Neurological Examination Made Easy Rajendra Bhalchandra Kenkre
Chapter Notes

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History, Neurological Examination and Equipment1

The art of taking a good clinical history laying stress on certain points is of importance in reaching a diagnosis in neurological diseases.
Put down in own words what the patient has to say. Classic example would be giddiness then the patient must be precise of nature, position and duration of his symptoms. The character of the pain is of importance whether aching, burning, shooting, and the severity of the pain. As far as possible the clinician must listen to the patient without putting words in his mouth.
Tumors of posterior fossa—are common in children particularly brainstem gliomas and some such as meningiomas are common in adults.
Muscular dystrophies occur at younger age.2
Multiple sclerosis usually starts between the ages of 20 and 30 and rarely starts after 55.
Strokes occur in the age group 55 to 70. Nevertheless do occur in younger age groups more commonly in certain regions of the world.
Women are exposed to side effects of oral contraceptives with increased risk of stroke and neurological complications of pregnancy such as fits, chorea, cortical sinus thrombosis.
Duchenne's muscular dystrophy occurs in boys.
Family History
Many neurological diseases such as dystrophies, mitochondrial myopathies, peripheral neuropathies, developmental disorders in children—dyslexia, hereditary spastic paraplegia, Huntington's chorea have genetic basis and it is important to record the history in one or more siblings or in past generations history of the disease even though some family members may be mildly affected.
Social History
Neurological patients have significant disability and in many diseases of the nervous system recovery is uncertain and may take years as in strokes. In few of the diseases such as multiple sclerosis there is profound disability resulting in the patient being dependent on family and 3social support. Also after major head injury resulting in damage to central nervous system relatives may have to be counseled that recovery of certain brain functions may occur with time.
It is important to know the financial circumstances and their long-term commitment to care and the support they receive from the community where they live and work.
Past Medical History
This is important to understand the etiology or to find out conditions associated with neurological disorders.
  • History of hypertension in strokes.
  • Diabetes in peripheral neuropathy.
  • History of head injury if patient has fits.
  • History of measles in subacute sclerosing panence-phalitis.
  • History of surgery for malignancy if patient has metastasis in the brain or spinal cord or shows signs and symptoms referable to peripheral nervous system, muscles or has myasthenia gravis and rarely periodic paralysis.
History of Illness
Time Course
The onset: Abruptly over a few minutes, hours, days, weeks and months.4
Headache is a common symptom. It may be of trivial nature but at times it is of grave significance, therefore, in taking the history thoroughness is required. How long the patient has suffered from headache and what is the severity? Is it constant or paroxysmal or occurs at special time of the day? What are the precipitating factors such as in migraine head injury. Is there allergy to food, drugs, pollen and dust? Is there family history of headache? Is the character throbbing and dull. Is it preceded by aura such as in migraine. Are there visual disturbances? Has there been double vision or impairment of vision? Is there anxiety, tension or depression? Is there sleep disturbance? Is the pain of lancinating type and occurs in paroxysms and is present on the face and forehead as in trigeminal neuralgia. Is there history of toothache, nasal catarrah or fever and altered sensorium? Has the patient has had exanthematous illness? Is the headache of abrupt onset and pounding type as in subarachnoid hemorrhage? Is there history of taking oral contraceptive pills?
Drug History
Type of medication, whether consumes habit forming drugs by mouth, injections or inhalation. Use of oral contraceptives. History of tobacco and alcohol.
History of exposure to toxins such as manganese, mercury, lead, pesticides.5
History of travel to endemic areas of infection like malaria, schistosomiasis, etc.
Occupational disease in neurosurgeons was reported who undertook brain biopsy of patients with bovine spongio-form encephalopathies, the disease was transmitted from the patient to the surgeon during the handling of the tissue.
Mesothelioma of the lung which may result in cerebral metastasis is found more commonly in asbestos workers.
Deep sea divers may be at risk of damage to the spinal cord and brain resulting in paraplegia and cerebral anoxia.
In recent times it has been observed that certain individuals working at high altitudes may be exposed to anoxic insult to certain regions of the brain giving rise to Parkinsonian like features.
What the patient can do now, i.e. his current abilities that he has to face difficulties in sitting down, rising from chair, turning in bed. Is he able to eat, wash, go to the toilet? Is he able to walk, write? Has his hand writing changed.
Relatives ought to be interviewed in situations such as (1) When the patient is a child? (2) When there is loss of consciousness? (3) When there is memory defect or mental change? (4) When details of illnesses in other 6family members need be checked? A telephone call to the GP may give vital information about the patient's social and medical history which may be difficult to obtain at the time of admission. In school going children recent deterioration in mental function may point to slow virus disease such as subacute sclerosing panencephalitis.
The instruments required for bedside neurological examination are relatively simple.
  1. The ophthalmoscope: Simple instrument is quite adequate provided it gives even white disk of bright light.
  2. The torch giving a fine bright beam.
  3. The percussion hammer: Ideally the handle should be long and flexible but hammer with short handle with thick resilent rubber at the end would suffice.
  4. Pins for testing sensation: Sharp pins with red and white head. These are also useful for testing visual fields.
  5. Two point discriminator for testing discriminatory sense at any two points on the skin.
  6. The stethoscope.
  7. Snellen's chart, two bottles for testing smell.
  8. Tuning fork to test vibration sense.
  9. The examination couch: This should be securely covered and the patient should feel comfortable.7
To the experienced clinician, physician and neurologist first impressions are of vital importance which lay the foundation for subtlety in history taking and neurological examination at a later stage during the interview.
Listen to the patient's approach, shuffling of feet in Parkinson's disease, unilateral dragging of the feet as in hemiplegia and bilateral dragging as in spastic paraplegia.
Loud conversation in the waiting room may indicate that either the patient is deaf, nervous or dysarthric.
Coming Through the Door
The stooped flexed rigid posture of Parkinson's disease– trying to make a space for himself as if walking through a narrow space. The absence of smile and blinking.
Size of the Patient
Tall, obese, wasted, skeletal deformity, abnormal size of the head, size of the face as in acromegaly.
The mode of dress: unkempt, casual dress, presence of tatoos.
Look for the presence of kyphosis, scoliosis, torticollis, short neck, basilar invagination profound wasting and weakness. While shaking hands with the patient compare the grip. Involuntary movements—tics, habits spasms, dystonia, exophthalmos, lid retraction, blinking–absence of blinking is common in Parkinson's disease.8
The Voice
For clarity of words and contents of a speech.
The Patient in Bed
The accuracy of history is just as vital in the house where physician may have opportunity to talk privately and unobtrusively to the relatives. Doctors must show confidence and precision in history taking and examination. This is usually achieved over length of time and experience in seeing patients of all classes and colors.
Mental Examination
The higher cerebral functions can be divided into the following:
  1. Attention, orientation and concentration
  2. Memory (Immediate short-term and long-term)
  3. Calculation
  4. Abstract thought
  5. Visual and body perception.
If the patient is uncooperative one must suspect disturbance of conscious level which may be organic as due to stroke, post-epileptic syndrome, hypoglycemia drug abuse, alcohol withdrawal. There may be functional cause such as depression.9
Ask the patient to subtract 7 from 100 and from the result and so on, e.g. 100 minus 7 equal to 93. 93 minus 7 equal to 86. The interpretation of the test is affected by anxiety. Patient may also be asked to repeat numbers you give to him. The patient's ability to count forwards and backwards numbers, e.g. you say one, two, three, four and so on and ask the patient to repeat the numbers forwards and backwards that is four, three, two, one. Note the mistakes on digit recall.
Whether the patient knows his age, his name, address, the names and numbers of his children, his parents names and their addresses and ages. Whether the patient knows where he is and who the doctors are and who the nurses are and that if he can identify doctors and nurses. What time of the day? What day of the week? What date of the month? And what year? If the patient can be asked what is your name? What is your job? Where do you live?
Assess fatigability and ability to follow a coherent line of thought serial 7s and digit span give indication of incoherent thought.
Test the patient's ability to do simple sums, handle money, count, read and write numbers of 2 or more digits.10
Memory to recent events such as if he can identify events of the day, previous week, month and years. See if he can repeat numbers forward and backwards. Korsakoff's psychosis is one classic example wherein memory to recent events is disturbed and also the patient is not oriented to time, place and person and makes up stories to cover his memory defect this is called confabulation.
Memory can also be tested by telling the patient an address and a name, usually a familiar address to the patient and asking him to repeat it immediately. Short-term memory can also be tested by asking the patient to remember the name and the address after 5 minutes. Long-term memory can be tested for instance if the patient is a soldier and as to what wars he was involved and if he remembers the name of his commander and chief of the Army staff at that time in his career. He can also be asked as to the year of Independence from colonial rule, name of the prominent Indian who was shot dead after the partition of India. Year constitution of India was framed.
Loss of short-term memory has localizing value. In hippocampal and mamillary bodies lesions due to vascular accidents, encephalitis, tumors, and if accompanied by confabulation indicates diffuse encephalopathy due to thiamine deficiency.
Abstract Thought
Abstract thought is a useful test for frontal lobe lesions and also dementias. It is tested by assessing patient's is 11correct interpretation of proverbs. Such as stitch in time saves nine. Ask the patient to explain difference between pair of objects such as table and a chair, shirt and trousers.
Visual and Body Perception
Visual and body perception tests, parietal and occipital lobe lesions and are called agnosias. The sensory pathways are found to be normal on testing. Then ask the patient to show to you his index finger, middle finger and so on failure to do so is finger agnosia. Ask the patient to close his eyes and place an object, e.g. coin, key in his hand and ask him, what it is. Failure to give correct answer is astereognosis. Similarly ask the patient to close his eyes and then write a number on his palm and ask him what it is. Failure to give correct answer agraphesthesia.
Emotional State
Whether the patient is anxious, depressed, excited frightened, apathetic or euphoric whether the patient laughs or cries suddenly and inappropriately.
Delusions and Hallucinations
Listen to the flow of speech of the patient and if during his speech there is evidence of delusions and hallucinations which may be auditory or visual.
Physical Examination
The Peripheral Nerves
Palpate the ulnar nerve at the elbow and the lateral popliteal nerve below the knee as it courses around the 12head of the fibula. Thickening of the nerves occurs in hereditary, neuropathy and in leprosy. In leprosy almost always greater auricular nerve is also thickened and patches of sensory loss and trophic changes are evident. Tapping the nerve during the stage of regeneration following nerve injury may produce paresthesia in its distribution (Tinnel's sign). The sign also may be elicited at the wrist – over ulnar and some times median nerves if they are pressed by ganglion at the site.
Head and Neck
In children as well as adults gross degree of hydro-cephalus are obvious. In craniostenosis the sutures may be felt as hard ridges. In acromegaly the size of the head is elongated, the jaw is elongated and the hands and feet are enlarged, skin is coarse. In basilar invagination, the hairline is low. On palpation feel for the fontanelle, bony lumps, fracture grooves. Anterior fontanelle must be felt and measured which may close prematurely as in cranio-stenosis and normally closes at 18 months. In states of hydrocephalus it is tense and bulging. Ausculate the head for bruits as in angiomas or over extradural meningioma carotid bruits are also heard in carotid stenosis. Neck stiffness to be noted as in meningitis. Other causes of neck rigidity are cervical spondylosis and Parkinson's disease.
Kernig's Sign
Positive in meningitis, subarachnoid hemorrhage. Flex the leg at the hip with the knee flexed, then try to extend the 13knee repeat the test on the other side. Resistance to knee straightening bilaterally indicates meningeal irritation.
Neck Stiffness
Gently lift the head off the bed feel for the tone in the neck. Rotate the head gently feel for stiffness. If the neck moves easily in all places, it is normal. Neck stiffness indicates meningeal irritation, bacterial, viral meningitis and subarachnoid hemorrhage.
Straight Leg Raising
In lumbar disk, raising the leg may produce root pain on the affected side (Lasegue's sign).
Observe for kyphosis, lordosis, scoliosis besides pointing towards diseases such as Friedreich's ataxia, syringo-myelia. It may also be a normal racial characteristic. Rigidity of the spine is seen in spasm of paravertebral muscles resulting from tetanus, disk disease. Look feel for tenderness of the spine and spinous processes.
General Examination
The Ears
Otitis media must be most carefully looked for in any case of meningits. Auroscopy should be routinely done, a polyp in the middle ear may be visible behind the drum.14
The Skin
Look for signs of vasomotor instability. Peripheral vascular deficiency is often associated with migraine, syncope and anxiety.
Allergic lesions and dermatographia: von Recklinghausen's phenomenon, Café au lait patches, subcutaneous and plexiform neurofibromata. Their presence may be important in diagnosis of intracranial neurofibromata.
Adenoma sebaceum: Pink globular discrete spots on the cheek, nose and chin, which may become deep red. These spots spare forehead and upper lip. This is associated with tuberous sclerosis.
Cutaneous angiomata, telangiectases: Facial nevi occur in Sturge-Weber disease and with disorders of the neuronal crest, syringomyelia. Spider nevi, occur with hepatic cirrhosis and pregnancy and in some normal people.
Herpes zoster: Viral infection, eruptions in segmental distribution in spinal lesions. May also be seen in metastatic disease, multiple sclerosis and even trauma.
Herpes simplex: Eruption especially in children.
Skin malignancy: Melanoma may have multiple metastasis in the nervous system and primary lesion in the skin may have been removed years earlier.
Bedsores: Are to be checked for over gluteal region, scars, burns and destruction of terminal phalanges can occur in syringomyelia, leprosy and hereditary sensory neuropathy. Ulcers on external genitalia, mouth, eyes, occur in 15Behçet's syndrome which may be accompanied by diffuse cerebral and spinal cord disease.
Tufts of hair: May also over lie developmental spinal abnormalities.
The Heart
Several ways where diseases of the heart can be correlated with diseases of the nervous system.
Pulse rate and regularity: A slow pulse occurs in increased intracranial pressure, complete heart block—Stokes-Adams syndrome. A very fast rate is found in nervousness, systemic infections, paroxysmal tachycardia and severe hemorrhage. Irregular pulse and irregular heart rate – Fibrillation may produce cerebral emboli.
The other changes in heart rhythm such as slow PR interval, Wolff-Parkinson-White syndrome may produce faintness especially if there is carotid or vertebral atheroma.
Heart sound: Cardiac murmurs as in mitral stenosis may be significant in Sydneham's chorea. Mitral and aortic disease may be associated with cerebral emboli especially if there is bacterial endocarditis. Aortic stenosis causes episodes of fainting. Aortic regurgitation may be associated with neurosyphilis. Congenital cardiac lesions such as patent ductus arteriosus may predispose to cerebral abscess formation.
Subclavian stenosis may result in a steal of blood from the vertebrobasilar system especially on exercise and if there is subclavian bruit the radial pulse may be delayed and the blood pressure may be lower in the affected arm.16
Blood pressure: It is very important to record blood pressure in lying and standing position and in both arms. In subclavian steal syndrome there is significant difference in blood pressure in the two arms.
The Lungs
Bronchial carcinoma: Commonest site for cerebral metastasis in males.
Bronchiectasis: Commonest cause of cerebral metastatic abscesses.
Tuberculosis: Meningitis, encephalitis and tuberculoma.
Bronchitis and emphysema: Headache, fluctuating consciousness level and involuntary movements (asterixis).
Pancoast tumor: Pain and marked sensory impairment in the distribution of the lower brachial plexus.
Small oat cell carcinoma: The lung and mesothelioma may be associated with myasthenia gravis, Eaton-Lambert syndrome.
The Abdomen
Carcinoma of the stomach, colon and kidney may first present themselves with cerebral metastasis and they present themselves in the brain as metastasis years after removal of primary tumor growth. Neuroblastoma in children may give rise to deposits in the orbit and the frontal bone. Hepatosplenomegaly may be associated with sarcoidosis, reticulosis and leukemia. Alcoholism-cirrhosis which may be complicated by Wernicke-Korsakoff's syndrome.17
The Pelvis
Malignancy of the pelvic organs may cause lesions of the central nervous system such as extradural or intramedullary tumors giving rise to paraplegia as in prostatic cancer.
Pregnancy: May be associated with chorea or other psychological disorder and epilepsy such as due to cerebral venous thrombosis. Fits, hemiparesis may follow induced abortion due to air emboli as amniotic emboli. Pituitary tumor may be associated with or may present as primary amenorrhea.
The Breasts
Very common site of the primary tumor in cerebral and spinal metastasis. Careful examination is essential both in women and men. Galactorrhea is a symptom of prolactinoma. Premature breast development can occur in hypothalamic lesions.
The Thyroid
Note for signs of thyrotoxicosis presence of thyroidectomy scar. Exophthalmos with ophthalmoplegia. Muscle wasting and weakness—Thyrotoxic myopathy is a rare possibility.
Hypothyroidism myxedema: Tendon reflexes are prolonged especially ankle jerks and they relax slowly. Hoarseness of voice due to recurrent laryngeal nerve palsy may be due to thyroid enlargement or past thyroidectomy.
The Glands
Metastatic carcinoma or possible Hodgkin's disease. Granulomata such as sarcoid may cause cerebral deposits.18
Lymphatic leukemia and Hodgkin's disease — there may be cerebral demyelination. HIV disease is to be thought of. Glandular fever—Infectious mononucleosis. A Guillain-Barré like syndrome is manifested.
The Teeth
Unsuspected dental abscesses – are a potent source of cerebral abscesses especially if there is congenital heart disease. Defective teeth, defective closure and temporo-mandibular joint disease can give rise to facial pain.
Gum hypertrophy is seen in phenytoin and also phenobarbitone and carbamazepine use.
The Tongue
Wasted tongue, fibrillating tongue as in motor neuron disease, large tongue as in congenital hypothyroidism.
The Nails
Blue line at nail beds and on the gums lead poisoning.
Koilonychia—Severe Anemia
Clubbing of the nails is seen in congenital heart disease, chronic chest disease, bronchial malignancy, chronic hepatic disease.
Nicotine staining on the nail beds especially indicates bronchial carcinoma if there is cerebral metastasis.
Lack of Blinking, Absence of Facial Expression (Mask like Face)
Parkinson's disease.