NEURO EVALUATION

HEALTH HISTORY –
COMMON S/SX
Headache Dizziness/Vertigo
Weakness Numbness
Fainting and blacking out Seizures
Tremors, Involuntary Movements
HEADACHES
• H/A has a wide range of causes, ranging from benign to
life threatening, and always warrants a thorough ax.

• Always ax the severity of the h/a and its location, duration,

and any associated sx:
Double vision Vision changes
Weakness Loss of sensation
Nausea Vomiting
 Tension Headache
PROCESS Unclear; possible heightened CNS pain sensitivity
LOCATION Usually bilateral, may be generalized or localized to the back of
the head and upper neck or to the frontotemporal area
QUALITY & Steady, tightening; nonthrobbing pain; mild to moderate
SEVERITY intensity
ONSET & Gradual, lasting fro 30 minutes to 7 days
DURATION
ASSOCIATED Photophobia, phonophobia, scalp tenderness
Sx
AGGRAVATING Sustained muscle tension, as in typing and driving; stress,
FACTORS sleep disturbances
RELIEVING Massage, relaxation
FACTORS
Migraines
PROCESS Neuronal dysfunction, possibly brainstem in origin
LOCATION unilateral
QUALITY & Throbbing or aching pain, moderate to severe in intensity
SEVERITY
ONSET & Fairly rapid, reaching a peak in 1 to 2 hours
DURATION
ASSOCIATED Nausea, vomiting, photophobia, phonophobia
Sx
AGGRAVATING Alcohol, stress, menses, high altitude, noise, bright light
FACTORS
RELIEVING Quiet, dark room; sleep
FACTORS
Cluster Headache
PROCESS unclear
LOCATION Unilateral, usually behind ot around the eye or temple
QUALITY & Sharp, continuous, intense; severe
SEVERITY
ONSET & Abrupt, peaks within minutes, lasts for 15 minutes to 3
DURATION hours
ASSOCIATED Lacrimation, rhinorrhea, miosis, ptosis, eyelid edema,
Sx conjunctival infection
AGGRAVATING Alcohol
FACTORS
Headaches from Eye Disorders
PROCESS Probably due to sustained contraction of the EO muscles
LOCATION Around and over the eyes; may radiate to the occipital area
QUALITY & Steady, aching, dull
SEVERITY
ONSET & Gradual with variable duration
DURATION
ASSOCIATED Eye fatigue, redness of conjunctiva
Sx
AGGRAVATING Prolonged use of the eyes
FACTORS
RELIEVING Rest of the eyes
FACTORS
Headaches from Acute Glaucoma
PROCESS Sudden increase in intraocular pressure
LOCATION Pain in and around one eye
QUALITY & Steady, aching, often severe
SEVERITY
ONSET & Often rapid with variable duration
DURATION
ASSOCIATED Blurred vision, nausea, vomiting, halos around lights,
Sx reddening of eye
Headaches from Sinusitis
PROCESS Mucosal inflammation of the paranasal sinuses
LOCATION Usually frontal sinuses above the eyes or over the maxillary
sinus
QUALITY & Aching or throbbing, severity variable, consider possible
SEVERITY migraine
ONSET & Often daily several hours at a time, persisting until treatment
DURATION
ASSOCIATED Local tenderness, nasal congestion, discharge and fever
Sx
AGGRAVATING Coughing, sneezing
FACTORS
RELIEVING Nasal decongestants, antibiotics
FACTORS
Headaches from Meningitis
PROCESS Virus or bacterial infection of the meninges surrounding the
brain and spinal cord
LOCATION Generalized
QUALITY & Steady or throbbing, very severe
SEVERITY
ONSET & Fairly rapid, usually <24 hours
DURATION
ASSOCIATED Fever, stiff neck, photophobia, change in mental status
Sx
AGGRAVATING
FACTORS
RELIEVING Immediate antibiotics until diagnosis if bacterial or viral
FACTORS
Headaches from Subarachnoid Hemorrhage
PROCESS Bleeding from a ruptured cerebral saccuar aneurysm
LOCATION Generalized
QUALITY & Very severe “worst of my life”
SEVERITY
ONSET & Sudden onset, can be less than a minute
DURATION
ASSOCIATED Nausea, vomiting, loss of consciousness, neck pain
Sx
AGGRAVATING Rebleeding, increase intracranial pressure, cerebral edema
FACTORS
RELIEVING Subspecialty treatments
FACTORS
Headaches from Brain Tumor
PROCESS Mass lesion causing displacement of or traction on
pain-sensitive arteries and veins or pressure on nerves
LOCATION Variable
QUALITY & Aching, steady, dull pain worse on awakening
SEVERITY
ONSET & Often brief, depends on location and rate of growth
DURATION
ASSOCIATED Seizures, hemiparesis, personality changes, nausea,
Sx vomiting, vision change, gait change
AGGRAVATING Coughing, sneezing, sudden head movements
FACTORS
RELIEVING Subspecialty treatments
FACTORS
Postconcussion Headache
PROCESS Follows mild acceleration-decceleration TBI
LOCATION Often but not always localized to the injured area
QUALITY & Dull, aching, constant; may have features of tension and
SEVERITY migraine headaches
ONSET & Within 7 days of injury up to 3 months
DURATION
ASSOCIATED Drowsiness, poor concentration, confusion, memory loss,
Sx blurred vision, dizziness, irritability, restlessness, fatigue
AGGRAVATING Mental and physical exertion, straining, stooping, emotional
FACTORS excitement, alcohol
RELIEVING Rest; medication
FACTORS
Headaches from Trigeminal Neuralgia
PROCESS Vascular compression of CN V, usually near entry to pons
leading to focal demyelination
LOCATION Cheek, jaw, lips, or gums; CNV2 and CNV 3 > CNV 1
QUALITY & Shock-like, stabbing, burning; severe
SEVERITY
ONSET & Abrupt
DURATION
ASSOCIATED Exhaustion from recurrent pain
Sx
AGGRAVATING Touching certain areas of the lower face or mouth; chewing,
FACTORS talking, brushing teeth
RELIEVING Medication; neurovascular decompression
FACTORS
DIZZINESS/VERTIGO
• Dizziness and light-headedness are common, somewhat
vague, complaints that prompt more specific history and
neurological examination

• *true vertigo = spinning sensation within the patient or of

the surroundings

• Ataxia, diplopia, and dysarthria are suspicious for

vertebrobasilar TIA or stroke
WEAKNESS
• It is important to clarify what the patient means (fatigue,
apathy, drowsiness, or actual loss of strength).

• TRUE MOTOR WEAKNESS can arise from the CNS, a

peripheral nerve, the NMJ, or a muscle.
• Abrupt onset of motor and sensory deficits occurs in TIA
and stroke

• Progressive subacute onset of LE weakness suggests

Guillain-Barre Syndrome

• Chronic, more gradual, onset of LE weakness occurs in

primary and metastatic spinal cord tumors
• Proximal limb weakness, when symmetric with intact
sensation, occurs in myopathies from alcohol, drugs, and
inflammatory muscle disorders like polymyositis and
dermatomyositis.

• In the NMJ disorder myasthenia gravis,, there is proximal

typically symmetric weakness that gets worse with effort,
often associated with bulbar symptoms (diplopia, ptosis,
dysarthria, and dysphagia)
NUMBNESS, ABNORMAL
SENSATION
• Sensory changes can arise at several levels:
• Local nerve compression or entrapment seen in hand numbness in
distributions specific to the median, ulnar, or radial nerve
• Nerve rot compression with dermatomal sensory loss from
vertebral bone spurs or herniated discs
• In dysesthesias, light touch or pinprick, for examples, may
cause a burning or irritating sensation
• Burning pain occurs in painful sensory neuropathies from
conditions like diabetes

• Always establish the pattern of sensory loss

• A pattern of stocking, then glove, sensory loss occurs in
polyneuropathies
• Multiple patchy areas of sensory loss in different limbs suggests
mononeuritis multiplex, seen in diabetes and rheumatoid arthritis
FAINTING AND BLACKING OUT
• Always begin by finding out whether the patient has
actually lost consciousness
• Near syncope or presyncope: patient hears external noise or voices
throughout the episode, felt light-headed or weak, but failed to
actually lose consciousness
• True syncope: patient actually experienced complete loss of
consciousness; sudden but temporary loss of consciousness and
postural tone from transient global hypoperfusion of the brain
SEIZURES
• “sudden excessive electrical discharge from cortical
neurons”
• May be symptomatic with an identifiable cause, or
idiopathic
Focal Seizures
• Conceptualized as originating within networks limited to
one hemisphere
• May be discretely localized or more widely distributed

1. Focal Seizures without impairment of Consciousness

2. Focal Seizures with impairment of Consciousness
Focal Seizures s Impairment of
Consciousness
Clinical Manifestation Postictal State
Jacksonian* Tonic then clonic movements that
starts unilaterally in the hand,
foots, or face, and spread to other
body parts on the same side
Other motor* Turning of the head and eyes to
Normal consciousness
one side, or tonic and clonic
movements of an arm or leg
without the Jacksonian spread
With A “funny feeling” in the
autonomic epigastrium, nausea, pallor,
symptoms* flushing light-headedness
Focal Seizures s Impairment of
Consciousness
Clinical Manifestation Postictal State
With subjective sensory Numbness, tingling; Normal consciousness
or psychic phenomena simple visual, auditory, or
olfactory hallucinations
such as flashing light,
buzzing, or odors

Anxiety or fear; feelings

of familiarity or unreality; Normal consciousness
dreamy states; fear or
rage; flashback
experiences; more
complex hallucinations
Focal Seizures c Impairment of
Consciousness
Clinical Manifestation Postictal State
May or may not start with the May remember initial autonomic or
autonomic and psychic symptoms; psychic symptoms, but is amnesic for
person appears confused the rest of the seizure. Temporary
Automatisms include automatic motor confusion and headache may occur
behaviours such as chewing,
smacking the lips, walking about, and
unbuttoning clothes
Generalized Seizures
• Originating at some point within and rapidly engaging,
bilaterally distributed networks but do not necessarily
include the entire cortex
• Localization and lateralization are not consistent from one
seizure to another
• May begin with body movements, impaired consciousness
or both

• Toxic and metabolic causes include withdrawal from

alcohol or sedative drugs, uremia, hypoglycemia,
hyperglycemia, drug toxicity, bacterial meningitis.
Tonic-Clonic (Grand Mal)
Clinical Manifestation Postictal State
Sudden loss of consciousness Confusion, drowsiness, fatigue,
Body stiffness into tonic extensor headache, muscular aching, and
rigidity sometimes temporary persistence of
Clonic phase of rhythmic muscular bilateral neurologic deficits such as
contraction follows hyperactive reflexes and Babinski
Breathing resumes and is often noisy responses
with excessive salivation
Patient is amnesic about the seizure
Injury, tongue biting, and urinary
incontinence may occur
Absence
Clinical Manifestation Postictal State
Sudden brief lapse of consciousness In typical absence, a prompt return to
with momentary blinking, staring, or normal
movement of the lips and hands but no
falling In atypical absence, some postictal
confusion
a. Typical absence lasts < 10s
b. Atypical absence lasts > 10s
Myoclonic
Clinical Manifestation Postictal State
Sudden, brief, rapid jerks, involving Variable
trunk or limbs. Associated with a
variety of disorders
Myoclonic Atonic (Drop Attack)
Clinical Manifestation Postictal State
Sudden loss of consciousness with Either a prompt return to normal or a
falling but no movements brief period of confusion
TREMORS, INVOLUNTARY MOVEMENTS
• Tremors are the most common movement disorder
• May be an isolated finding or part of a neurologic disorder
LEVELS OF
CONSCIOUSNESS
Alert
Lethargy
Obtunded
Stupor
Coma
LEVEL OF CONSCIOUSNESS: TECHNIQUES AND PATIENT
RESPONSE
Level Technique Patient Response
Alert Speak to the patient in a (+) eye opening
normal tone of voice Responds fully and appropriately
to stimuli
Lethargy Speak to the patient in a Appears drowsy but with (+) eye
loud voice opening and looks at examiner,
responds to questions but then
falls asleep
Obtunded Shake the patient gently (+) eye opening with slow
response
(+) confusion
Decreased alertness and interest
in environment
LEVEL OF CONSCIOUSNESS: TECHNIQUES AND PATIENT
RESPONSE
Level Technique Patient Response
Stupor Apply painful stimulus (eg. Arouses from sleep only after
Pinch a tendon, rub the painful stimuli
sternum, roll pencil across Slow to absent verbal responses
the nail bed) Minimal awareness of the
environment or self
Lapses to unresponsive state
when stimulus ceases
Coma Apply repeated painful Remains unarousable with eyes
stimuli closed
No evident response to inner
need or external stimuli