Neurological History and Examination

• Taking a detailed history and performing a careful examination can help the doctor to determine the site of a specific neurological lesion and reach a diagnosis, or at least differential diagnoses.¹
• A systematic approach is required.
• This is a general article, attempting to cover all aspects of neurological history and examination. You are referred to other related articles where relevant for more detail.
• Mental state examination may also be an important consideration and this is covered in the separate article Mini Mental State Examination (MMSE).

• Gait:
  • Look at the patient's gait as they walk in to the room.
  • Is there evidence of e.g. hemiparesis, footdrop, ataxic gait, a typical Parkinsonian gait.
  • Separate articles discuss Abnormal Gait and Gait Disturbance in Children in more detail.
• Speech:
  • Is there a problem with articulation (dysarthria)? Here comprehension is retained and speech construction is normal. There is usually weakness or incoordination of the orolingual muscles. Ask the patient to say 'West Register Street' if you are uncertain.¹
  • Is there a problem with phonation (dysphonia)? This is usually due to laryngeal problems which can cause voice hoarseness. There may be reduced speech volume.¹
  • Is there a problem with language function (dysphasia)? This is due to a lesion in the language areas of the dominant hemisphere.
  • A separate article discusses Dysarthria and Dysphasia in more detail.
• Involuntary movements:
  • Is there evidence of, e.g. tremor, tics, chorea, hemiballismus, orofacial dyskinesias?

Specific emphasis should be placed on the following:

Presenting complaint

• Ask about the symptoms:
  • What are they?
  • Which part of the body do they affect? Are they localised or more widespread?
  • When did they start?
  • How long do they last for?
  • Were they sudden, rapid or gradual in onset? Is there a history of trauma?
  • Are the symptoms static or deteriorating, or are there exacerbations and remissions?
  • Does anything trigger the symptoms, e.g. exercise, sleep, posture or external stimuli such as light or smell?
• Ask about any associated symptoms (other features of neurological disease):¹
  • Headache
  • Numbness, pins and needles, cold or warmth
  • Weakness, unsteadiness, stiffness or clumsiness
  • Nausea or vomiting
  • Visual disturbance
  • Altered consciousness
  • Psychological changes, e.g. agitation, tearfulness, depression or elation, sleep disturbance
  • For children ask about performance at school
• Try to understand how the symptoms may affect the patient's life, ask about activities of daily living.

Past medical history

Some neurological problems can present years after a causative event.¹

• Enquire about other medical problems, past and present. These may give clues to the diagnosis. For example:
  • A person in atrial fibrillation may be producing multiple tiny emboli.
  • There may be vascular problems or recurrent miscarriage to suggest antiphospholipid syndrome.
  • There may be diabetes.
• Ask about pregnancy, delivery and neonatal health.
• Ask about any infections, convulsions or injuries in infancy, childhood or adult life. Particularly ask about head or spinal injury, meningitis or encephalitis.

Systematic enquiry

The systematic enquiry is very important here. For example:

• Loss of weight and appetite may suggest malignancy and this may be a paraneoplastic syndrome.
• Gain in weight may have precipitated diabetes.
• Polyuria may suggest diabetes. Difficulty with micturition or constipation may be part of the neurological problem but was not volunteered in the general history. In men, enquire about erectile dysfunction.

Social history

• Note smoking and drinking habits. Alcohol is a significant neurotoxin, both centrally and peripherally.
• Ask about drugs including prescribed, over-the-counter and illicit. This includes complementary and alternative medicines.
• Ask about occupation and what it involves. There may be exposure to toxins. Is repetitive strain injury likely? Is there prolonged visual work which may predispose to tension headache or migraine?¹ The job may involve driving but the patient has admitted to convulsions. He may work at heights or in a dangerous environment.
• Ask about marital status. Has there been recent bereavement or divorce which may have affected symptoms?
• Ask about sexual orientation and consider likelihood of sexually transmitted infection, e.g. syphilis, HIV

Family history

Consider if there may be a genetic basis or predisposition.¹ For example:

• A cousin with Duchenne muscular dystrophy or Becker muscular dystrophy would be very important for a boy who cannot run like his peers.
• Huntingdon's chorea is unusual in that it is a familial disease that does not present until well into adult life.
• A family history of, e.g. type 2 diabetes, cerebral aneurysm, neuropathies, epilepsy, migraine or vascular disease may be important.¹

Examination of speech¹

• Look for spontaneous speech, fluency and use of appropriate words during conversation.
• Ask the patient to name objects.
• Ask the patient to carry out some commands to assess their comprehension.
• Ask the patient to read aloud. This can show evidence of any dyslexia.
• Ask the patient to repeat a simple sentence. Inability to do this suggests a conduction dysphasia.
• Look at the patient's handwriting. There may be problems with form, grammar or syntax which may suggest a more global language problem and not just a speech disorder.

Examination of the neck

• Examine the neck movements:
  • Is there evidence of degenerative disease which may be producing radicular symptoms in the upper limbs? Examine flexion, extension and rotation.
  • Look for Lhermitte's sign. This is when neck flexion causes an electric shock-like feeling on the limbs. It is due to disease in cervical spinal cord sensory tracts (seen in, e.g. multiple sclerosis, syringomyelia, tumours).¹
  • Is there any neck stiffness (can be a sign of meningeal irritation)? The chin can normally touch the chest when the neck is flexed but this is not possible if neck stiffness is present. This may be a sign of meningitis or subarachnoid haemorrhage.
• Palpate the supraclavicular fossae:
  • Look for enlarged lymph nodes or cervical ribs.
• Listen for any bruits:¹
  • Listen at the carotid bifurcation at the angle of the jaw for carotid bruits.
  • Listen over the supraclavicular fossa for vertebral or subclavian bruits.
  • A common carotid bruit may be heard by listening between these two sites.
  • Listen with the bell of the stethoscope over a closed eyelid for bruits due to cerebral arteriovenous malformations.
  • Listen for cardiac murmurs to ensure that any bruit heard is not just due to transmission of these.
  • Note that just because a bruit is not heard, it does not mean that there is no significant stenosis present.

Cranial nerves

• Examination of the cranial nerves takes practice. The cranial nerves and their function is summarised below.²
  • I (olfactory nerve): smell
  • II (optic nerve): visual acuity, visual fields and ocular fundi
  • II, III (optic nerve and oculomotor nerve): pupillary reactions
  • III, IV, VI (oculomotor, trochlear and abducent nerves): extra-ocular movements, including opening of the eyes
  • V (trigeminal nerve): facial sensation, movements of the jaw, and corneal reflexes
  • VII (facial nerve): facial movements and gustation
  • VIII (vestibulocochlear nerve): hearing and balance
  • IX, X (glossopharyngeal and vagus nerves): swallowing, elevation of the palate, gag reflex and gustation
  • V, VII, X, XII (trigeminal, facial, vagus and hypoglossal nerves): voice and speech
  • XI (accessory nerve): shrugging the shoulders and turning the head
  • XII (hypoglossal nerve): movement and protrusion of tongue
• A separate article describes Examination of the Cranial Nerves in detail.

Examination of the sensory system

There are separate articles that describe sensory examination in detail:

• Neurological Examination of the Upper Limb
• Neurological Examination of the Lower Limb

Both the upper and lower limbs should be examined. Work in a methodical way. A logical progression is required when examining each sensory modality.

• With the lower limbs, you may want to start testing over the groin and to move down the front of the leg and up the posterior side as this moves progressively from L1 to S3 dermatomes.
• With the upper limbs, you may want to start testing over the shoulder and to move along the lateral aspect of the arm and up the medial side as this moves progressively from C4 to T3 dermatomes.
• The dermatomal (segmental) and peripheral nerve innervation is labelled in the diagrams below.

• Light touch and pin prick (sharp touch)
  • Both light touch and pin prick are conducted along the same pathways.
  • Light touch can be tested by using a light touch of the finger, a piece of cotton wool or a small brush. It is important to touch and not to stroke as moving sensations, such as rubbing and scratching are conducted along pain pathways.
  • Test sharp touch using a dedicated disposable pin. Test light touch using the light touch of a finger, a piece of cotton wool or a piece of tissue paper.
• Temperature
  • One approach is to touch the patient with a tuning fork as the metal feels cold.
  • Containers of warm and cool water may be used for more accurate assessment. Ask the patient to distinguish between warm and cool on different areas of the skin with their eyes closed.¹
• Proprioception (joint position sense)
  • This can be tested at the distal interphalangeal joint of the index finger and at the interphalangeal joint of the big toe.
  • The examination technique is described in the articles on neurological examination of the upper and lower limbs.
• Vibration sense
  • This can be examined using vibrating 128 Hz tuning fork.
  • Please refer to the above mentioned articles for examination technique.
• Two-point discrimination
  • This is usually just performed on the pulp of the fingers using a two-point discriminator.
  • The technique is described in the article neurological examination of the upper limbs (link below).

Examination of the motor system

There are separate articles that describe motor examination in detail:

• Neurological Examination of the Upper Limb (click here)
• Neurological Examination of the Lower Limb (click here)

Both upper and lower limbs should be examined. The following gives a brief outline of the examination.

• Inspection
  • Start by looking at the patient.
  • Note the resting posture. Is there unusual rotation or posture of a joint? Is the patient symmetrical?
  • Look for muscle wasting or hypertrophy. Is it focal or diffuse? An upper motor neurone (UMN) lesion will produce disuse atrophy but a lower motor neurone (LMN) lesion or myopathy will produce much more marked wasting.
  • Look for muscle fasciculation (sign of lower motor neurone disease process). These are subcutaneous twitches over a muscle belly at rest. Tapping the belly may stimulate fasciculation.¹
• Tone
  • Hypertonia is found in upper motor neurone lesions; hypotonia is found in lower motor neurone lesions and cerebellar disorders.¹
  • In the upper limbs:
    • Ask the patient to let their shoulders and arms 'go floppy'.
    • Flex and extend their shoulder passively and feel for abnormality of tone.
    • Repeat for the elbow and wrist.
  • In the lower limbs:
    • Ask the patient to let their legs 'go floppy'.
    • Internally and externally rotate the 'floppy' leg. Assess for any increased or reduced tone.
    • Then lift the knee off the bed with one of your hands. Does the ankle raise off the bed as well signifying increased tone?
    • Ankle clonus can also be tested and is discussed in the article on Neurological Examination in the Lower Limbs.
• Power
  • As with sensation, test each group of muscles in a systematic order.
  • The Medical Research Council (MRC) has a recommended grading system for power (see table).
  • Examination of power in both the upper and lower lower limbs is described in the articles on neurological examination of the upper and lower limbs and so will not be repeated here.

• Deep tendon reflexes
  • Eliciting deep tendon reflexes requires good technique and an appropriate tendon hammer is required.
  • How to elicit the various tendon reflexes is described in the articles on neurological examination of the upper and lower limbs.
  • Tendon reflexes tend to be brisk when there is an UMN lesion and depressed in a LMN lesion. Isolated loss of a reflex can point to a radiculopathy affecting that segment.
  • Reflexes can either hyperactive (+++), normal (++), sluggish (+) or absent (-). ± is used when the reflex is only present on reinforcement.¹
• Superficial tendon reflexes
  • In the lower limbs, this is the plantar response.
  • To elicit this, the patient should be lying down with their legs extended.
  • Use a blunted point and run this along the lateral border of the foot, starting at the heel and moving towards the big toe.
  • Stop on the first movement of the big toe.
  • An extensor plantar response (upgoing big toe) is pathological and signifies an upper motor neurone lesion.
• Coordination
  • The cerebellum helps in the coordination of voluntary, automatic and reflex movement.¹
  • Tests of cerebellar function in the upper limbs are described in the article neurological examination of the upper limbs (link above) and include:
    • The finger-nose test
    • Rapid alternating movement
  • Tests of cerebellar function in the lower limbs are described in the article neurological examination of the lower limbs and include:
    • The heel-shin test
    • The heel-toe test
  • Romberg's test examines lower limb cerebellar function but also tests balance mechanisms that rely on the cerebellar, vestibular and proprioceptive systems.
    • Ask the patient to keep their eyes open and stand with their feet together, arms by their sides.
    • Then ask them to maintain this position when they close their eyes.
    • Patients who have cerebellar lesions often cannot stand in this position even with their eyes open. If balance is only lost when the eyes are closed, this signifies a proprioceptive or vestibular lesion.¹
    • Be ready to catch the patient by standing behind.