NEUROSURGICAL NEUROSURGICAL HISTORY & EXAMINATIONHISTORY & EXAMINATION

Essam Elgamal FRCS(SN)

In conjunction with information from other systems,

previous medical history, family and social history, current medications.Confirmation from relative or a friend.

HistoryHistory

HeadacheVisual disorderLoss of consciousnessSpeech disorderMotor disorderSensory disorderSphincter disorder

HistoryHistory

Lower cranial nerve disorderMental disorder

HEADACHE

OnsetCourse

Duration

Severity

Character

features

Site

Relieving factors

Precipitating factors

Timing

Associated

VISUAL DISORDER

Onset

CourseDuration

Impairment

Diplopia

Hallucinations

Precipitating factors

LOSS OF CONSCIOUSNESS

Onset Course Duration

Tongue bitingIncontinence

Limb twitching

Alcohol/Drug Abuse

Head injury

Cardiovascularor

Respiratorysymptoms

Precipitating factors

SPEECH DISORDER

Onset

CourseDuration

Articulation

ExpressionUnderstanding

MOTORDISORDER

Onset

CourseDuration

Coordination

Weakness

Involuntary movementRelieving

factors

PrecipitatingFactors

SENSORYDISORDER

Onset CourseDuration

Pain

Numbness

Site

Relievingfactors

Precipitatingfactors

SPHINCTERDISORDER

OnsetCourse Duration

IncontinenceOr

Retention

Bladder

Anal

LOWER CRANIAL

NERVEDISORDER

Onset Course Duration

Deafness

Tinnitus

Vertigo

Balance/staggering

Swallowing

Precipitating factors

MENTALDISORDER

Onset Course Duration

Memory

Intelligence

Behaviour Personality

ExaminationExamination

General: Neurological disease systemic signsSystemic disease affect nervous system

ExaminationExamination

Temperature Blood pressure Neck stiffness Pulse irregularity Carotid bruit/murmer Cyanosis Weight loss Breast lump

Lymphadenopathy Hepatosplenomegaly Prostatic irregularity Septic source Skin marks Anterior fontanelle Head circumference

Conscious levelHigher functions:Cognitive skills

MemoryReasoning

Emotional status

Cranial Nerves

Upper & Lower Limbs:Motor;

StatusTonePowerReflexes

Sensory;PainTouchTemperatureProprioceptionSteriognosis

Coordination

GCSGCS

Eye Opening:Spontaneous 4

To speech 3

To pain 2

None 1

GCSGCS

Verbal response:Orientated 5

Confused 4

Words 3

Sounds 2

None 1

GCSGCS

Motor response:Obeys commands 6

Localising to pain 5

Flexing to pain 4

Decorticated 3

Decerebrated 2

None 1

Cognitive skills Cognitive skills (Dominant Hemisphere)(Dominant Hemisphere)

– Listen to languageHesitant Expressive dysphasiaFluent Receptive dysphasia

– Doesn’t understand Receptive – Cannot name objects Nominal– Doesn’t read Dyslexia– Doesn’t write Dysgraphia– Numerical calculation Dyscalculia– Cannot recognise objects Agnosia

Cognitive skills Cognitive skills (Non-dominant Hemisphere)(Non-dominant Hemisphere)

Doesn’t find his way Geographical agnosia

Cannot dress himself Dressing apraxia

Copy geometric pattern Constructional apraxia

Minimental function test

Memory TestMemory Test

ImmediateRecentRemoteVerbalVisualRretrograde amnesiaPost-traumatic amnesia

Reasoning and problem solving

Compare with expected abilities Emotional state

Depressed

Anxiety

Apathy

Uninhibited

Slowness

Cranial nervesCranial nerves

I Olfactory II Optic

Acuity

Field

Fundus

Pupils

III, IV, VI Oculomotor, Trochlear, AbducentOcular movement

Diplopia

Nystagmus

Cranial nervesCranial nerves

V TrigeminalSensoryMotor

VII FacialUMN weakness, LMN palsy

VIII AuditoryCochlear component

Weber’s test Conductive; louder in affected earNeural; louder in normal ear

Rinne’s test

Cranial nervesCranial nerves

IX, X Glossopharyngeal & Vagus

Gag reflex

XI Accessory Sternomastoid

Trapezius

XII Hypoglossal

Motor systemMotor system

Asymmetry / deformityM. statusM. tone

Increased– Clasp-knife

– Lead-pipe

– Cog-wheal

– Clonus

Motor systemMotor system

PowerGrade 5 Normal

Grade 4 against some resistance

Grade 3 against gravity but not resistance

Grade 2 elimination of gravity

Grade 1 flickers

Grade 0 None

ReflexesReflexes

Upper LimbBiceps C5,C6

Triceps C6,C7,C8

Hoffman sign

Co-ordinationFinger-nose test

Finger-finger test

Dysadiadocholinesia

Arm bounce

Rebound phenomenon

ReflexesReflexes

Lower limbKnee

Ankle

Planter

Coordination

Romberg’s test

Gait

SensationSensation

Pain Touch Temperature Joint sensation Vibration Two point discrimination Sensory inattention (detect stimuli in both limbs) Streognosis Graphaesthesia

SphinctersSphincters

Distended bladderEvidence of incontinenceAnal reflex