CLINICAL LOCALIZATION AND HISTORY IN NEUROLOGY

ZAMZURI IDRISNEUROSAINS

HISTORY• History of presenting complaint shoud cover the followings:1. nature of complaint2. the onset, how did it begin, sudden or gradual in onset3. the duration; acute, subacute and chronic4. the time course; stepwise fashion, progressed then

stabilized 5. other positive neurological symptoms6. precipitating and relieving factors7. extent of any deficit such as inability to put the slippers on,

unable to walk, cook, comb hairs8. affects on function or daily activities9. previous treatment and investigations

HISTORY 2On direct questioning (part of history presenting complaint) should cover the followings:

I. other negative neurological symptoms - headache, numbness, seizures, vision and else (to show that you did ask the relevant issues here!!!).

II. bowel and bladder statusIII.risk factorsIV.neuroendocrine questionsV. developmental history if you think the case has strong

developmental aetiology

Good History Taking

• Obtaining a good history. • As Goethe stated "The eyes see what the

mind knows”

ONSET

• INSIDIOUS ONSET = VASCULAR• ACUTE = INFECTION / VASCULAR • SUBACUTE = INFECTION / METABOLIC• CHRONIC = TUMOUR [ HIGH GRADE VS LOW

GRADE]• CHILDHOOD = ?CONGENITAL

PAIN• Pain should be further defined in terms of the following:a. Location (Ask the patient to point with one finger, if

possible.) b. Radiation (Pay attention to any dermatomal relationship.) c. Quality (stabbing, stinging, lightninglike, pounding, etc) d. Severity or quantity (Estimate functional limitation.) e. Precipitating factors (stress, periods, allergens, sleep

deprivation, etc) f. Relieving factors (sleep, stress management, etc) g. Diurnal or seasonal variation

Weakness

• Onset• Pattern and duration of weakness• Progression• Precipitating/relieving factors• Association with pain, numbness, bowel and

bladder dysfunctions etc• Affect on daily activities/severity

others

• Important miscellaneous factors of the history include the following:

I. Results of previous attempts to diagnose the condition

II.Any previous therapeutic intervention and the response to those treatments

PHYSICAL EXAMINATION

1. Higher Mental Functions [HMF]a) Conscious level• Normal/alert• Drowsy• Stuporous• Comatose• According to GCS for trauma patient

CONT.b) Speech• Handedness.• Language; spoken and written language.• Spontaneous speech; word output, melody (an affective component of speech =

non dominant hemisphere), grammer, neologism, paraphasia• Repetition [Bank Bumiputra Malaysia Bhd (1 score)]• Comprehension; auditory and visual.• Reading (abnormality = alexia/dyslexia)• Writing sentences (1 score) (abnormality = agraphia) : Perception of written

language is located in angular gyrus. But if both affected, alexia and agraphia = lesion is in inferior parietal lobule. The alexia without agraphia (able to write but inability to read aloud, name colors or understand written script) occurs in lesion affecting the left geniculocalcarine tract. They may also have right homonymous hemianopia.

• Naming (2 score for naming 2 objects correctly)• Echolalia – repeat words or phrases that he or she heard.• Neologisms – made-up words.

LANGUAGEType Spontaneous speech Naming Repetition Comprehension Usual localization

Broca Non fluent Poor Usually poor Good(The only)

Broca’s area

Wernicke Fluent(The only)

Poor Poor Poor Wernicke’s area (posterior aspect of superior temporal gyrus)

Conduction FluentThe onlyConduction area!!!Poor

Very poor Good Supramarginal gyrus, arcuate fasciculus. (occlusion of posterior temporal branch of MCA)

Anomic Fluent Poor(only)

Good Good ? angular gyrus, non localising

Global Non fluent Poor Poor Poor Entire perisylvian cortex

Transcortical motor aphasia.

Non fluent(The only)

intact good Lesion in supplementary motor area or dorsolateral frontal cortex.

Transcortical sensory aphasia

Fluent intact Poor(The only)

Lesion at the joining area of temporal, parietal and occipital lobes.

c) Mini Mental State [COMPONENTS]• Not all patients were asked in details, depends on presenting complaints and clinical

suspicion.• Orientation: person, time, place, date, day (5 score)• Attention span (count days backwards) (5 days = 5 score)• Memory: immediate (repeat three things: 3 Score), recent (what did you have for your

breakfast/lunch today? or repeat the task on immediate memory testing after 5 minutes: 3 score) and remote.

Short term memory and Registration:• inner circuit of limbic system (hippocampal gyrus, Ammon's horn, the fornices,

mamillothalamic tracts, mamillary bodies, anterior thalamic complexes and dorsomedial thalamic nuclei)

• cingulate gyrusLong term memory is more diffusely represented.Calculations: addition and substraction (100 - 7 test). It depends on schooling level (5 score for 5

consecutive tests).Language - see above on speech session, the one with the score values noted above and also, the

three stage command test is correctly executed (touch your right ear with your left hand and then your nose = 3 score)

Construct the intersecting pentagon or filled up the numbers in the clock (1 score).Obey of what is written on piece of paper (1 score).

• Note: Total score for mini mental state test is 30, if less than 23 = Cognitively impaired. A score of less than 20 (out of a possible 30) has an 87% sensitivity for detecting dementia.

In summary: Elements of Mini-Mental State Examination are:

• orientation to time and place• registration of spoken information• attention and calculation• recall of information from registration task• language tests – naming objects, repeated

phrases, following 3-staged command, reading a command and following it, writing a sentence

• construction – copying a shape

HMF

Others• logical thinking (raining day, fire in the house)• abstract analysis (proverbs)• fund of knowledge• psychiatric elements: illusions, delusions,

hallucinations

d) Specific Frontal and Parietal Lobes Functions

Frontal lobes Questions - social disinhibition, poor judgement and apathy.Dorsolateral frontal cortex lesion:• difficulty with abstraction of thought• social withdrawal• isolation• dominant - SpeechOrbitofrontal or medial temporal limbic lobe lesion:• irritability• euphoria• poor concentration• angerPrefrontal cortex contains social rules.

Parietal lobes Questions:A) Dominant hemisphere:• apraxia (inability to perform a requested motor act despite no motor impairment, examples are

dressing, ideational, constructive apraxia)• neglect (dominant hemisphere)• agnosia (finger agnosia)B) Non-dominant hemisphere:• spatial orientation

Other lobes - temporal (memory) and occipital (visual field, spatial perception).Gerstmann’s syndrome = agraphia, acalculia, right-left disorientation and finger agnosia +/- alexia and

+/- aphasia = Dominant parietal lesion)

2. Cranial Nerves a. Olfactory (1)• Smell.• Hyposmia/anosmia - incomplete or complete.• Foster-Kennedy syndrome: anosmia

associated with ipsilateral optic atrophy and• contralateral papilloedema (large olfactory

meningioma).

b. Optic nerves (2)( right and left)• Visual acuity (bedside snellen chart, reading

newspaper).• Field of vision.• Colour vision.• Light reflex - direct and indirect light reflex.• Optic fundi.

c. 3rd, 4th and 6th nerves• Ptosis (complete = 3rd nerve palsy, partial = Horner’s or

sympathetic outflow pathology)• Squint• Fixation• Pursuit movements (all directions)• Convergence• Reflex eye movements: • Occulocephalic (Doll’s eye)• Calorie test• Pupils:

• Size• Shape• Symmetry reaction• Compare right and left

d. Trigeminal nerve (5)• Motor.• Sensory (also general sensory to anterior 2/3,

posterior 1/3 by IX).• Corneal reflex.• Jaw jerk.

e. Facial nerve (7)• Facial muscles:

• Forehead wrinkling• Eye closure• Blowing• Nasolabial fold• Angle of mouth

• Taste: anterior 2/3 of tongue, the posterior 1/3 by IX. Posterior oropharynx and larynx by CN X.

• Hyperacusis.• Sensory innervation to external auditory area.

f. Vestibulo-cochlear nerve (8)• Whispering• Watch clicking test• Tuning fork 256/512 Hz (128 Hz for vibration = touch gently

= low value, hearing = higher value: want to hear loud!!! = the way to remember)

• Rinne’s test; Rinnies positive (AC > BC ) indicates:– normal hearing or– sensorineural deafness

• BC > AC : Conductive deafness.• Weber’s test: Lateralise to conductive deafness side when

comparing normal and• conductive deafness side, and lateralize to normal side if

sensorineural deafness side is compared to normal ear.

g. 9th and 10th nerves• Uvula (up to normal side) - Inner Normal (IN –

Inner Normal).• Palatal movements.• Gag reflex.• Swallowing test.

h. Accessory nerve• Sternocleidomastoid muscles.• Shrugging of shoulder.

i. Hypoglossal nerve• Tongue wasting.• Fasciculation.• Protruding the tongue (go to weaker side) - outer

abnormal (OUT).• Rapid movements of tongue.

3. Motor system• Size (bulk): atrophy vs hypertrophy or normal

(compare right and left).• Tone: – spasticity (pyramidal signs: clasp-knife spasticity)– rigidity (extrapyramidal signs: lead pipe, cogwheel

rigidity – superimpose tremor)– hypotonia

Power (test individual muscle in case of localized wasting or weakness) • Neck-flexion (C1 - 4), extension.• Sternocleidomastoid - turning head: spinal accessory nerve and C3/4.• Trapezius - upper fibres: spinal accessory nerve and C3/4 (Shrug the shoulder).• Rhomboids - dorsal scapular nerve, C5. with hand on the hip, the patient tries to

force the elbow backward.• Serratus anterior - the patient pushes the outstretch arms onto the wall - long

thoracic nerve C5/6/7.• Pectoralis major: patient adducts his “anteriorly flexed” arm against resistance -

C5/6/7/8 - Medial and Lateral Pectoral nerves.• Shoulder - abduction (C5/6 = Deltoid; axillary or circumflex nerve. But please note

that the supraspinatus initiates the abduction - suprascapular nerve - C5; shoulder adduction(C6/7/8 = Teres major/latissimus dorsi, thoracodorsal nerve - C7).

• Teres major: adduct the fully horizontal arm (subscapular nerve C6).• Elbow - flexion (C5/6 = Biceps, musculocutaneous nerve), extension (C6/7/8 =

Triceps, radial nerve).• Wrist - flexion (C6/7 = FCR, median nerve), extension (C7/8 = Extensor carpi

Radialis Longgus, radial nerve)• Grip (small muscles of the hand = LOAF supplied by median nerve, others by

ulnar, extensor part - radial nerve; Test individual muscle in case of localized wasting/weakness). Dorsal interrosei - abducts, Palmar interrosei - adducts the fingers = ulnar nerve (T1) = the way to remember = when ask for money, on the palm side - fingers closed but when hand relaxes on the table (dorsal side) - the fingers tend to open-up or in abduction.

• Hip - flexion (L1/2 = Iliopsoas), extension (L5/S1 = Gluteal maximus), abduction (L4/5/S1 = Gluteal medius), adduction (L2/3/4 =Adductors by obturator nerve).

• Knee - flexion (L5/S1 = Hamstring muscles, sciatic nerve), extension (L3/4 = Quadriceps femoris, femoral nerve)

• Ankle - dorsiflexion (L4/5 = Tibialis anterior muscle, deep peroneal nerve), plantar flexion (S1/2 = Gastrocnemius, soleus, tibial nerve).

• Inversion of foot - (Tibial nerve, L4/5. Tibialis posterior muscle etc), Eversion of foot - (superficial peroneal nerve, L5/S1, Peroneal compartment, longus, brevis and tertius).

• Toes - flexion ( S1/2), extension (L5/S1) ; Big toe extension = L5/S1!!!

• Note : Sciatic nerve divided into common peroneal or fibular nerve and tibial nerve. The tibial nerve supplies the posterior compartment of leg. The common peroneal nerve divides into superficial peroneal (lateral/peroneal compartment) and deep peroneal nerve supplies the anterior compartment of leg.

Co-ordination: finger-nose or finger-finger test, heel-knee test.

Reflexes - right and left:A. Deep tendon jerk (monosynaptic: UMN lesions = hyper-reflexic)• Biceps jerk = C5/6• Supinator jerk = C5/6• Triceps jerk = C7/8• Knee jerk = L3/4• Ankle jerk.= S1/2• Small muscles of the hand jerk = C8/T1

Note : important to do jaw jerk, if all limbs hyper-reflexic, to rule out higher lesion, above the V nerve nuclei in brainstem. Absent reponse can be normal, what you looking for is hyper-reflexia in jaw jerk.

B. Superficial reflexes (polysynaptic = UMN lesions = absence of it)– Abdominal - upper (T6 - 9), midabdominal (T9 - 11

and lower half (T11 -L1)– Cremasteric (L1 - 2)– Superficial anal reflex (S3 - 5)– Bulbocavernosus reflex (S3 - 4)– Babinski reflex. UMN - up going big toe (Hoffman

reflex in hand: UMN - the little and thumb moves together when the extended middle finger was gently tap onto the nail).

C. Frontal lobe release phenomenon• sucking reflex• grasp reflex• snout reflex - tapping on upper or lower lip

with percussion hammer - pursuing response• glabellar reflex

(normally due to diffused frontal lesions bilaterally or bilateral corticobulbar lesions)

Reflex classifications:• 0 = absent• 1+ = hyporeflexic• 2+ = normal• 3+ = hyper-reflexic• 4+ = present of clonus (not sustainable)• 5+ = sustainable clonus

4. Sensory system• Superficial sensations – touch, pain, temperature.• Deep sensations - vibration, joint position.• Cortical sensations - tactile localization, tactile

discrimination, stereognosis = ability to recognize common objects placed in the hand, purely from the feel of size, shape and texture in the absence of impairment of primary sensations. (abnormality = astereognosis, in parietal cortical lesion), graphesthesia = ability to identify traced figures on the skin (agraphesthesia = parietal lobe dysfunction), two-point discrimination (on dorsum of hands or feet > 20 - 30 mm, able to discriminate two stimuli applied simultaneously (finger tip > 5mm).

Important landmark for sensory dermatomes

• C2/3 - neck• C4/5 - shoulder• C7 - middle finger• T4 - nipple (C4 meets with T2 dermatomes on chest)• T10 - umbilicus• T12/L1 - groin area• L2 - thigh• L3 - knee• L4 - medial side of shin• L5 - lateral side of shin and medial dorsum of foot• S1 - sole and lateral part of dorsum foot• S3/4/5 - medial gluteal and anal regions

5. Cerebellar signs

• Dysarthria• Titubation (head nodding)• Under and over shoot (dysmetria)• Nystagmus• Intention tremor• Dysdiadokokinesia• Rebound phenomenon• Pendular knee jerk• Ataxia

6. Romberg’s test

• Stands with eyes open and closed = Romberg’s test is negative or normal.

• Stands with eye open and falls with eye closed = Romberg’s test is positive = dorsal column disease or loss of joint position sense.

• Unable to stand with eyes open and feet together = severe unsteadiness due to cerebellar syndromes and both central and peripheral vestibular syndromes.

• Stands with eyes open, rocks backwards and forwards with eyes closed – suggest a cerebellar disease.

7. Involuntary movements (if see one, better video it)

• TRY TO DESCRIBE IT IN WORDSHyperkinesia Hypokinesia

- Chorea- Dystonia- Hemifacial spasm- Myoclonus- Tics- Tremor- Ballism(unilateral - hemiballimus)- Athetosis- Dysmetria- Moving toes/fingers- Restless legs- Myokymia- Blepharospasm

- Parkinsonism (akinesia/bradykinesia)- Psychomotor depression, Catatonia, Obsessional slowness- Freezing phenomenon- Hypothyroid slowness- Stiff muscles

8. Gait

• A) Spastic gait• Spastic hemiplegic gait• Spastic paraparetic or quadriparetic gait

• B) Ataxic gait• Cerebellar ataxic gait• Sensory ataxic gait

• C) Steppage gait in foot drop

• D) Apraxia of gait

• E) Parkinsonian gait

• Assess by normal walking and turning.• Walk on toes, walk on heel and walk on heel-toes.• Gait test is testing many components of neurology.

• 9. Skin Manifestation of CNS diseases

• 10. Meningeal signs • Neck stiffness (Brudzinski). Flex the head, not

rotating it.• Kernig’s sign (k = knee )

• 11. Skull and Spine• 12. Peripheral nerves

13. The autonomic nervous system• Pupils (Horner’s syndrome = partial ptosis,

miosis, hemihydrosis, enopthalmos and flushing).

• Resting pulse and BP test.• Skin.• Bladder and bowel functions.

• “DO NOT FORGET TO CHECK FOR OTHER SYSTEMS”

INTERACTION• LOCALISATION - BRAINSTEM : CROSSED SIGNS AND FACIAL AS A GUIDE [BULBAR (lmn) AND

PSEUDOBULBAR (umn)PALSY]- HEMIPARESIS: WITH/OUT FACIAL NERVE PALSY

CAN AND CAN NOT TALK AND IN COMA, LOWER LIMB HYPERREFLEXIC- PARAPARESIS- TETRAPARESIS- LOBAR FEATURES AND VISUAL PATHWAYS- SPINAL CORD LESION: BROWN-SEQUARD SYNDROME, POST COLUMN, CENTRAL

CORD SYNDROME ETC.- RADICULOPATHY- POLYRADICULOPATHY- PLEXOPATHY- NERVES- MUSCLES- FALSE LOCALISING SIGNS- RAISED ICP [SYMPTOMS AND SIGN - CUSHING REFLEX]- FUNDUS : OPTIC ATROPHY AND PAPILLOEDEMA