'5 minute' Neurology
History is THE most important element of Neurological Diagnosis and review especially as the examination may often be unremarkable or non-localising.
Typical questions:
Mental Status
Changes in memory or mood
ability to care for oneself, ability to manage money
difficulty with language
geographical orientation, etc.
Skull, Spine, & Meninges
Cranial Nerves
Abnormalities in vision, hearing, smell, taste, speech or swallowing
Facial weakness or numbness
Motor Function
History of muscular weakness
tremor or difficulty in initiating movements
loss of muscle bulk, especially localised
Sensory Function
Coordination
Gait & Station
General Symptoms
PHx, Medication, Social
The most important part of the Neurological exam is observation. More than half of the exam is performed by simple observation - how he/she speaks, thinks, walks, moves and simply interacts with you as examiner. Simple but careful observation will begin to localise a lesion. Formalised testing merely refines the diagnosis, and may only need a few extra steps.
Mental Status
Cognition - essentially tested during history taking.
Language - tested during history taking, except for naming.
Cranial Nerves
Visual fields by confrontation – vision is processed by 1/3 of the cerebral hemispheres.
Check pupils and eye movements – don’t forget testing saccades as well as pursuits
Facial strength - best tested by observing the patient for asymmetries during natural speech. Observe for symmetry of eye blinks.
Lower cranial nerves (IX-XII) - only need to be tested if dysphagia and dysarthria are present.
Motor Examination
Adventitial movements – tics, tremor and bradykinesia are best observed during history taking
Pronator drift – implies upper motor neuron dysfunction
External rotation of leg – implies upper motor neuron dysfunction
Muscle tone – important for diagnosing subtle upper motor neuron lesions and Parkinson’s disease
Functional strength testing – more important than formal push-pull testing, more reliable, and quicker!
Sensory examination
Focus sensory testing to the patient’s symptoms
Sensory testing is purely subjective, so don’t over-interpret
Check for sensory level on the back if a spinal cord lesion is suspected
Touching nose with eyes closed – an excellent test of proprioception
Romberg test - tests proprioception (peripheral nerves and dorsal columns), and is not a test of cerebellar function!
Coordination
Many things cause ataxia – cerebellar lesions, sensory disorders and upper motor neuron lesions
Don’t forget truncal stability – truncal ataxia implies a lesion of the cerebellar vermis
Reflexes
The only purely objective part of the neurological exam
Look for asymmetries and sustained clonus
Don’t over-interpret the Babinski sign. Easy to elicit +ve and -ve!
Gait
Author: Dr Dylan Jenkins, Oct 2023
from: Ralph F. Józefowicz MD, Uni of Rochester