CLINICAL LOCALIZATION AND HISTORY IN NEUROLOGY

ZAMZURI IDRIS NEUROSAINS

HISTORY
1. 2. 3. 4. 5. 6. 7. 8. 9. History of presenting complaint shoud cover the followings: nature of complaint the onset, how did it begin, sudden or gradual in onset the duration; acute, subacute and chronic the time course; stepwise fashion, progressed then stabilized other positive neurological symptoms precipitating and relieving factors extent of any deficit such as inability to put the slippers on, unable to walk, cook, comb hairs affects on function or daily activities previous treatment and investigations

HISTORY 2
On 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 status III. risk factors IV. neuroendocrine questions V. 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.

LANGUAGE
Type Spontaneous speech Naming Repetition Comprehension Usual localization

Broca
Wernicke

Non fluent
Fluent (The only)

Poor
Poor

Usually poor
Poor

Good (The only)

Poor

Brocas area
Wernickes area (posterior aspect of superior temporal gyrus)

Conduction

Fluent The only Conduction 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 gyrus Long 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 - Speech Orbitofrontal or medial temporal limbic lobe lesion: irritability euphoria poor concentration anger Prefrontal 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). Gerstmanns 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 = Horners or sympathetic outflow pathology) Squint Fixation Pursuit movements (all directions) Convergence Reflex eye movements: Occulocephalic (Dolls 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) Rinnes test; Rinnies positive (AC > BC ) indicates:
normal hearing or sensorineural deafness

BC > AC : Conductive deafness. Webers 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), twopoint 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. Rombergs test
Stands with eyes open and closed = Rombergs test is negative or normal. Stands with eye open and falls with eye closed = Rombergs 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 WORDS
Hyperkinesia - Chorea - Dystonia - Hemifacial spasm - Myoclonus - Tics - Tremor - Ballism(unilateral - hemiballimus) - Athetosis - Dysmetria - Moving toes/fingers - Restless legs - Myokymia - Blepharospasm Hypokinesia - 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. Kernigs sign (k = knee )
11. Skull and Spine 12. Peripheral nerves

13. The autonomic nervous system Pupils (Horners 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
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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