related to the chief complaint

Give an example of an infectious neurologic disease.

Meningitis or encephalitis

Give an example of a genetic or congenital neurologic disease.

Muscular dystrophy or congenital hydrocephalus

Give an example of a traumatic neurologic disease.

Spinal cord injury or traumatic brain injury

Give an example of a degenerative neurologic disease.

Parkinson’s disease or Alzheimer’s disease

Give an example of a vascular neurologic disease.

Stroke or cerebral hemorrhage

Give an example of a toxic neurologic disease.

Lead poisoning or alcohol-induced neuropathy

Give an example of a metabolic neurologic disease.

Hypoglycemia or inherited metabolic disorder

Give an example of a neoplastic neurologic disease.

Brain tumor or spinal cord tumor

Give an example of an inflammatory-immune neurologic disease.

Multiple sclerosis or Guillain-Barré syndrome

Give an example of a psychogenic neurologic disease.

Conversion disorder or psychogenic seizures

Give an example of an iatrogenic neurologic disease.

Medication-induced neuropathy or post-surgical nerve injury

In the temporal profile, what does the X-axis represent?

Time

In the temporal profile, what does the Y-axis represent?

Intensity of symptoms (1 to 10)

How do signs and symptoms of stroke/cerebrovascular disease usually present?

Always sudden in onset

What was the temporal profile symptoms and time in the example stroke case?

Weakness 1 hour before admission, followed by slurred speech 30 minutes prior to admission

Is stroke-related weakness usually generalized or focal?

It is usually unilateral/one-sided, not generalized

When is the peak severity of symptoms in stroke?

Maximal at the onset

How are stroke symptoms described in terms of onset and duration?

Permanent, persistent, and sudden onset

How do brain tumor symptoms typically present?

They are usually non-specific and can mimic symptoms of other medical conditions

Give examples of non-specific symptoms of brain tumors.

Headache, fever, and generalized body weakness

What is the usual time course of headache in brain tumor patients?

Several weeks to months

How can headaches in brain tumors progress over time?

They may begin intermittent, then become persistent and progressive

In the temporal profile example, what additional symptoms accompanied the headache

Weakness, vomiting, and seizure

What was the chief complaint in the tumor example case?

Seizure

Are tumor symptoms typically sudden or chronic in onset?

They are chronic, subtle, and not sudden

What types of symptoms in tumors are steadily progressive?

Headache and weakness

What types of symptoms in tumors can appear suddenly?

Vomiting and seizure

Why should you clarify the type of weakness in a tumor patient?

To determine if it is generalized or unilateral, which affects localization

What was the earliest symptom noted in the dementia temporal profile case?

Poor memory 5 years prior to admission

What new symptom appeared 2 years PTA in the dementia case?

Losing and misplacing things

What mood-related change appeared 1 year PTA in the dementia case?

Irritability

What alarming symptom was noted a few months PTA in the dementia case?

Forgetfulness in turning off the stove

How does dementia usually present in terms of time course?

Progressive neurologic signs and symptoms over years due to progressive neuronal loss

Are dementia symptoms maximal at onset?

No, they are subtle and not maximal at onset

Why are dementia symptoms often neglected?

Because they are very subtle and progress slowly

What type of disease is dementia?

A degenerative disease

What cognitive domains are affected in dementia aside from memory?

Attention, executive function, and visuospatial perception

When is a symptom in the Review of Systems included in the HPI?

If it is connected to the chief complaint

Are ROS and past medical history part of the HPI?

No, but they can be risk factors for the chief complaint

What were the presenting symptoms in the CNS infection example case?

On and off fever for 5 days PTA and headache 1 day PTA

What neurologic exam finding is associated with CNS infection in the example?

Neck rigidity

How long does fever usually linger in chronic meningitis?

INTERMITTENT

• For 2 weeks or more, along with headache

Can CNS infections be acute, subacute, or chronic?

Yes, depending on the type of infection

What is the typical course of bacterial and viral CNS infections?

Acute (< 1 week)

What is the typical course of CNS tuberculosis (chronic meningitis)?

Subacute (< 1 month)

What is the typical course of fungal CNS infections?

Chronic (weeks to months)

What are the two symptoms that are always present in CNS infections?

Fever and headache

What is the clincher symptom in differentiating CNS infection from other febrile illnesses?

Headache

What does intermittent fever mean in the temporal profile of CNS infection?

Fever alternately occurs and goes back to baseline (line goes back to 0)

What does remittent fever mean in CNS infection?

Severity does not go away completely; the line does not touch the X-axis

What was the first symptom in the demyelinating disease case example?

Blindness 2 years prior to admission, which later recovered

What symptom recurred 6 months PTA in the demyelinating disease case?

Blindness, which resolved after a month

What additional symptom appeared with recurrent blindness in the demyelinating disease case?

Weakness of the lower extremities, resolved after 2 months

What new symptom was noted 1 week PTA in the demyelinating disease case?

Right upper extremity weakness

What disease is described in the temporal profile of demyelinating disease?

Multiple Sclerosis

What should be avoided when taking a neurologic history?

Avoid suggesting to the patient the symptom that you are seeking

Why should symptoms not be suggested to the patient during history taking?

Because patients often do not present in a textbook manner, and suggesting may bias their responses

What is the best way to collect data in neurologic history taking?

Collect data from the patient first before analyzing with references

What should be learned about each symptom during history taking?

How each symptom began and how it progressed\

• onset

• progression

Why is it important to estimate the patient’s mental capacities during history taking?

To determine the reliability and consistency of their responses

Who besides the patient may provide useful information in neurologic history taking?

Caregivers, family members, or other informants

Why is having a backup source of information useful in neurologic history taking?

It helps verify consistency and reliability of the patient’s history

How can educational background help in neurologic history taking?

It may influence the reliability and interpretation of symptoms

Why is it important to get the patient’s own interpretation of symptoms?

Because subjective terms (e.g., dizziness) may mean different things to different patients

What is an example of a subjective symptom that needs clarification?

Hilo or dizziness, which may mean swaying, spinning, or loss of consciousness depending on the patient

How should a physician approach unusual or weird symptoms in neurologic history taking?

Consider an atypical presentation of a common disease rather than assuming a rare disease

How is the outline of the neurological examination organized?

It corresponds to the cranio-caudal design of neuroanatomy

• top to bottom

What neuroanatomical part is tested by the Mental Status Exam?

Cortical brain

What neuroanatomical part is tested by the Cranial Nerve Exam?

Subcortical brain and brainstem

What neuroanatomical parts are tested by the Motor Exam and Reflexes?

Spinal cord, nerve root, peripheral nerve, and muscle

What neuroanatomical parts are tested by the Sensory Exam?

Spinal cord, nerve root, peripheral nerve

What neuroanatomical part is tested by the Cerebellar Exam?

Cerebellum

What neuroanatomical parts are tested by Coordination and Gait?

Cerebellum plus integration of cortical, subcortical, and sensory systems

What neuroanatomical part is tested by meningeal signs?

Meninges

What is the Mental Status Exam looking for in neurology?

Signs of dysfunction in specific lobes of the cerebral cortex

How is the Mental Status Exam in neurology different from the Mini Mental Status Exam in psychiatry?

The neurologic exam emphasizes localizing cortical lobe dysfunction, not screening for dementia

Which cranial nerves are located in the subcortical brain?

Cranial nerves I (olfactory) and II (optic)