Clinical Skills - Neurology

How to diagnose

How to follow-up

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 “In life, the tracts are not marked in red”

Practical neurology is not about learning neuroanatomy or

obscure neurological syndromes.

Neurology is about listening, making an accurate

diagnosis, and then applying a practical approach to the
presenting problems.

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 Taking a History

Commonest conditions seen in neurology:

Headache
Blackouts
Cerebrovascular disease
Multiple sclerosis
Parkinsonism
Giddiness
Symptoms with no disease

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 Why History?

In new onset neurological disease the history gives 80-90%

of diagnoses.

The examination adds 10-20% and increases the confidence

in the diagnosis.

Tests (eg MRI, CT, PET, SPECT, EEG) add the rest.

i.e. if you don’t know the diagnosis after the history-start again!
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 General Principles
- Pearls of Wisdom

John Patten “The secret is to be a good listener”

“Make every effort made to put the patient at ease”

“Every symptom must be analysed in detail”

Brian Matthews “ There can be few physicians so dedicated to

their art that they do not experience a slight
decline in spirits on learning that their patient’s
complaint is of giddiness” 5
 The Aim:
“To arrive at the correct diagnosis in the least number of moves”

The Method:
Where is the lesion?

What is the lesion?

What is the effect of the lesion?

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 The Basics
1. Introduction

2. Age, occupation and handedness

3. Presenting symptoms:
Time course
Negative or positive symptoms
Anatomical localisation
Previous neurological history
Family history
Coexisting medical disorders

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 Time Course

Eg. Stroke –what was patient doing when it happened?

Eg. Sub-arachnoid haemorrhage –how long till pain is at its most

intense

Eg. Demyelination –When was the first neurological or

ophthalmological symptom?

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Negative/Positive symptoms

Eg: Epilepsy vs Stroke

Eg: Hallucination vs Failure to recognise

Eg: Visual scintillation vs Hemianopia

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 Anatomical Localisation

Eg Visual field:

Is field loss in one eye or both eyes?

Eg Arm and leg symptoms:

Are symptoms in arm and leg on one side, opposite sides or both sides?

Most of the time you only need to know a few things

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 Corticospinal tract
• Originates in primary motor cortex
• Internal capsule
• Pons
• Pyramids
• Crosses in the pyramidal decussation

• In brain on opposite side in cord on the

same side
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One complication From
Right Cortex

Midbrain
To the
R face

Pons
A crossed motor deficit
(eg R face, L arm/leg)
Facial
localises to the pons Medulla
nuclei

Decussation
SC

To left limbs 12
 The Visual Fields

“Homonymous” “Monocular”
field defect = defect =
lesion behind the lesion in front
optic chiasm of chiasm

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Dorsal-columns

• Vibratory and joint position

sense.

• Sensory neurones run on the

same side of spinal cord

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Spino-thalamic pathway

• Conveys pain and temperature

• Sensory neurones cross to the

opposite side of spinal cord

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Somatosensory Cortex
• Somatosensory neurones from
one side of the body project to
the opposite side of the cortex.
• Cortical sensation is complex

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 Previous Neurological History

Eg: Epilepsy/Febrile seizures as child

Eg: Unable to join army because of myotonia

Eg: Episode of visual disturbance ? cause

Nb Patients may not know the relationship (if any) between previous
symptoms or illness and current complaint

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Family History:

Dementia age 60

Dementia age 50 Aunt Jerky 70

LH 44
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Co-existing Medical Disorders

Eg: Hypertension
Diabetes

N.B. Patients don’t know the relevance of these questions

and it is sometimes worth explaining
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Drugs….and Effects

Eg Statins
Rarely cause myositis

Eg Codeine
Commonly causes headache

Eg Cigarettes and Beer

Cause all sorts of problems

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 What About Chronic
Disease?

Eg Epilepsy, PD, Multiple sclerosis (MS)

What can you do to help this individual at this point?

Ask about: New symptoms…and their effect

Drugs….and their effect
Life stage and impact of illness

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New symptoms from existing
condition

Eg Continence in MS

Why? Incontinence is distressing and easily treatable

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 Drugs….and Effects

Eg Parkinsons treatment
10% of patients each year after diagnosis develop PD complications

Eg Statins

Rarely cause myositis

Eg Cigarettes and Beer

Cause all sorts of problems

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Life Stage/Style and Impact

Different diseases have different impacts at different life stages.

Eg: Epilepsy and pregnancy.

Aim is to inform, establish patient on minimum

number and amount of least teratogenic medication.

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How to do a CNS
examination

(there is no “perfect” way)

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 Cognitive Function

A. Mini Mental State Examination

B. Addenbrookes- 100 point score-

C. Your own combination, to test: Level of arousal

Frontal lobes
Parietal lobes
Temporal lobes
Occipital lobes

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 Cranial Nerves

1. Olfactory: Test airway (eg perfume, lavender), then test each side

2. Optic: A) Acuity
B) Fields
C) Pupil response
D) Fundoscopy

3, 4 and 6. Oculomotor (Medial superior and inferior recti,

inferior oblique)
Trochlear (Superior oblique)
Abducens (Lateral rectus)

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 Eye Movements

SR IO IO SR

LR MR LR

IR SO SO IR

Test saccadic (frontal) and pursuit (occipital) movements

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5. Trigeminal Facial sensation and Corneal reflex
Muscles of mastication

7. Facial Facial muscles

8. Vestibulo-Cochlear

Gait, Nystagmus, Hearing (Rinne’s and Weber’s)

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9. Glosso-pharyngeal: Almost purely sensory.

10. Vagus: Palate movement, Voice, Cough, Swallow

11. Accessory: Sternomastoid, Trapezius

12. Hypoglossal: Tongue movements.

Deviation to side of lesion

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 The PNS (Motor)

Motor: Look (wasting/fasciculation)

Tone
Power
Reflexes
Coordination/Rapid Repetitive Movements

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 The PNS (Sensory)

1. Pinprick/Temp
2. Light touch
3. JPS
4. VBS

Plus: Graphaesthesia/Sterognosis/2 point discrimination

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The PNS (Cerebellum)

Balance

Coordination (Finger to Nose, Heel to

Shin) and Dysdiadochokinesis

Speech

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 Todays Task (s)

1. Take a history from a patient. It can be either the

acute presentation or the continuing problems.

2. Work out - where is the lesion, what is the lesion,

how does it affect the patient.

3. Present this.

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