ASSESSING THE NERVOUS

SYSTEM IN A PATIENT
1. Introduction – Background knowledge
2. Neurologic Hostory and Examination
3. Investigations in Neurology
 Contents

• Some aspects of neurological history

• Concentrate on neurological examination
• A look at coma, delirium and dementia.
• Formulation of the nature of the neurological diagnosis
• Include some remarks on neurological investigations.
 INTRODUCTION – BACKGROUND KNOWLEDGE

• It's composed of two parts:

1. Central nervous system (CNS)
• Which consists of the brain and the spinal cord
2. Peripheral nervous system (PNS)
• Which consists of the cranial and spinal nerves.
• The autonomic nervous system (ANS) although functionally a
separate system, is part central and part peripheral.
 THE BRAIN

• All information we have concerning our own body and the outside
world is received centrally by the brain through the sensory pathways.
• The brain is concerned with all kinds of voluntary motor activity and
regulation of visceral, endocrine and somatic functions.
• The brain is also concerned with such higher mental functions as
consciousness, thought, memory, attention, emotion, creative and
imaginative ability, speech and sleep.
• The brain comprises around 2% of total body weight.
• The brain and the spinal cord are metabolically highly active organs in the
body demanding about 15 – 20% of the total cardiac output and about 20% of
the total oxygen consumption.
• This is because the brain has a relatively high metabolic demand, due to being
largely reliant on oxidative metabolism.
• Loss of consciousness occurs within 10 seconds of the interruption of arterial
blood supply to the brain and irreparable damage to brain tissue occurs after
only a few minutes.
• The normal cerebral blood flow is about 750 mL per minute.
• Glucose is the metabolic fuel for the neurons.
• Both hypoxemia and hypoglycemia produce neurological dysfunction
promptly.
• Disruption of arterial blood flow to the brain for more than five minutes may
result in permanent damage to nerve cells.
• Hyperglycemia can also lead to neuronal dysfunction under pathological states
The Monro-Kellie
hypothesis

• The cranium, enclosing the

brain, forms a fixed
space comprising three
components:
• blood,
• cerebrospinal fluid, and
• brain tissue.
• These components remain in
a state of dynamic
equilibrium, therefore any
decrease in any one of them
results in an increase of the
other two.
 Cerebral perfusion pressure

• Cerebral perfusion pressure (CPP) drives oxygen and nutrient supply to brain
tissues.
• The brain can autoregulate blood flow in order to ensure constant flow that is
isolated from fluctuations in systemic blood pressure.
• This microcirculation is regulated by cerebral vessel constriction and dilatation.
• Most of the blood within the cranial cavity is contained within the low-pressure
venous system.
• Venous compression is the main method of displacing blood volume in the
aforementioned mechanism.
• This is the mechanism that is frequently lost secondary to head trauma, leading
to cerebral ischaemia and neuronal death (secondary brain injury).
• CPP can be calculated using the following formula:
CPP = MAP – ICP
 APPROACH TO THE NEUROLOGIC PATIENT
This is achieved through history, physical examination and investigations to arrive
at a diagnosis and treat/support the patient.
Approached in a stepwise manner - termed the neurologic method - which
consists of the following:
• Identifying the anatomic location of the lesion or lesions causing symptoms
• Identifying the pathophysiology involved
• Generating a differential diagnosis
• Selecting specific, appropriate tests
Identifying the anatomy and pathophysiology of the lesion through careful
history taking and an accurate neurologic examination markedly narrows the
differential diagnosis and thus the number of tests needed.
This approach should not be replaced by reflex ordering of CT, MRI, and other
laboratory testing; doing so leads to error and unnecessary cost.
To identify the anatomic location, the examiner considers questions
such as:-
• Is the lesion in one or multiple locations?
• Is the lesion confined to the nervous system, or is it part of a systemic
disorder?
• What part of the nervous system is affected?
Specific parts of the nervous system to be considered include the
cerebral cortex, subcortical white matter, basal ganglia, thalamus,
cerebellum, brain stem, spinal cord, brachial or lumbosacral plexus,
peripheral nerves, neuromuscular junction, and muscle.
Once the location of the lesion is identified, categories of pathophysiologic
causes are considered; they include
• Vascular
• Infectious
• Neoplastic
• Degenerative
• Traumatic
• Toxic-metabolic
• Immune-mediated
When appropriately applied, the neurologic method provides an orderly
approach to even the most complex case, and clinicians are far less likely to
be fooled by neurologic mimicry—eg, when symptoms of an acute stroke are
actually due to a brain tumor or when rapidly ascending paralysis suggesting
Guillain-Barré syndrome is actually due to spinal cord compression.
 History

The most important part of the neurologic evaluation.

Patients should be put at ease and allowed to tell their story in their own words.
Usually, a clinician can quickly determine whether a reliable history is forthcoming
or whether a family member should be interviewed instead.
History of present illness should include the following:

• Specific questions clarify the quality, intensity, distribution, duration, and

frequency of each symptom.
• What aggravates and attenuates the symptom and whether past treatment was
effective should be determined.
• Asking the patient to describe the order in which symptoms occur can help
identify the cause.
• Specific disabilities should be described quantitatively (eg, walks at most 25 feet
before stopping to rest), and their effect on the patient’s daily routine noted.
 History
Past medical history and a complete review of systems are essential because neurologic
complications are common in other disorders, especially alcoholism, diabetes, cancer, vascular
disorders, and HIV infection.

Family history is important because migraine and many metabolic, muscle, nerve, and
neurodegenerative disorders are inherited.

Social, occupational, and travel history provides information about unusual infections and exposure
to toxins and parasites.

Sometimes neurologic symptoms and signs are functional or hysterical, reflecting a psychiatric
disorder.
Typically, such symptoms and signs do not conform to the rules of anatomy and physiology, and the
patient is often depressed or unusually frightened.
However, functional and physical disorders sometimes coexist, and distinguishing them can be
challenging.
 Neurological symptoms

• Cognitive symptoms, especially • Loss of vision

memory impairment • ‘Positive’ visual symptoms, including
• Headache components of migraine auras,
• Loss of awareness unformed and formed hallucinations
• Loss of consciousness • Double vision
• Alteration of perception, including • More than double vision (polyopia,
déjà vu palinopsia)
• Dizziness, vertigo • Oscillopsia (a visual sensation of
stationary objects swaying back and
• Loss of balance forth)
• Falls • Difficulty swallowing
• Loss of sense of smell
 Neurological symptoms

• Deafness • Altered sensation

• Tinnitus • Loss of sensation
• Difficulty with speech • Pain
• Weakness • Symptoms of postural
• Abnormal movements of muscles hypotension
(including cramp, fasciculations)
• Impairment of sexual function
• Abnormal movements of parts of the
body (including tremor, dystonia, • Impairment of bladder control
myoclonus) • Impairment of bowel control
• Clumsiness
• Impairment of control of limbs
 Physical Examination
and Testing Scheme of Neurological Examination
1. Higher mental functions:
Consciousness, orientation, memory,
A physical examination to evaluate intelligence, speech, sleep.
all body systems is done, but the 2. Cranial nerves including fundoscopy.
focus is on the nervous system –
neurological examination. 3. Motor system
4. Sensory system
• In many situations, a 5. Reflexes
cerebrovascular examination is 6. Cerebellar functions
also done.
• Diagnostic tests may be needed
7. Stance and gait
to confirm a diagnosis or exclude 8. Head and spine
other possible disorders. 9. Signs of meningeal irritation
10.Autonomic function
 GENERAL EXAMINATION
Specifically look for:-
State of consciousness and mental state:
Metabolic disturbances such as diabetic ketoacidosis, hypoglycemia, uremia, hepatic
failure and poisoning may give rise to abnormalities of consciousness and mental
functions.

Cardiovascular findings:-
Examine Pulse, blood pressure and heart.
Hypertension is associated with a high-risk of thrombotic and hemorrhagic strokes.
A high proportion of cerebrovascular complications are due to:-
 Structural heart diseases such as valvular heart disease and congenital heart disease.
 arrhythmias such as atrial fibrillation.
 ischemic heart disease and.

 Diabetes Mellitus
The neurological complications due to diabetes can be acute or chronic.
Acute complications are:-
I. coma and.
II. convulsions due to severe hyperglycemia with or without ketoacidosis and
hypoglycemia.
The chronic complications are generally due to:-
i. vascular or
ii. nonvascular causes.
Among the vascular complications are those caused by large artery disease
(cerebrovascular disease).
Microvascular complications are caused by small artery disease leading to
mononeuropathies (cranial and peripheral nerves).
Nonvascular complications are thought to be due to direct metabolic effect on the
nerves. They include peripheral neuropathies and autonomic neuropathies.
Cyanosis Fever
Cyanotic congenital heart disease • Central nervous system (CNS) infections
may be complicated by are accompanied with fever.
brain abscess • meningitis,
• encephalitis and
paradoxical cerebral embolism
• brain abscess
seizures and
cerebral venous and arterial • Even in the absence of direct
thrombosis. involvement of the CNS, several
systemic infections give rise to delirium
Cyanosis in respiratory failure may which is a toxic state of confusion e.g.,
be associated with carbon dioxide typhoid.
narcosis
• Delirium common in children and the
aged
• febrile convulsions are common in
children below 5 years
Nutrition Lymph Nodes
• Several nutritional disorders affect • Generalized lymphadenopathy
the nervous system. may be a presenting feature of
Lymphomas, tuberculosis,
• Deficiency of thiamine leads to
leukemias, AIDS, syphilis which
peripheral neuropathy, and may affect the nervous system.
Wernicke’s encephalopathy.
• Localized metastatic lymph nodes
• Deficiency of niacin and secondary to carcinoma lung may
cyanocobalamin may give rise to point to metastases in the brain or
disturbances of higher mental paraneoplastic neurological
functions. manifestations of malignancy
• In addition, vitamin B12 deficiency
may be associated with subacute
combined degeneration of the cord.
Skin Face
• Café-au-lait spots, naevi, neurofibromata • Several facial abnormalities point to
and vascular malformation such as neurological diseases.
angiomatoses may all be associated with
lesions in the brain, spinal cord, cranial • External markers of neurological disease.
nerves or spinal nerves. That can be easily recognized by the physician
at the first examination include:-
• Sensory loss occurring in peripheral
• Facial asymmetry,
neuropathy, mononeuritis multiplex and
syringomyelia may lead on to trophic • hemiatrophy,
ulcers and destructive lesions in the • pouting of lips and transverse smile in
extremities. myopathies
Eyes • mask-like facies of parkinsonism,
• Kayser-Fleisher rings which suggest • acromegalic facies
Wilson’s disease, proptosis, pulsatile
exophthalmos and specific neurological • vascular naevi in Sturge-Weber syndrome,
abnormalities such as paralysis, strabismus • adenoma sebaceum in tuberous sclerosis
and nystagmus should be looked for. etc
 Substance abuse

Several substances which cause Phenothiazines

addiction lead to acute and chronic • Akathisia, i.e. inability to sit
damage to the nervous system. quiet, associated with a feeling
Prominent among them are: of restlessness and anxiety,
Alcohol • dystonias,
• Tremors, • secondary parkinsonism,
• varying grades of altered • seizures etc
consciousness, Excessive smoking of tobacco –
• peripheral neuropathy, Tremors, restlessness, insomnia
• cerebellar dysfunction,
• delirium tremors on alcohol
withdrawal.
Scheme of Neurological Examination

• Higher mental functions:

Consciousness, orientation,
memory, intelligence, speech, sleep.
• Cranial nerves including fundoscopy.
• Motor system
• Sensory system
• Reflexes
• Cerebellar functions
• Stance and gait
• Head and spine
• Signs of meningeal irritation
• Autonomic function
HIGHER FUNCTIONS – Mental or intellectual functions

Higher functions include • Orientation to time, place, and

• level of consciousness, person
• intellectual performances, • Attention and concentration
• emotional state, • Memory
• thought processes, • Verbal and mathematical
abilities
• complex sensory perceptions,
• Judgment
• complex motor acts,
• Reasoning
• speech and language.
• Disturbances of higher functions may occur directly from a focal or diffuse
organic brain disease or indirectly from the emotional reactions to the illness
or from a combination of the two.
• Psychiatric disorders also affect the higher functions considerably.
• Proper evaluation of higher functions is possible only when the person is alert
and attentive with normal comprehension.
• For initial screening of higher functions, a short, quick and concise
“minimental state examination” may be done in all cases.
• If the screening test is normal, further detailed testing is not usually necessary
and the student can proceed with the rest of the neurological examination.
• But if the screening test is abnormal, detailed mental status examination has
to be done.
• Assess the level of consciousness before proceeding with further
examination.
The patient’s attention span is assessed first; an inattentive patient cannot cooperate
fully and hinders testing. Any hint of cognitive decline requires examination of
mental status which involves testing multiple aspects of cognitive function, such as
the following:
• Orientation to time, place, and person
• Attention and concentration
• Memory
• Verbal and mathematical abilities
• Judgment
• Reasoning
Loss of orientation to person (ie, not knowing one’s own name) occurs only when
obtundation, delirium, or dementia is severe; when it occurs as an isolated symptom,
it suggests malingering.
insight into illness and fund of knowledge in relation to educational level are
assessed, as are affect and mood.
Vocabulary usually correlates with educational level.
The patient is asked to do the following:
• Follow a complex command that involves 3 body parts and discriminates
between right and left (eg, “Put your right thumb in your left ear, and stick
out your tongue”)
• Name simple objects and parts of those objects (eg, glasses and lens, belt
and belt buckle)
• Name body parts and read, write, and repeat simple phrases (if deficits
are noted, other tests of aphasia are needed)
Spatial perception can be assessed by asking the patient to imitate simple
and complex finger constructions and to draw a clock, cube, house, or
interlocking pentagons; the effort expended is often as informative as the
final product. This test may identify impersistence, perseveration,
micrographia, and hemispatial neglect.
Praxis (cognitive ability to do complex motor movements) can be assessed
by asking the patient to use a toothbrush or comb, light a match, or snap
the fingers.
LEVEL OF CONSCIOUSNESS
Fully Conscious State
• An individual is termed as “conscious” in the narrow limits of clinical
terminology when he is aware of himself and his surroundings during
wakefulness.
• In this state, a normal person is fully alert, oriented to his surroundings
and responds appropriately to external stimuli which may be auditory,
verbal, visual, tactile or painful.
• His speech is normal and he has normal voluntary motor activity.
• His eyes are open with intermittent blinking and his eye movements are
normal.
• Consciousness is maintained by the reticular activating system in the
brainstem, through its thalamocortical projections as a result of constant
Confusional State

i. Inability to think with customary speed and clarity, leading to

impairment of problem— solving ability and coherence of ideas about a
subject.
ii. Inability to carry out more than simple commands.
iii. Loss of awareness of the surrounding environment
iv. Inability to sustain long conversation, with frequent drifting from one
topic to another.
v. Disorientation in time and place.

Note: Bear in mind that a patient with Wernicke’s dysphasia may mimic
confusion state.
Somnolence
• A somnolent person appears to be asleep, but he can be aroused transiently by verbal or
painful stimuli and made to perform simple motor tasks and appropriate verbal
responses, but immediately he drifts back into a sleeplike state when the stimulus is
stopped.
Stupor
• The patient who appears to be asleep can be aroused transiently only by vigorous and
repeated painful stimuli. When aroused, the eyes are opened but spontaneous eye
movements will not be present. Response to simple verbal commands is either slow and
inadequate, or absent. Restlessness and spontaneous stereotyped movements are
common. He immediately drifts back into sleep-like state when the stimulus ceases.
Semi-coma
• It is the lighter stage of coma in which painful stimuli, shaking, or shouting will cause
transient stirring movements, moaning or muttering, and quickening of respiration. As
soon as the stimulation ceases the patient drifts to his original state. Most of the
superficial and muscle stretch reflexes may be elicitable and plantar responses may be
either flexor or extensor.
 Sleep
• Sleep is a physiological state of unconsciousness in which the pulse
and the respiratory rate fall, the eyes deviate upwards, the pupils are
constricted but reactive to light, the muscle-stretch reflexes are
absent, and the plantar responses become extensor.
• Sleep differs from abnormal alterations of consciousness in that the
subject can be easily woken up with verbal or tactile stimuli and he
resumes normal mental function promptly.
• Normal sleep occurs in 5 stages. The first 4 stages (I to IV) are called
nonrapid eye movement (NREM) sleep and the fifth-one, rapid eye
movement sleep (REM).
• These stages are identified by simultaneous recording of EEG, EMG and electro-
oculogram; this combination is called polysomnogram.
• When a person falls asleep, he passes through stages I to IV of NREM sleep which
takes about 70 to 100 minutes, followed by REM sleep for the next 25 to 30 minutes.
• After this again stage I of NREM begins.
• This cycle of NREMREM sleep is called a sleep cycle and usually 4 to 6 such sleep
cycles are repeated in a night’s sleep in a healthy adult.
• However, the duration and the number of sleep cycles vary with age and sex.
 Stage I of NREM is called drowsiness and
 stage II of NREM, light sleep.
 Stages III and IV of NREM sleep and REM sleep are called deep sleep.
 Stages VI REM
• During drowsiness and light sleep, the muscle tone in the limbs is
maintained, there may be gross body movements but no eye movements.
• In the deep sleep stage of NREM also, there will not be any eye movements,
the limb tone is maintained, and there may be gross limb movements.
• In the REM sleep, there will be conjugate eye movements, but the limbs are
hypotonic, the person will be still, with small twitching and tremulous
movements in the face, hands and feet.
• Normal sleep is essential to maintain functional normalcy and normal
neurological reactions.
• Prolonged insomnia leads to abnormality of higher functions and
psychological behavior.
• Adequacy of sleep for each individual depends on the duration and depth
of sleep.