CLINICAL LOCALIZATION AND

HISTORY IN NEUROLOGY
ZAMZURI IDRIS
NEUROSAINS
 HISTORY
• History of presenting complaint shoud cover the followings:
1. nature of complaint
2. the onset, how did it begin, sudden or gradual in onset
3. the duration; acute, subacute and chronic
4. the time course; stepwise fashion, progressed then
stabilized
5. other positive neurological symptoms
6. precipitating and relieving factors
7. extent of any deficit such as inability to put the slippers on,
unable to walk, cook, comb hairs
8. affects on function or daily activities
9. 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.
Type Spontaneous speech
LANGUAGE
Naming Repetition Comprehension Usual localization

Broca Non fluent Poor Usually poor Good Broca’s area

(The only)
Wernicke Fluent Poor Poor Poor Wernicke’s area
(The only) (posterior aspect of
superior temporal
gyrus)

Conduction Fluent Very poor Good Supramarginal gyrus,

The only arcuate fasciculus.
Conduction (occlusion of posterior
area!!! temporal branch of
Poor MCA)

Anomic Fluent Poor Good Good ? angular gyrus, non

(only) localising

Global Non fluent Poor Poor Poor Entire perisylvian

cortex

Transcortical motor Non fluent intact good Lesion in

aphasia. (The only) supplementary motor
area or dorsolateral
frontal cortex.

Transcortical sensory Fluent intact Poor Lesion at the joining

aphasia (The only) 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).
Gerstmann’s 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 = Horner’s or
sympathetic outflow pathology)
• Squint
• Fixation
• Pursuit movements (all directions)
• Convergence
• Reflex eye movements:
• Occulocephalic (Doll’s 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)
• Rinne’s test; Rinnies positive (AC > BC ) indicates:
– normal hearing or
– sensorineural deafness
• BC > AC : Conductive deafness.
• Weber’s test: Lateralise to conductive deafness side
when comparing normal and conductive deafness side;
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 (Best noted when tongue relaxed
inside).
• 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), two-
point 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)
• Alternating fingers movement
• Under and over shoot (dysmetria)
• Nystagmus
• Intention tremor
• Dysdiadokokinesia
• Rebound phenomenon
• Pendular knee jerk
• Ataxia
 6. Romberg’s test
• Stands with eyes open and closed = Romberg’s test is
negative or normal.
• Stands with eye open and falls with eye closed =
Romberg’s 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 Hypokinesia

- Chorea - Parkinsonism (akinesia/bradykinesia)

- Dystonia - Psychomotor depression, Catatonia,
- Hemifacial spasm Obsessional slowness
- Myoclonus - Freezing phenomenon
- Tics - Hypothyroid slowness
- Tremor - Stiff muscles
- Ballism(unilateral - hemiballimus)
- Athetosis
- Dysmetria
- Moving toes/fingers
- Restless legs
- Myokymia
- Blepharospasm
 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.
• Kernig’s sign (k = knee )

• 11. Skull and Spine

• 12. Peripheral nerves
 PORT WINE STAIN –
Sturge Weber syndrome

NF

Lisch nodules in NF

SHAGREEN/CAFÉ AU LAIT
13. The autonomic nervous system
• Pupils (Horner’s 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
• 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