Never ever presume a neurological diagnosis without interacting with a patient and just by seeing the radiology report or just by listening the patient's complaints. Examine a patient without any presumption & bias, You will always feel rewarded.
Listen to the patient. Patient is the best guide and will provide you the important clue for the diagnosis. History taking is an opportunity to interact with people from diversified background.
While taking history of a patient who is suspected to have a neurological disorder it should always be prudent to take history pertaining to lesions of brain, spinal cord and peripheral nerves. In this manner you can complete and cover the entire central and peripheral nervous system.
So, if you suspect a lesion of the cerebral hemisheres, History of Seizure, Headache, Vision and , Deterioration of conscious level or loss of consciousness, Weakness of the face or limbs should be taken into detail.
If you suspect a lesion of cerebellum, then history of imbalance, ataxia and difficulty in walking should always be taken.
And if you suspect a lesion of the brain stem ( Midbrain , pons, medulla Oblongata), the symptoms of multiple cranial nerve deficits ( speech abnormality, nystagmus, difficulty in deglutition, loss of Gag reflex), and long tract signs ( weakness in limbs, hyperrelexia, increased tone in limbs, positive Babinski sign) are expected.
In patients with lesions of the spinal cord history must include details about weakness of the limbs, bladder and bowel involvement.
History of headache must include Onset ( sudden, gradual), Site ( holocranial, hemicranial , temoral)Frequency, duration, severity, Character ( Aching, throbbing), timing ( e.g., morning , evening), Precipitating factors (coughing, strenuous work) , Relieving factors ( analgesics, rest) , Associated features ( nausea, vomiting, visual disturbance).
History of Visual Disorder should include onset, frequency, impairment ( uniocular or both eyes, partial or total), diplopia, Precipitaing factor, Associated features
History of Loss of Consciousness may be due to syncope because of cardiac causes or vasovagal shock or due to neurological causes like a part of seizure or neurotrauma or a space occupying lesion in the brain. Loss of consciousness may also be due to low blood sugar level in a patient on diabetic treatment or alcohol or drug abuse.
Speech disorder may be a difficulty in Articulation or Expression or Understanding.
Weakness in the limbs may be Quadriparesis, Hemiparesis or Monoparesis with or without involvement of facial muscles.
History of Sensory system abnormalities may expressed by the patient as Numbness, feeling of crawling of ants or insects, Tingling or inability to feel a part of the body.
History of cranial nerve deficits may be expressed by the patient as inability to smell, inability to read, loss of vision, diplopia, frequent changes of spectacle, partial closure of the eyelid ( Ptosis)loss of sensation over the face, drooling of saliva from the side, difficulty in closing eye, slurring of speech or change in voice, difficulty in hearing or Deafness, Tinnitus, Vertigo or Dizziness, inability to swallow, inability to shrug and turn face and inability to protrude tongue.
Neurological examination is straight forward, It is like substraction and addition of numbers, like 2+2=4. So, if there is right hemiparesis of body and face and the deep tendon reflexes are increaded, there must be some lesion on the left side of the brain. There is nothing wrong in rechecking the neurological examination findings. But, be sure of your neurological examination findings. Your examination may have a great impact on clinical outcome and plan of the treatment. In Neuroscience most of the things are evident. As students we used to think that many things may be theortical. But, with the advent of newer and advanced neuroradiology, microneurosurgery and functional neurosurgery, lot of procedures are now based on physiological and neuroanatomical localization.
One should begin with systemic examination. See Pallor ( anemia), Icterus ( jaundice), Lymhadenopathy. Anemia may explain many symptoms. Lymhadenopathy may indicate infection, lymphoma or metastasis.
Listen to the patient. Patient is the best guide and will provide you the important clue for the diagnosis. History taking is an opportunity to interact with people from diversified background.
While taking history of a patient who is suspected to have a neurological disorder it should always be prudent to take history pertaining to lesions of brain, spinal cord and peripheral nerves. In this manner you can complete and cover the entire central and peripheral nervous system.
So, if you suspect a lesion of the cerebral hemisheres, History of Seizure, Headache, Vision and , Deterioration of conscious level or loss of consciousness, Weakness of the face or limbs should be taken into detail.
If you suspect a lesion of cerebellum, then history of imbalance, ataxia and difficulty in walking should always be taken.
And if you suspect a lesion of the brain stem ( Midbrain , pons, medulla Oblongata), the symptoms of multiple cranial nerve deficits ( speech abnormality, nystagmus, difficulty in deglutition, loss of Gag reflex), and long tract signs ( weakness in limbs, hyperrelexia, increased tone in limbs, positive Babinski sign) are expected.
In patients with lesions of the spinal cord history must include details about weakness of the limbs, bladder and bowel involvement.
History of headache must include Onset ( sudden, gradual), Site ( holocranial, hemicranial , temoral)Frequency, duration, severity, Character ( Aching, throbbing), timing ( e.g., morning , evening), Precipitating factors (coughing, strenuous work) , Relieving factors ( analgesics, rest) , Associated features ( nausea, vomiting, visual disturbance).
History of Visual Disorder should include onset, frequency, impairment ( uniocular or both eyes, partial or total), diplopia, Precipitaing factor, Associated features
History of Loss of Consciousness may be due to syncope because of cardiac causes or vasovagal shock or due to neurological causes like a part of seizure or neurotrauma or a space occupying lesion in the brain. Loss of consciousness may also be due to low blood sugar level in a patient on diabetic treatment or alcohol or drug abuse.
Speech disorder may be a difficulty in Articulation or Expression or Understanding.
Weakness in the limbs may be Quadriparesis, Hemiparesis or Monoparesis with or without involvement of facial muscles.
History of Sensory system abnormalities may expressed by the patient as Numbness, feeling of crawling of ants or insects, Tingling or inability to feel a part of the body.
History of cranial nerve deficits may be expressed by the patient as inability to smell, inability to read, loss of vision, diplopia, frequent changes of spectacle, partial closure of the eyelid ( Ptosis)loss of sensation over the face, drooling of saliva from the side, difficulty in closing eye, slurring of speech or change in voice, difficulty in hearing or Deafness, Tinnitus, Vertigo or Dizziness, inability to swallow, inability to shrug and turn face and inability to protrude tongue.
Neurological examination is straight forward, It is like substraction and addition of numbers, like 2+2=4. So, if there is right hemiparesis of body and face and the deep tendon reflexes are increaded, there must be some lesion on the left side of the brain. There is nothing wrong in rechecking the neurological examination findings. But, be sure of your neurological examination findings. Your examination may have a great impact on clinical outcome and plan of the treatment. In Neuroscience most of the things are evident. As students we used to think that many things may be theortical. But, with the advent of newer and advanced neuroradiology, microneurosurgery and functional neurosurgery, lot of procedures are now based on physiological and neuroanatomical localization.
One should begin with systemic examination. See Pallor ( anemia), Icterus ( jaundice), Lymhadenopathy. Anemia may explain many symptoms. Lymhadenopathy may indicate infection, lymphoma or metastasis.
Examine Pulse: Bradycardia is an omnious sign of raised intrcranial pressure ( ICP)
Irregular Pulse may indicate syncope
Blood pressure : Hypertension may indiacte raise ICP
Respiratory Rate: Irregular Respiration, Bradycardia and Hypertension are parts of Cushing reflex which is due to raised ICP.
Neck rigidity may indicate meningitis or subarachnoid hemorrhage. Restriction of neck movement may be due to cervical spondylosis. One should be very careful while examining a patient with head injury. if a patient is unconscious and his GCS is 8 or less, it is presumed that there may be associated cervical spine injury. So, in severely head injured patient , neck should be immobilized by putting a cervical collar while shifting the patient
Neurological examination begins with higher mental function. orientation to time, place and person should be asked.
cranial nerve examination: Soap may be used to examine olfaction. Vision should be seen in both eyes. If patient is unable to count fingers, then perception of light should be examined with a torch. Pupillary light reflex,ie, constrction of both the pupils when light is projected in eye , gives a clue about both second and third cranial nerves. because second cranial nerve (Optic Nerve) is afferent and third cranial nerve ( Occulomotor nerve) is efferent of this light reflex. Although this is very simple examination but it has great value. We often presume that vision is normal and miss it. A child with craniopharyngima, an adult with clinodal meningima or pituitary adenoma may not have any vision in one eye but even patiets or their parents may not be aware about the uniocular visual loss. So, if a doctor misses this finding, there may be catastrophic consequences. As immediately following the surgery , there is natural tendency in everyone to check the vision and it could be concluded that this visual loss be due to surgery. Optic nerve tumor, optic nerve injury, retinal detachmentmay also present with uniocular visual loss.
3,4,6 cranial nerves function may be examined by seeing the conjugate eye movements of both eyes together.
5th cranial nerve, 7th cranial nerve is by examining the face. sensation over the face is mainly by the Vth cranial nerve ( Trigeminal nerve). There are three sensory divisions of Trigeminal nerve ( V1, V2, V3). 7th cranial nerve is the motor supply to the face.
Hearing is through 8th cranial nerve. Ideally 8th cranial nerves should be examined by Tuning forks. If patient hears the rubbing of fingers of the examiner close to each ear, it may give some clue to the intact hearing.
If the gag reflex is intact, 9th and 10th cranial nerves are intact.
Patient is asked to Shrug the shoulder and turn the face against the resistance to examine sternocleidomastoid and trapezius muscle which are suppled by the spinal accessory nerve.
Protrusion of tongue is possible with the 12th cranial nerve. If Hypoglossal nerve is damaged the tongue deviates to the injured side on protruding.
Sensory nervous examination should be done before motor examination. Because patients usually are cooperative and sensory system examination is subjective and needs patient,s cooperation.
Motor examination : Movement of all four limbs. Power in all four limbs should be checked separately and should be compared with your own strength. Deep tendon reflexes and tone should also be examined.
Gait; If a patient is able to walk, gait should alsio be examined to complete the thorough neurological examination
Irregular Pulse may indicate syncope
Blood pressure : Hypertension may indiacte raise ICP
Respiratory Rate: Irregular Respiration, Bradycardia and Hypertension are parts of Cushing reflex which is due to raised ICP.
Neck rigidity may indicate meningitis or subarachnoid hemorrhage. Restriction of neck movement may be due to cervical spondylosis. One should be very careful while examining a patient with head injury. if a patient is unconscious and his GCS is 8 or less, it is presumed that there may be associated cervical spine injury. So, in severely head injured patient , neck should be immobilized by putting a cervical collar while shifting the patient
Neurological examination begins with higher mental function. orientation to time, place and person should be asked.
cranial nerve examination: Soap may be used to examine olfaction. Vision should be seen in both eyes. If patient is unable to count fingers, then perception of light should be examined with a torch. Pupillary light reflex,ie, constrction of both the pupils when light is projected in eye , gives a clue about both second and third cranial nerves. because second cranial nerve (Optic Nerve) is afferent and third cranial nerve ( Occulomotor nerve) is efferent of this light reflex. Although this is very simple examination but it has great value. We often presume that vision is normal and miss it. A child with craniopharyngima, an adult with clinodal meningima or pituitary adenoma may not have any vision in one eye but even patiets or their parents may not be aware about the uniocular visual loss. So, if a doctor misses this finding, there may be catastrophic consequences. As immediately following the surgery , there is natural tendency in everyone to check the vision and it could be concluded that this visual loss be due to surgery. Optic nerve tumor, optic nerve injury, retinal detachmentmay also present with uniocular visual loss.
3,4,6 cranial nerves function may be examined by seeing the conjugate eye movements of both eyes together.
5th cranial nerve, 7th cranial nerve is by examining the face. sensation over the face is mainly by the Vth cranial nerve ( Trigeminal nerve). There are three sensory divisions of Trigeminal nerve ( V1, V2, V3). 7th cranial nerve is the motor supply to the face.
Hearing is through 8th cranial nerve. Ideally 8th cranial nerves should be examined by Tuning forks. If patient hears the rubbing of fingers of the examiner close to each ear, it may give some clue to the intact hearing.
If the gag reflex is intact, 9th and 10th cranial nerves are intact.
Patient is asked to Shrug the shoulder and turn the face against the resistance to examine sternocleidomastoid and trapezius muscle which are suppled by the spinal accessory nerve.
Protrusion of tongue is possible with the 12th cranial nerve. If Hypoglossal nerve is damaged the tongue deviates to the injured side on protruding.
Sensory nervous examination should be done before motor examination. Because patients usually are cooperative and sensory system examination is subjective and needs patient,s cooperation.
Motor examination : Movement of all four limbs. Power in all four limbs should be checked separately and should be compared with your own strength. Deep tendon reflexes and tone should also be examined.
Gait; If a patient is able to walk, gait should alsio be examined to complete the thorough neurological examination
Thank you sir for the wonderful post.Basic but detailed explanation of the topic.
ReplyDeleteDear Dr Rahul, These facts are useful for managing any patient who is suffering from neurological disorder. Although we very often see patients who present to us with MRI or CT scan with them, even then detailed conversation with the patient and brief neurological examination are of great significance.
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