Neurological history and examination

Neurological history taking

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. 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 Mini Mental State Examination (MMSE) article.

Observation of the patient

Gait

• Look at the patient's gait as they enter the room.

• Note if there evidence of, for example, hemiparesis, footdrop, ataxic gait, a typical Parkinsonian gait.

• See the separate Abnormal Gait and Gait Abnormalities in Children articles.

Speech

• Note any problem with articulation (dysarthria). Comprehension is retained and speech construction is normal. Is there weakness or incoordination of the orolingual muscles? Ask the patient to say 'West Register Street' if you are uncertain.

• Note any problem with phonation (dysphonia). This is usually due to laryngeal problems which can cause voice hoarseness. There may be reduced speech volume .

• Note any problem with language function (dysphasia). This is due to a lesion in the language areas of the dominant hemisphere.

See the separate Dysarthria and Dysphasia article.

Involuntary movements

Establish whether there is evidence of involuntary movements - for example, tremor, tics, chorea, hemiballismus, or orofacial dyskinesias.

History

NICE quality standard on recognition and referral of suspected neurological conditions

The National Institute for Health and Care Excellence (NICE) has issued a quality standard, which includes the following statements:¹

• Under-12s with headache and red flag symptoms should be referred immediately for neurological assessment - please see our professional article Migraine in Children for more detail.

• Under-4s with suspected abnormal head size or shape should have their head circumference assessed using a standardised growth chart.

• Adults with suspected dystonia should be referred for neurological assessment.

• Adults with transient rotational vertigo on head movement should be assessed in primary care using the Dix-Hallpike manoeuvre - see our professional BPPV article for more information.

• Adults with a functional neurological disorder should be supported to manage symptoms that form part of the disorder in non-specialist care.

• NHS care for adults with suspected neurological conditions should be tailored to the patient's needs and preferences.

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? For example, worsening of symptoms with hot environments - eg, sauna, hot bath or hot weather in demyelinating disorders (called Uhthoff's sign).

  • Does anything trigger the symptoms - eg, exercise, sleep, posture or external stimuli such as light or smell?

• Ask about any associated symptoms (other features of neurological disease):
  

  • Headache.

  • Numbness, pins and needles, cold or warmth.

  • Weakness, unsteadiness, stiffness or clumsiness.

  • Nausea or vomiting.

  • Visual disturbance.

  • Altered consciousness.

  • Psychological changes - eg, 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 .

• 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 mellitus.

• 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 mellitus.

• Polyuria may suggest diabetes mellitus. 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 (such as cocaine usage that can be linked to cardiovascular problems). 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-type headache or migraine? The job may involve driving but the patient has admitted to convulsions. He/she 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 the likelihood of sexually transmitted infection - eg, syphilis, HIV.

Family history

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

• A cousin with Duchenne muscular dystrophy or Becker's muscular dystrophy would be very important for a boy who cannot run like his peers.

• Huntington's chorea is unusual in that it is a familial disease that does not present until well into adult life.

• A family history of, for example, type 2 diabetes mellitus, cerebral aneurysm, neuropathies, epilepsy, migraine or vascular disease may be important.

Examination

Examination of speech

• 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: neck flexion causes an electric shock-like feeling on the limbs. It is due to disease in cervical spinal cord sensory tracts (seen in, for example, multiple sclerosis, syringomyelia, tumours) .

  • Is there any neck stiffness? This 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:
  

  • 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.

See also the separate article on Examination of the Spine.

Cranial nerves

Examination of the cranial nerves takes practice. This should include testing of the olfactory, optic, oculomotor, trochlear, abducent, trigeminal, facial, vestibulocochlear, glossopharyngeal, vagus, accessory and hypoglossal nerves.

Examination of the sensory system

See the separate Neurological Examination of the Upper Limbs and Neurological Examination of the Lower Limbs articles. Both the upper and lower limbs should be examined. Work in a methodical way. A logical progression is required when examining each sensory modality. The following sensory modalities should be tested:

• Light touch and pinprick (sharp touch).

• Temperature.

• Proprioception (joint position sense).

• Vibration sense.

• Two-point discrimination.

Examination of the motor system

See the separate Neurological Examination of the Upper Limbs and Neurological Examination of the Lower Limbs articles. Both upper and lower limbs should be examined. Examination should include;

• Inspection.

• Tone.

• Power.

• Deep tendon reflexes.

• Superficial tendon reflexes.

• Co-ordination.