Do the history and signs point to the site of the lesion, or lesions or to a system?
Do the time course and character of the findings point to a recognisable disease?
History
The narrative, from the patient, and witnesses provides vital data. How to take a present, past and family history is assumed. Pitfalls occur in three areas:
First, vividness comes from a verbatim account. Abbreviations are rife. ‘Fitted on way to A&E – bitten tongue….’ is familiar medical shorthand. The inference is a generalised tonic–clonic seizure, but it does not indicate what was actually said:
I was standing on the 73 bus near King’s Cross first thing taking mum to hospital. I felt all dizzy …. my eyes went all funny, my legs went weak and out I went. I came to on the floor, in a pool of blood. Mum says I fainted. But then the ambulance came and they said I was shaking. I’d bitten my lip….I was right as rain in a minute but they said they thought I’d had a fit.
Syncope, a simple faint, is obvious.
Secondly, identify temporal patterns:
Intermittent events with recovery. Common: epilepsy, migraine, syncope and TIAs. Rarer: paroxysmal dyskinesias.
Intermittent, with relapses and remissions: MS is the typical example.
Progressive, chronic: neurodegenerative and neoplastic disorders.
Acute or subacute and progressive: usually infective, vascular or inflammatory.
Acute onset, single insult, with some recovery. Stroke is the prime example. Guillain–Barré and traumatic brain injury are others.
The long time scale can sometimes be forgotten – prolonged febrile convulsions in infancy or a head injury long ago can be of relevance to later seizures. Family history may be relevant.
Thirdly, one’s own attitude – the balance between critical appraisal and sympathy. Judgmental approaches interfere with diagnosis, and lead to complaints. Our principal purpose is to help.
Many patients find unfamiliar questions difficult. There is no such thing as a ‘hopeless historian’ – it’s the neurologist’s fault. Patients today are well‐informed, but the unsympathetic neurologist remains well described. Patients do actually suffer from their complaints. That first visit carries a burden – a serious diagnosis is often in mind. Patients and relatives hang upon single comments. Depression and anxiety are common.
Nature of Symptoms
Foundations of neurology emphasised distinctions between positive and negative or primary and secondary phenomena, though these are not rigid. Many brain, cord, root and nerve lesions are destructive, that is with negative, primary effects such as paralysis. Destructive lesions may also cause positive, secondary phenomena, typically release of neuronal inhibition, such as exaggerated tendon reflexes. Positive also describes irritative phenomena, such as seizures.
Symptoms can thus be of two types:
Primary (direct) abnormalities, often negative: one part fails to work. Primary abnormalities can also be positive (irritative) – focal seizures from a glioma, or pain in the distribution of a trapped median nerve.
Secondary (indirect) abnormalities, usually positive, indicate typically over‐activity from release of inhibition, such as spasticity.
Neurological Examination: Preliminary Assessment
Gordon Holmes wrote in 1946: ‘More can often be learned of a patient’s disabilities by observing his ordinary actions, as dressing and undressing, walking when apparently unobserved, than by specific tests’. We rely on this approach intuitively – it is the way we form impressions and gauge people. Refine these skills. Think about:
Greeting, manner, orientation, attention, mental state, mood, personal hygiene, dress
Cognitive clues – turning to a companion before answering implies uncertainty
Speech, language, facial appearance
Gait, stance, clumsiness, weakness, involuntary movements, sensory symptoms
Risk factors, lifestyle, tobacco, alcohol, drugs, religion, illness beliefs, fears
Disability, aids, state benefits, aspects of daily living, driving, employment, sports
Endocrine or other clues – hypothyroidism, hypopituitarism, bruises
Relations with GP, hospital staff, attitudes towards treatment, expectations.
Brief Neurological Examination
Detailed examination is impracticable in a busy practice. We need a robust, safe and rapid approach:
Impressions (see above), gait, balance, arm swinging
Head: visual acuity, fundi, pupils, eye and face movements, tongue
Limbs: posture of arms outstretched, wasting, fasciculation, tone, power, coordination, reflexes, plantars
Sensation: ask the patient
Brief general exam, BP lying/standing.
Detailed Examination
The Queen Square scheme is adapted into Table 4.1.
Table 4.1 Detailed examination.
| History and general assessment |
| Complaints, past and family history |
| Personal (confidential) issues, alcohol drugs, tobacco, travel, occupation |
| Previous opinions, medical notes |
| Review of systems |
| Examination |
| Initial appraisal, mental state, cognition, speech |
| Stance, gait, balance, hand preference, skull, spine |
| Cranial Nerves I‐XII |
| Motor System |
| Movements, upper limb posture, wasting, tone, power, reflexes, coordination, diaphragm, neck |
| Sensation (sensory chart) |
|
|
