HISTORY TAKING AND PHYSICAL EXAMINATION

IN
DIAGNOSING OF
NEUROLOGIC DISORDERS

By Dr. THAMRIN SYAMSUDIN, SpS(K)

THREE IMPORTANT STEPS IN THE DIAGNOSIS OF

NEUROLOGIC DISEASE
1. HISTORY TAKING / ANAMNESIS
2. PHYSICAL EXAMINATION
3. SUPPORTING MEASURES (LABORATORY, RADIOLOGY, ETC)
BEAR IN YOUR MIND !!!
CENTRAL NERVOUS SYSTEM IS LOCATED
WITHIN THE (SKULL/VERTEBRAE) BONES
IT CAN NOT BE :

INSPECTED

PALPATED

AUSCULTATED
NEED A CORRECT AND THOROUGH TECHNIQUE

 STIMULUS RESPONSE
TECHNIQUE
(FROM SIMPLE TO
COMPLEX METHODS)

HIERARCHY IN NEUROLOGIC EXAMINATION

(GENERALLY WRITTEN IN RESUME)
1. ANAMNESIS :

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

2. PHYSICAL EXAMINATION

GENERAL STATUS

INTERNAL STATUS (REVIEW OF THE

SYSTEMS)

NEUROLOGICAL STATUS
i. MENINGEAL IRITATION
ii. CRANIAL NERVES
iii. MOTOR SYSTEM
iv. SENSORY SYSTEM
v. REFLEXES
vi. COORDINATION (AND GAIT)

ANAMNESIS
TAKING OF HISTORY FROM
THE PATIENTS OWN SELF (ALLO-ANAMNESIS) OR
FROM THE RELATIVES/FAMILIES (HETEROANAMNESIS)
THAT AIM TO GET AND COLLECT DATA
ABOUT PATIENTS SYMPTOMS AND/OR SIGNS

THE COURSE OF ILLNESS IN ANAMNESIS

o STATISTICAL DATA : AGE, SEX, MARITAL STATUS,
RESIDENCE, HANDEDNESS, ETC
o CHIEF COMPLAINT AND HISTORY OF PRESENT
ILLNESS
o PAST MEDICAL HISTORY
o FAMILY HISTORY (INCL. SEXUAL HISTORY)
o SOCIAL HISTORY (PATIENTS HABITS THE USE OF
ALCOHOL, TOBACCO, AND RECREATIONAL DRUGS)
o OCCUPATIONAL HISTORY

1. CHIEF COMPLAINT :
SYMPTOM THAT FORCED THE PATIENT TO SEEK
MEDICAL FACILITIES (HOSPITAL, CLINIC, OUT-PATIENT
CARE, PRIVATE PRACTICE, ETC)
SOME TYPICAL CHIEF COMPLAINTS :
RIGHT/LEFT LIMBS WEAKNESS
(HEMIPARESIS) IN STROKE
CONVULSION IN EPILEPSY
UPPER/LOWER LIMBS WEAKNESS
(PAREPARESIS) IN MYELOPATHY

2. HISTORY OF PRESENT ILLNESS

ANALYSIS OF CC CONSIST OF :
ONSET OF TIME
SEVERITY AND THE COURSE/NATURE
LOCALIZATION AND DISTRIBUTION
RELATION TO TIME
CONCOMITTANT SYMPTOMS
CONDITIOS THAT WORSEN SYMPTOMS
CURRENT MEDICATION (INCL. DOSES)
DEVELOPMENT :
a. RELAPSING/RECCURENCE
b. CHRONIC DISEASE
OTHER CONCURRENT DISEASE 0

3. PAST MEDICAL HISTORY

PAST EVENTS THAT RELATE TO PRESENT ILLNESS
HISTORY OF PREVIOUS ILLNESS, OPERATION,
ALLERGIES)

EXAMPLE :

RISK FAKTORS OF STROKE

CNS INFLAMMATION OR LABOUR TRAUMA IN

EPILEPSY
TRUMA OF SPINE IN MYELOPATHY

PHYSICAL EXAMINATION
CONSIST OF :
1. GENERAL STATUS
2. INTERNAL STATUS
3. NEUROLOGICAL STATUS

GENERAL STATUS
DETERMINE

STATE OF CONSCIOUSNESS
BLOOD PRESSURE
PULSE / HEART RATE
RESPIRATORY RATE
TEMPERATURE

INTERNAL STATUS
LOOK FOR THE OTHER CONDITIONS
/ILLNESSES THAT RELATE TO THIS
NEUROLOGIC PROBLEM

NEUROLOGICAL STATUS
EXAMINATION OF

MENINGEAL IRITATION

NUCHAL RIGIDITY

BRUDZINSKI SIGNS

LASEAGUE SIGN

KERNIG SIGN

CRANIAL NERVES
CN I (OLFACTORY) - SENSE OF SMELL
CN II (OPTIC) VISUAL ACUITY, VISUAL FIELDS,
FUNDUSCOPY

CN III (OCCULOMOTOR), IV (TROCHLEAR),

AND VI (ABDUSCENS)
EXTRAOCCULAR MOVEMENT
OTHER FUNCTION OF CN III :
LID RETRACTION, REACTION TO LIGHT,
ACCOMODATION,
PUPIL (SIZE, REGULARITY, EQUALITY)

CN V (TRIGEMINAL)

SENSATION OF FACE, OPEN/CLOSE JAW,

MASTICATION, CORNEAL REFLEX)

CN VII (FACIAL)
FACIAL MOVEMENT AND
EXPRESSION,
TASTE OF ANTERIOR
TWO THIRD OF
TONGUE,
BLINKING REFLEX

CN VIII (VESTIBULO-COCHLEAR)
BALANCING
SENSE OF HEARING

CN IX (GLOSSOPHARYNGEAL) AND CN X
(VAGUS)
ELEVATION OF PALATE/UVULA, GAG REFLEX

CN XI (SPINAL
ACCESSORY)
HEAD MOVEMENT,
SHOULDER
SHRUG/ELEVATION

CN XII TONGUE
MOVEMENT

MOTOR SYSTEM
MUSCLE BULK
MUSCLE TONUS
MUSCLE POWER/STRENGTH
FASCICULATION

SENSORY SYSTEM
SUPERFICIAL SENSORY MODALITIES : PAIN
PERCEPTION, TEMPERATURE DISCRIMINATION, LIGHT
TOUCH
DEEP SENSORY MODALITIES : VIBRATION SENSE,
POSITION SENSE
CORTICAL FUNCTION : TWO-POINT DISCRIMINATION
(EXTINCTION), STEREOGNOSIS

REFLEXES
PHYSIOLOGIC REFLEX [MUSCLE STRETCH (DEEP)
REFLEX] : BICEPS, TRICEPS, BRACHIORADIAL, KNEE
JERK (KPR), ANKLE JERK (APR)
SUPERFICIAL REFLEX : ABDOMINAL SKIN REFLEX,
CRESMATERIC, ANAL, BULBOCAVERNOUS
PATOLOGIC REFLEX : BABINSKI, CHADDOCK,
HOFFMANN TROMMER, REGRESSION

COORDINATION
FINGER TO NOSE TEST
PRONATION-SUPINATION
(RAPID ALTERNATING MOVEMENT)
HEEL TO KNEE TEST
TANDEM, AND
HEEL TO TOE

MENTATION (HIGHER CORTICAL FUNCTION)

EMOTIONAL STATE
SENSORIUM AND INTELECTUAL RESOURCES
(ORIENTATION, COMPREHENSION, INSIGHT, MEMORY,
LANGUAGE, ETC.)
CONTENT OF THOUGHT
STREAM OF MENTAL ACTIVITY

SUPPORTIVE MEASURES
LABORATORY : BLOOD AND URINE TEST
COMPLETE BLOOD COUNT
LIPID PROFILE
RENALFUNCTION TES
LIVER FUNCTION TEST, ETC
CSF EXAM (LUMBAL PUNCTURE)
NEURORADIOLOGY
INVASIVE : ANGIOGRAPHY, MYELOGRAPHY,
PNEUMO-ENCEPAHALOGRAPHY
NON-INVASIVE : SKULL/VERTEBRAE X-RAY,
CT-SCAN, MRI, PET, SPECT
NEUROPHYSIOLOGY
EEG, EVOKED POTENTIAL STUDY, EMG,
NERVE CONDUCTION STUDY

NEUROLOGY : INTRODUCTION
TERM :
NEURO : NEURAL TISSUE
LOGOS : STUDY
THE STUDY OF NEURAL TISSUE BOTH
IN HEALTHY OR PATOLOGIC STATE.

NERVOUS SYSTEM
CONSIST OF :
CENTRAL NS
TWO HEMIPHERES
BRAIN STEM : MIDBRAIN, PONS, CEREBELLUM, MED.
OBLONGATA
SPINAL CORD
PERIPHERAL NS
CRANIAL NERVES
NERVE ROOTS
PERIPHERAL NERVES
AUTONOMIC NS
SYMPATHETIC
PARASYMPATHETIC

ETIOLOGY IN NEUROLOGIC DISORDERS :

TRAUMA : HEAD / SPINE TRAUMA
VASCULAR : STROKE
INFECTION : ENCEPHALITIS, MENINGITIS
TUMOUR
DEGENRATIVE PROCESS : PARKINSON,
DEMENTIA
IDIOPATHIC : EPILEPSY

CENTRAL NERVOUS SYSTEM

BRAIN HEMISPHERES COVERED BY
CEREBRAL CORTEX
HIGHER CORTICAL FUNCTION
PERCEPTION
COGNITION
MOTOR

DIENCEPHALON
THALAMUS
HYPOTHALAMUS
SUBTHALAMUS
EPITHALAMUS

TRANSMISSION
INFORMATION
SENSATION
MOTOR
HOMEOSTASIS

NERVOUS SYSTEM : FUNCTION

REGULATE VOLUNTARY OR INVOLUNTARILY
HUMANS BEHAVIOUR TO MAINTAIN LIFE
SENSATION : RECEIVE SENSATION FROM
ENVIRONMENT (SENSES)
VISION
HEARING
TASTE
SMELL
SOMESTETIC
BALANCE

MOVEMENT :
OLUNTAIR
V
INVOLUNTAIR

INTERNAL REGULATION
NEURALINPUTAUTONOM
ENDOCRINEHORMONE

REPRODUCTION
HORMONALFUNCTION
SPERMPRODUCTION(TESTIS)
OVUMPRODUCTION(OVARY)

ADAPTATION
SURVIVALADAPTTOLEARNINGCONDITION
TOSOLVEPROBLEMBASEDON
PREVIOUSEXPERIENCES

NERVOUS SYSTEM
RECEIVE SENSATION
RESPONSE TO EXTERNAL STIMULI
COORDINATE OTHE ORGANS TO MAINTAIN LIFE
STORE, ORGANIZE, RETRIEVE PRVIOUS EXPERIENCE
BASAL GANGLIA : TONE, MOVEMENT
CEREBELLUM : COORDINATION, TONE, MOVEMENT
BRAIN STEM : CRANIAL NERVE NUCLEI,
RECEIVE SENSORY INPUT FROM SKIN AND MUSCLES
IN HEAD AND NECK

 SPINAL CORD :
RECEIVE INPUT
FROM UPPER NEURON, EFECTOR
o
o
o
o

CERVICAL
7 SEGMENTS
THORACAL
12 SEGMENTS
LUMBAL 5 SEGMENTS
SACRAL 5 SEGMENTS

SUBSPECIALTIES IN NEUROLOGY
NEUROPEDIATRIC OR
DEVELOPMENTAL NEUROLOGY
NEURO-RADIOLOGY
NEURO-PHYSIOLOGY
NEURO-PSYCHOLOGY
NEURO-ANATOMY
NEURO-REHABILITATION
CEREBRO-VASCULAR DISEASE (CVD)
CNS INFECTION
EPILEPSY
PERIPHERAL NERVE
NEURO-OPHTHALMOLOGY