NEUROLOGY Hx
Headache, [SOCRATES] ® type/severity • Disturbed gait, sensation and weakness
• Time course (esp. SAH vs IIH) a. Dysesthesia (unpleasant feel)
a. Acute (secs) = SAH, stroke, focal/generalised seizure b. Paraesthesia (pins & needles) & numb
b. Subacute (hrs-days) = infection, inflammatory disorder (Guillain–Barré • Disturbances of vision, hearing, smell, speech &
syndrome) swallowing
c. Insidious (wks – mths) = IIH, tumour, neurodegenerative
• Triggers? ® auras, hormone changes? Consider pattern of symptoms:
• Assoc. (photo/phono-phobia, cold, mental clouding, rhinorrhoea, flushed head) • Unilateral vs bilateral
History of Fits, faints or funny turns [Seizures/Strokes] • Sensory vs motor vs sensori-motor
presenting • Pre-event [LAD] • Distal vs proximal weakness
complaint a. LOC o Cranial vs Long tract (UL vs LL)
b. auras • PNS vs ANS (bladder, ED, irregular BP)
c. DIZZY (vertigo, lightheaded), • Dermatomal/myotomal distribution or not
d. vision issue, speech,
e. trauma è extra-dural, sub-dural heam.
• During event (what happened? , duration – hrs, days?)
• After event [WILD] (weakness incontinence, Lateral Tongue biting, drowsiness)
• Previous episodes / scans (MRI, CT)
• Underlying CV cause (i.e. palpitation, SOB)
• Risk of Cerebrovascular disease: epilepsy/convulsions | HT | DM | Dyslipidaemia
Current Conditions o Previous stokes / STEMIs
o Previous accidents (e.g. head/spinal injuries) or Infection (meningitis, STIs)
• Anticonvulsants, anti-Parkinsonian drugs, COCP [ stroke risk]
Medications
• Steroids, stains & Opiates
Past MHx
Surgeries/ • Chemotherapy for malignancy (leukaemia, myeloma or lymphoma)
Treatments • Splenectomy ( thrombocytopenia or lymphoma)
Tests Results of CT or MRI brain scan
Other Allergies? + Vaccinations [strep. Pneumoniae, FluVax]
Occupation • exposure to toxins (e.g. heavy metals)
Smoking • cerebrovascular disease [ vascular risk]
Social Hx
Alcohol • blackouts, alcoholic dementia, myopathy
Drugs • Marijuana + cocaine induced headache
• Family Hx of migraine, stroke, Alzheimer’s, epilepsy
Family Hx
• X-LINKED: Colour blindness, DMD | Autosomal dominant (neurodegenerative disease): Huntington’s chorea, MS
• CVS – CAD SPIFE, RESP – SCSC FAWIF, GIT – BLIND CRAP, GU – FUNDWISE | PORN HAWC | Menstrual Cycle
SR
General: Fever | weight loss/gain | Speech | Smell | Hearing | Sight
Red flags on history Red flags on Examination
• Fever, photophobia or neck stiffness (meningitis or encephalitis) • Abnormal vitals
• New neurological symptoms (haemorrhage, malignancy or stroke) • Neurological abnormalities
• Dizziness (stroke) • Decreased LOC è other cause [CV, metabolic, psychogenic]:
• Visual disturbance (temporal arteritis or glaucoma) o Arrhythmias = assoc. with palpitations
o Aortic stenosis = LOC with heavy exercise
• Sudden onset occipital headache (subarachnoid haemorrhage)
o Transient ischaemic attacks = ‘drop attacks’ means the patient falls but NO LOC.
• Worse on coughing or straining (raised intracranial pressure)
o Vasovagal syncope = LOC due to abrupt drop in HR, BP (due to stress)
• Postural, worse on standing, lying or bending over or Pemberton’s sign
(raised intracranial pressure) o Micturition syncope = LOC due to urination
• Severe enough to wake the patient from sleep o Hypoglycaemia (diabetics on insulin) = sweating, weakness and confusion
BEFORE LOC.
• Vomiting (raised intracranial pressure or carbon monoxide poisoning)
o Psychogenic non-epileptic seizures (PNES) ® LOC [no response to
• History of trauma (intracranial haemorrhage) anticonvulsants] ® need psychotherapy to Rx anxiety and depression
• Pregnancy (pre-eclampsia) • Meningismus (similar to meningitis without inflammation of meninges ® i.e. stiff neck,
• Recent hed trauma within 3/12 = ?SDH\ photophobia)
• Headaches with use of medications/illicit drugs (e.g. anticoagulants, • Papilledema è Idiopathic intracranial hypertension (IIH), Raised ICP
sympathomimetic agents)
Examination Indication Purpose
Mental state Mental health • “A routine assessment to check your brain function that I do on all my patients of similar age”
examination (MSE) disorder • provides snapshot of a patient's emotions, thoughts, and behaviour at the time of observation
• helps identify the presence and severity of a variety of mental health conditions and the risk a patient
poses to him- or herself, or to others
Mini-Mental State Exam Elderly • tests cognitive function among the elderly è
(MMSE) • measures of orientation, registration (immediate memory), short-term memory (but not long-term
memory) as well as language functioning
• Orientation è registration è registration è attention + calc è recall è language
• Score out of 30 (> 25 - normal, 21-24 = mild cognitive impairment, <20 = dementia)
, Cranial Nerve Examination (upper CN – I, II, III, IV, VI)
• Today I have been asked to check your cranial nerves. These are the nerves that supply your face and neck
• Responsiveness + Orientated [“tell me how you got here today?”]
• Ptosis (drooping one/both eyelids = old age, 7th nerve palsy, Horner’s (ptosis + anhidrosis, myosis, anophthalmos)
GI
• Proptosis / strabismus (misalignment/deviation of one/both eye)
• Facial asymmetry & facial drooping (salivation)
• Obvious muscle wasting (Temporal)
• Alcohol wipe smell (test each nostril separately
o “Close eyes + cover one nose” “Describe to me what you smell”
CN I
o DDx (anosmia): Kallman URTI, smoking, ethmoid tumours, basal skull/frontal fracture, post pituitary surgery, congenital (eg. Kallmans syndrome),
meningioma of olfactory groove, infectious (meningitis)
• ENSURE YOU POSITION PATIENT AT EYE LEVEL!!
Acuity
• Cover one eye and read the smallest line you can
[snellan chart]
o If unable: ® “How many fingers” [CF] ® Hand movement [HM] ® Perception of Light (PL] ® NPL
• “Cover your own eye with one hand and then the other!”
• Cover your left eye with your left hand ® “look into my eye and say ‘yes’ when you see my finger moving”
• Repeat with coloured object (NARROWER visual field – cones located centrally in macula, rods peripheral)
• Repeat for other eye
Visual
Fields
CN 2
AFRO
CAP
Ishihara Plates:
Colour vision • optic neuritis (loss of red),
• Colour blindness: vit A deficiency / X-linked chromosome loss
• “Stare at point on the wall behind me ® now look at the red ball”
Accommodation
o Should see convergence of eyes
“Stare at a point behind me” ® Pen light from side and into eye slowly
• Check pupil size
Pupil light reflex • Repeat x2 (see constriction in blinded eye (direct) and then the other (consensual))
Reflexes (PEARL) Swing torch test
[Take glasses off] [Check size, • If light shone on damaged eye (NO consensual response)
shape of pupil] • If light shone on bad eye ® good eye ® bad eye (appears to dilate)
• Bad eye = Marcus Gunn pupil is a relative afferent pupillary defect indicating a decreased pupillary
response to light in the affected eye
• Failure of accommodation ONLY è midbrain lesion or with cortical blindness.
Pathology • Absent light reflex ONLY è midbrain lesion (e.g. Argyll Robertson pupil of syphilis – accomodates but
does not react), a ciliary ganglion lesion (e.g. Adie’s pupil)
• Amsler grid è AMD
Definition Distribution vision Light reflex
Optic Disc Optic disc swelling due to None
Papilloedema Bilateral Huge blind spot
(Fundoscopy) raised ICP DDx: retinoblastoma,
*Say would do Inflammed or infarcted optic Scotoma ®
Optic neuritis Unilateral Reduced
nerve head blindness
• Do you have any double vision (diplopia) ?
• Pursuit Movements (tracking) ® smooth conjugate movement
CN 3 • Saccades “Look left then right” “up and down”
Eye movements
[Draw large H ] o hypometric OR hypermetric/overshoot saccades
• Horizontal Nystagmus (MS or vascular lesion) 3 D’s -CN3 palsy:
Dilated pupils
Reflex types: o Vestibular lesion = nystagmus away from side of lesion Diplopia (down and out)
1) pursuit Divergent squint
o Cerebellar lesion = nystagmus to side of lesion
2) saccades
3) convergence • Vertical Nystagmus
CN 4
4)VOR o Midbrain lesion, floor of 4th ventricle
o EtOH, phenytoin
LR6 = abduction
Conjugate Gaze Palsy
SO4 = depressor
in eye adduction • PSP = Loss of vertical ® then horizontal gaze ® bilateral
(head tilt away fixed unequal eyes but reflex eye movements intact
from lesion • Parinaud’s syndrome = Involuntary upward dev of the eyes +
CN 6 loss of vertical agaze = pinealoma, MS, vascular
• One and a half syndrome = horizontal gaze palsy + impaired To exclude a CNIV lesion in context of 3rd nerve palsy, tilt head
adduction to same side as the lesion à the affected eye will intort if
CNIV intact)
, Cranial Nerve Examination (Lower CN – 5, 7-12)
“This is what the cotton wool/pin feels like” [Both sides of Head ® cheek ® jaw]
• Is it cold/hot or sharp/dull AND
• did it feel the same on both sides of the face?
Examine
Sensory division facial
of trigeminal sensation
V1 = ophthalmic [close
(sup. orbital) patients’
V2 = mandibular eyes]
(foramen
rotundum)
Dermatomes of the head and Facial sensation V, test all three Herpes zoster distribution of
neck divisions on each side the maxillary nerve
*Corneal Lightly touch cornea (not the conjunctiva) with cottonwool brought to the eye from side
reflex [Not
done] • No sensation = corneal ulceration / ACOUSTIC NERUOMA ( NO CN7 TO BLINK)
• (clench your teeth for me + relax): Feel for temporalis and masseter muscle wasting?
CN 5
Muscles of • (ask patient to bite down on wooden tongue depressor with molars): muscle strength
Motor division of mastication
trigeminal • (open your mouth – don’t let me close it): pterygoid muscle
V2 = maxillary • Jaw deviates to affected side
(foramen ovale)
Jaw Jerk Or • “Relax your jaw down slightly for me ® just going to tap tip of your chin/jaw lightly”
Masseter o è exaggerated jaw jerk = UMN lesion above pons [pseudobulbar palsy]
Reflex
NB: schwannoma from CNVIII can compress adjacent CNV and CNVII nerves, brainstem and cerebellum
• Frontalis (temporal) = “Raise your eyebrows and don’t me push them down “è NO wrinkle (UMN lesion –
FOREHEAD SPARING)
• OBICULARIS OCULI (ZYGOMATIC) “Close eyes TIGHTLY as you can and don’t let me open them” è Bell’s LMN
Facial movements palsy: upward movement of the eyeball and incomplete closure of the eyelid
• BUCCINATOR (BUCCAL) “Puff cheeks and don’t let me push them in” è asymmetry (LMN lesion)
• ZYGOMATIC MUSCLE (ZYG + BUCCAL) “Smile and show me your teeth” è facial paralysis (cortical lesion)
• CERVICAL Platysma + occipitalis
Q “Any change in • CNVII (chorda tympani) has sensory fibres for taste from anterior 2/3 of tongue ® fibres reach brain via CNV
taste” • Unilateral loss of taste: middle-ear lesions involving the chorda tympani (CN7) or lingual nerve (CNV)
Q “Any change in • Stapedius supplied by VII è controls stapes è hyperacusis when damaged
hearing”
Central causes (pons, medulla, upper
cervical cord) = FOREHEAD SPARING
Ø vascular lesion,
CN 7 Ø tumour,
Ø syringobulbia.
Peripheral causes
Ø aneurysm, tumour,
Ø chronic meningitis.
Ø Trigeminal ganglion causes include
trigeminal neuroma, meningioma
fracture
Headache, [SOCRATES] ® type/severity • Disturbed gait, sensation and weakness
• Time course (esp. SAH vs IIH) a. Dysesthesia (unpleasant feel)
a. Acute (secs) = SAH, stroke, focal/generalised seizure b. Paraesthesia (pins & needles) & numb
b. Subacute (hrs-days) = infection, inflammatory disorder (Guillain–Barré • Disturbances of vision, hearing, smell, speech &
syndrome) swallowing
c. Insidious (wks – mths) = IIH, tumour, neurodegenerative
• Triggers? ® auras, hormone changes? Consider pattern of symptoms:
• Assoc. (photo/phono-phobia, cold, mental clouding, rhinorrhoea, flushed head) • Unilateral vs bilateral
History of Fits, faints or funny turns [Seizures/Strokes] • Sensory vs motor vs sensori-motor
presenting • Pre-event [LAD] • Distal vs proximal weakness
complaint a. LOC o Cranial vs Long tract (UL vs LL)
b. auras • PNS vs ANS (bladder, ED, irregular BP)
c. DIZZY (vertigo, lightheaded), • Dermatomal/myotomal distribution or not
d. vision issue, speech,
e. trauma è extra-dural, sub-dural heam.
• During event (what happened? , duration – hrs, days?)
• After event [WILD] (weakness incontinence, Lateral Tongue biting, drowsiness)
• Previous episodes / scans (MRI, CT)
• Underlying CV cause (i.e. palpitation, SOB)
• Risk of Cerebrovascular disease: epilepsy/convulsions | HT | DM | Dyslipidaemia
Current Conditions o Previous stokes / STEMIs
o Previous accidents (e.g. head/spinal injuries) or Infection (meningitis, STIs)
• Anticonvulsants, anti-Parkinsonian drugs, COCP [ stroke risk]
Medications
• Steroids, stains & Opiates
Past MHx
Surgeries/ • Chemotherapy for malignancy (leukaemia, myeloma or lymphoma)
Treatments • Splenectomy ( thrombocytopenia or lymphoma)
Tests Results of CT or MRI brain scan
Other Allergies? + Vaccinations [strep. Pneumoniae, FluVax]
Occupation • exposure to toxins (e.g. heavy metals)
Smoking • cerebrovascular disease [ vascular risk]
Social Hx
Alcohol • blackouts, alcoholic dementia, myopathy
Drugs • Marijuana + cocaine induced headache
• Family Hx of migraine, stroke, Alzheimer’s, epilepsy
Family Hx
• X-LINKED: Colour blindness, DMD | Autosomal dominant (neurodegenerative disease): Huntington’s chorea, MS
• CVS – CAD SPIFE, RESP – SCSC FAWIF, GIT – BLIND CRAP, GU – FUNDWISE | PORN HAWC | Menstrual Cycle
SR
General: Fever | weight loss/gain | Speech | Smell | Hearing | Sight
Red flags on history Red flags on Examination
• Fever, photophobia or neck stiffness (meningitis or encephalitis) • Abnormal vitals
• New neurological symptoms (haemorrhage, malignancy or stroke) • Neurological abnormalities
• Dizziness (stroke) • Decreased LOC è other cause [CV, metabolic, psychogenic]:
• Visual disturbance (temporal arteritis or glaucoma) o Arrhythmias = assoc. with palpitations
o Aortic stenosis = LOC with heavy exercise
• Sudden onset occipital headache (subarachnoid haemorrhage)
o Transient ischaemic attacks = ‘drop attacks’ means the patient falls but NO LOC.
• Worse on coughing or straining (raised intracranial pressure)
o Vasovagal syncope = LOC due to abrupt drop in HR, BP (due to stress)
• Postural, worse on standing, lying or bending over or Pemberton’s sign
(raised intracranial pressure) o Micturition syncope = LOC due to urination
• Severe enough to wake the patient from sleep o Hypoglycaemia (diabetics on insulin) = sweating, weakness and confusion
BEFORE LOC.
• Vomiting (raised intracranial pressure or carbon monoxide poisoning)
o Psychogenic non-epileptic seizures (PNES) ® LOC [no response to
• History of trauma (intracranial haemorrhage) anticonvulsants] ® need psychotherapy to Rx anxiety and depression
• Pregnancy (pre-eclampsia) • Meningismus (similar to meningitis without inflammation of meninges ® i.e. stiff neck,
• Recent hed trauma within 3/12 = ?SDH\ photophobia)
• Headaches with use of medications/illicit drugs (e.g. anticoagulants, • Papilledema è Idiopathic intracranial hypertension (IIH), Raised ICP
sympathomimetic agents)
Examination Indication Purpose
Mental state Mental health • “A routine assessment to check your brain function that I do on all my patients of similar age”
examination (MSE) disorder • provides snapshot of a patient's emotions, thoughts, and behaviour at the time of observation
• helps identify the presence and severity of a variety of mental health conditions and the risk a patient
poses to him- or herself, or to others
Mini-Mental State Exam Elderly • tests cognitive function among the elderly è
(MMSE) • measures of orientation, registration (immediate memory), short-term memory (but not long-term
memory) as well as language functioning
• Orientation è registration è registration è attention + calc è recall è language
• Score out of 30 (> 25 - normal, 21-24 = mild cognitive impairment, <20 = dementia)
, Cranial Nerve Examination (upper CN – I, II, III, IV, VI)
• Today I have been asked to check your cranial nerves. These are the nerves that supply your face and neck
• Responsiveness + Orientated [“tell me how you got here today?”]
• Ptosis (drooping one/both eyelids = old age, 7th nerve palsy, Horner’s (ptosis + anhidrosis, myosis, anophthalmos)
GI
• Proptosis / strabismus (misalignment/deviation of one/both eye)
• Facial asymmetry & facial drooping (salivation)
• Obvious muscle wasting (Temporal)
• Alcohol wipe smell (test each nostril separately
o “Close eyes + cover one nose” “Describe to me what you smell”
CN I
o DDx (anosmia): Kallman URTI, smoking, ethmoid tumours, basal skull/frontal fracture, post pituitary surgery, congenital (eg. Kallmans syndrome),
meningioma of olfactory groove, infectious (meningitis)
• ENSURE YOU POSITION PATIENT AT EYE LEVEL!!
Acuity
• Cover one eye and read the smallest line you can
[snellan chart]
o If unable: ® “How many fingers” [CF] ® Hand movement [HM] ® Perception of Light (PL] ® NPL
• “Cover your own eye with one hand and then the other!”
• Cover your left eye with your left hand ® “look into my eye and say ‘yes’ when you see my finger moving”
• Repeat with coloured object (NARROWER visual field – cones located centrally in macula, rods peripheral)
• Repeat for other eye
Visual
Fields
CN 2
AFRO
CAP
Ishihara Plates:
Colour vision • optic neuritis (loss of red),
• Colour blindness: vit A deficiency / X-linked chromosome loss
• “Stare at point on the wall behind me ® now look at the red ball”
Accommodation
o Should see convergence of eyes
“Stare at a point behind me” ® Pen light from side and into eye slowly
• Check pupil size
Pupil light reflex • Repeat x2 (see constriction in blinded eye (direct) and then the other (consensual))
Reflexes (PEARL) Swing torch test
[Take glasses off] [Check size, • If light shone on damaged eye (NO consensual response)
shape of pupil] • If light shone on bad eye ® good eye ® bad eye (appears to dilate)
• Bad eye = Marcus Gunn pupil is a relative afferent pupillary defect indicating a decreased pupillary
response to light in the affected eye
• Failure of accommodation ONLY è midbrain lesion or with cortical blindness.
Pathology • Absent light reflex ONLY è midbrain lesion (e.g. Argyll Robertson pupil of syphilis – accomodates but
does not react), a ciliary ganglion lesion (e.g. Adie’s pupil)
• Amsler grid è AMD
Definition Distribution vision Light reflex
Optic Disc Optic disc swelling due to None
Papilloedema Bilateral Huge blind spot
(Fundoscopy) raised ICP DDx: retinoblastoma,
*Say would do Inflammed or infarcted optic Scotoma ®
Optic neuritis Unilateral Reduced
nerve head blindness
• Do you have any double vision (diplopia) ?
• Pursuit Movements (tracking) ® smooth conjugate movement
CN 3 • Saccades “Look left then right” “up and down”
Eye movements
[Draw large H ] o hypometric OR hypermetric/overshoot saccades
• Horizontal Nystagmus (MS or vascular lesion) 3 D’s -CN3 palsy:
Dilated pupils
Reflex types: o Vestibular lesion = nystagmus away from side of lesion Diplopia (down and out)
1) pursuit Divergent squint
o Cerebellar lesion = nystagmus to side of lesion
2) saccades
3) convergence • Vertical Nystagmus
CN 4
4)VOR o Midbrain lesion, floor of 4th ventricle
o EtOH, phenytoin
LR6 = abduction
Conjugate Gaze Palsy
SO4 = depressor
in eye adduction • PSP = Loss of vertical ® then horizontal gaze ® bilateral
(head tilt away fixed unequal eyes but reflex eye movements intact
from lesion • Parinaud’s syndrome = Involuntary upward dev of the eyes +
CN 6 loss of vertical agaze = pinealoma, MS, vascular
• One and a half syndrome = horizontal gaze palsy + impaired To exclude a CNIV lesion in context of 3rd nerve palsy, tilt head
adduction to same side as the lesion à the affected eye will intort if
CNIV intact)
, Cranial Nerve Examination (Lower CN – 5, 7-12)
“This is what the cotton wool/pin feels like” [Both sides of Head ® cheek ® jaw]
• Is it cold/hot or sharp/dull AND
• did it feel the same on both sides of the face?
Examine
Sensory division facial
of trigeminal sensation
V1 = ophthalmic [close
(sup. orbital) patients’
V2 = mandibular eyes]
(foramen
rotundum)
Dermatomes of the head and Facial sensation V, test all three Herpes zoster distribution of
neck divisions on each side the maxillary nerve
*Corneal Lightly touch cornea (not the conjunctiva) with cottonwool brought to the eye from side
reflex [Not
done] • No sensation = corneal ulceration / ACOUSTIC NERUOMA ( NO CN7 TO BLINK)
• (clench your teeth for me + relax): Feel for temporalis and masseter muscle wasting?
CN 5
Muscles of • (ask patient to bite down on wooden tongue depressor with molars): muscle strength
Motor division of mastication
trigeminal • (open your mouth – don’t let me close it): pterygoid muscle
V2 = maxillary • Jaw deviates to affected side
(foramen ovale)
Jaw Jerk Or • “Relax your jaw down slightly for me ® just going to tap tip of your chin/jaw lightly”
Masseter o è exaggerated jaw jerk = UMN lesion above pons [pseudobulbar palsy]
Reflex
NB: schwannoma from CNVIII can compress adjacent CNV and CNVII nerves, brainstem and cerebellum
• Frontalis (temporal) = “Raise your eyebrows and don’t me push them down “è NO wrinkle (UMN lesion –
FOREHEAD SPARING)
• OBICULARIS OCULI (ZYGOMATIC) “Close eyes TIGHTLY as you can and don’t let me open them” è Bell’s LMN
Facial movements palsy: upward movement of the eyeball and incomplete closure of the eyelid
• BUCCINATOR (BUCCAL) “Puff cheeks and don’t let me push them in” è asymmetry (LMN lesion)
• ZYGOMATIC MUSCLE (ZYG + BUCCAL) “Smile and show me your teeth” è facial paralysis (cortical lesion)
• CERVICAL Platysma + occipitalis
Q “Any change in • CNVII (chorda tympani) has sensory fibres for taste from anterior 2/3 of tongue ® fibres reach brain via CNV
taste” • Unilateral loss of taste: middle-ear lesions involving the chorda tympani (CN7) or lingual nerve (CNV)
Q “Any change in • Stapedius supplied by VII è controls stapes è hyperacusis when damaged
hearing”
Central causes (pons, medulla, upper
cervical cord) = FOREHEAD SPARING
Ø vascular lesion,
CN 7 Ø tumour,
Ø syringobulbia.
Peripheral causes
Ø aneurysm, tumour,
Ø chronic meningitis.
Ø Trigeminal ganglion causes include
trigeminal neuroma, meningioma
fracture
