• Select appropriate questions to elicit from the
patient with a neurological complaint during a
• Differentiate “normal” from “abnormal” findings
on neurological examination
• Identify common causes of various cranial nerve
• Differentiate conductive hearing loss from
sensorineural hearing loss
• Determine location of neurological lesion
• Differentiate amongst the various movement
• Differentiate atrophy, hypertrophy, and
• Differentiate between spasticity, rigidity, and flaccidity,
and identify common causes of each.
• Differentiate upper motor neuron lesions from lower
motor neuron lesions.
• Differentiate CNS disorders from PNS disorders, and
identify location of the lesion & common causes.
• Compare and contrast the five clinical levels of
• Given a case study perform the appropriate focused
history and physical examination and formulate a
• Determine if there is a neurological deficit
• Localize the site of the problem
• Determine the etiology of the problem
• Paresis – slight or incomplete paralysis
• Paralysis (plegia) – loss or impairment of
• Atrophy – a decrease in size
– enlargement of an organ or part due to an increase in size
of its constituent cells
– increase in size without true hypertrophy
• Spasticity – hypertonicity with increased DTRs
• Rigidity – stiffness or inflexibility
• Flaccidity – loss of tone with diminished DTRs
• Mental status
• Cranial nerves
• Motor function
• Sensory status
• Coordination and balance
• Chief complaint
• Visual disturbance?
• Tremors or dyskinesias?
• Loss of consciousness?
Key components of H&P
Complaint Hx P.E.
Associated seizure activity;
recent trauma or infection; illicit
drug use; exposure to toxic
Mental status exam; pupillary
reaction; corneal reflexes; gag
Vertigo Differentiate between true vertigo and lightheadedness!
Present at rest; affected by
CN VIII function; Dix-Hallpike
Headache Thorough hx; “worst headache ever?”; associated sx’s; neck
CN function; pupillary reaction;
fundoscopic exam; palpate
temporal artery; Marcus-Gunn
Seizures Previous hx; frequency; motor activity; aura; LOC; post-ictal
confusion; external etiology
Search for focal deficits; signs of
Weakness Generalized or focal; loss of strength; pain; progressive or
Asymmetry7; atrophy; sensory
deficits; fasciculations; DTRs
– Person, Place, Time, & Situation
• Cognitive function
– Illusions = misinterpretations of real external stimuli
– Hallucinations = subjective sensory perceptions in the absence of stimuli
– Short-term & long-term
– Rate & rhythm
– Simple vs. complex
Levels of Consciousness
• Alert and Oriented
– Clouded consciousness
– Slow thought, movement, and speech
– Marked reduction in mental and physical activity
– Vigorous stimuli needed to provoke a response
– Completely unconscious
– Cannot be aroused by painful stimuli
– Absence of voluntary movement
– +/- reflexes
Glasgow Coma Scale
• Hand drop
• Unilateral diplopia
• Ammonia reaction (CN V vs. CN I)
• Absence of pain or weakness in different
The “Difficult” Patient
• Observation is key!
• Use ingenuity!
• Be patient!
– May be threatening or violent
– Fail to participate
– Inattentive, preoccupied, inconsistent information
Testing Cognitive Function
• Information & vocabulary
– Simple math
– Word problems
• Abstract thinking
– Copy figures of increasing difficulty (i.e. circle, clock)
Abnormalities of Thought Processes
Circumstaniality Indirection and delay in reaching a point because of unnecessary detail.
Loose Associations Person shifts from one unrelated subject to another.
Flight of Ideas Almost continuous flow of accelerated speech with abrupt topic changes.
Incoherence Incomprehensible because of illogic, lack of meaningful connections,
abrupt topic changes, or disordered word use/grammar.
Confabulation Fabrication of facts or events to fill in gaps in impaired memory.
Perseveration Persistent repetition of words or ideas.
Echolalia Repetition of the words or phrases of others.
Neologisms Invented or distorted words.
Blocking Sudden interruption in mid-sentence or before completion of an idea.
Clanging Person chooses a word based on sound instead of meaning.
Abnormalities of Thought Content
Obsessions Recurrent, uncontrollable thoughts, images, or impulses that a
persons considers unacceptable or strange
Compulsions Repetitive acts that a person feels driven to perform to prevent or
produce some unrealistic future state of affairs.
Delusions False, fixed, personal beliefs that are not shared by other
members of the person’s culture.
Phobias Persistent, irrational fears; accompanied by a compelling desire
to avoid the stimulus.
Anxieties Apprehensions, fears, or tensions that may be free-floating or
focused (i.e. phobia).
Feelings of Unreality A sense that things in the environment are strange, unreal, or
A sense that one’s self is different, changed, or unreal. Identity is
Delirium vs. Dementia
• Although confusion and/or disorientation are signs of both Delirium and
Dementia, they are different
• Delirium is an acute confusional state
– It is potentially reversible
– Delirium usually occurs over a period of days to months
• Dementia is slow and insidious
– It progresses slowly over months to years
– Dementia is not reversible
Condition Onset Pattern Orientation Attention Memory Duration
Delirium Acute Fluctuating Usually
Impaired Hours or
Dementia Insidious Progressive Normal or
~Normal Impaired Months or
Psychosis Variable Variable ~Normal Normal or
• TIA = brief, intermittent visual loss
• Migraine = “wavy”
• Retinal detachment = “drawn curtain”
• Acute glaucoma = “rainbows” or “halos”
• Digitalis toxicity = yellow hue
• A sense of spinning
• Suggests dysfunction of
– Vestibular apparatus
– Vestibular nerve
• Differentiate from “lightheadedness” and
– Results from impairment of brain oxygenation
Testing for Aphasia
Comprehension of spoken language through recognition (“point to your nose”) or
understanding (“Can dogs fly?”).
Repetition Repeat items of increasing complexity. Note the fluency and accuracy of the
Naming Name a series of objects or colors. Gradually increase difficulty. Note the fluency
and accuracy of the responses.
Have the patient follow several simple written commands.
Writing Ask the patient to make up and write a sentence.
• CNS vs. PNS
– Brain/Brain stem
– Spinal cord
– Peripheral nerves
• Difficult when evaluating:
– Radicular pain
– Impaired intellect, memory, higher brain function
• Brain stem
– paralysis with loss of DTRs
– muscle atrophy with fasciculation
• LMN + anesthesia
– peripheral nerve or spinal root
– involves whole muscle groups
– increased or spastic mus