HISTORY
1. Chief Complaint (record on note and verbally present)
The Chief Complaint should begin every written and oral
presentation. It should include the patient's age, sex,
presenting symptoms and the duration of symptoms.
Ideally, the chief complaint should come from the
patient directly. If that is not possible, then the
chief complaint may come from a family member, friend,
EMT or referring physician. The source should be
documented if not the patient.
2. History of Present Illness (record on note and
verbally present)
The history of present illness is a chronologic history
of the patient's symptoms and evaluation starting from
the beginning (e.g., the patient was well until...). Ask
the patient to walk you through exactly what happened.
Often, small details separate the history of an embolic
from a thrombotic stroke; the headache of subarachnoid
hemorrhage from migraine. Attention should be given to
the temporal course, severity, associated symptoms,
provoking factors, and alleviating factors. Pertinent
past medical history, family history and social history
can be included in this section only if directly
relevant (e.g., for a patient with a suspected TIA,
inclusion of cardiac and peripheral vascular disease is
appropriate). Otherwise, this information is left for
later. It is essential to get the history of present
illness as complete and accurate as possible. If the
history is not obtainable from the patient, the student
needs to get on the phone and get the information from
wherever possible, including the family, co-workers and
treating doctors.
3. Past Medical and Surgical History (record on note and
verbally present)
List all major ongoing and past medical, psychiatric and
surgical problems. Often, it is helpful to review with
the patient the times he/she has been admitted to a
hospital for any reason.
4. Medicines and Allergies (record on note and verbally
present)
As many neurologic conditions, especially confusion,
altered mental state and weakness, can be due to
medicine side effects, this category is very important.
Get a complete list, including medicines which have
recently been discontinued as well. In addition, ask
above over the counter medicines and vitamins. In women,
ask about oral contraceptives, as this might not be
considered a medicine, per se.
Record all allergies to medicines and their reactions
(e.g., rash).
Note: some patients may report side effects as
allergies.
5. Family History (record all on note, but verbally
present only pertinent positives)
Record the age, any serious illness and cause of death
of close family members. Ask specifically if anyone else
in the family has any type of neurologic condition.
6. Social History (record on note , but verbally present
only pertinent positives)
Include Education; Occupational history (current
employment status, previous jobs); Marital status/family
situation; Life style/habits (alcohol, tobacco, drugs);
any potential toxic exposure from work or home.
7. Review of Systems (record on note, but verbally
present only pertinent positives)
Ask about all other major systems. Record all pertinent
positive and negatives. Include constitutional symptoms
(especially fever, sweats, weight change), skin,
respiratory, breast, cardiovascular, gastrointestinal,
endocrine, musculoskeletal, psychological and
genitourinary systems.
GENERAL PHYSICAL
EXAMINATION
The physical examination the neurologic patient is the
same physician examination for any other medical or
surgical patient with an emphasis on the neurologic
examination.
The general physical examination should include:
General appearance
Vital signs
Skin
Lymph nodes
Head, eyes, ears, nose and throat
Chest - heart, lungs, breasts
Vascular
Abdomen
Back
GU
Extremities
Other than the general appearance and the vital signs,
only the pertinent positives and negatives should be
verbally presented.
NEUROLOGIC PHYSICAL
EXAMINATION
The Neurologic exam on every patient must include
assessment of the mental state, cranial nerves, motor
system, reflexes, sensory system and coordination/gait.
All tests do not need to be performed on all patients.
However, each major area must be screened on all
patients. Additional testing can then be performed
depending on the patient's symptoms (e.g., more detailed
mental state testing is indicated in a patient with
memory loss; likewise, more detailed sensory testing is
required in a patient with a peripheral nerve injury).
Mental State Testing
A. Level of consciousness (awake or not; alert,
lethargic, somnolent, comatose)
1. Response to stimuli (voice, touch, pain)
2. Spontaneous movement and posture
B. Behavior
C. Attention
1. Digit span, days of the week
2. Vigilance
D. Language
1. Handedness
2. Spontaneous speech/fluency/articulation
3. Comprehension (simple, complex)
4. Naming (parts, parts of parts, lists)
5. Repetition
6. Reading
7. Writing (dictation or spontaneous)
E. Visual Spatial
1. Constructions (draw a clock)
2. Copy figures
3. Interpret a figure or picture
F. Memory
1. Immediate
2. Recent memory/new learning ability
3. Remote memory (historical or personal)
G. Other Higher Cortical functions
1. Calculations
2. Right/left orientation
3. Praxis
Cranial Nerves
A. Olfactory (1) - soap/coffee (not necessary unless
patient has symptoms)
B. Optic (2)
1. Visual acuity
2. Visual fields
3. Fundal exam - attention to optic disks
4. Pupils (2,3) - size, symmetry, reactivity
C. Oculomotor, Trochlear, Abducens (3,4,6)
1. Extraocular movements
2. Vergence/divergence
3. Nystagmus
4. Pursuit/saccades
5. Ptosis
D. Trigeminal (5)
1. Facial sensation
2. Muscles of mastication
3. Corneal reflex (5,7)
E. Facial (7)
1. Facial muscles - assess upper (frontalis), middle
(eye closure) and lower (smile)
2. Taste (not necessary unless patient has symptoms)
F. Vestibulocochlear (8)0
1. Gross hearing (finger rub, tuning fork, watch)
2. Weber (not necessary unless patient has symptoms)
3. Rinné (not necessary unless patient has symptoms)
4. Barany Maneuver (not necessary unless patient
has symptoms)
G. Glossopharyngeal and Vagus (9,10)
1. Gag Reflex
2. Voluntary palate elevation
3. Articulation (K, M, Ls)
H. Spinal Accessory (11)
1. Trapezius and SCM strength
I. Hypoglossal (12)
1. Tongue bulk and strength, comment about any
fasciculations
Motor Examination
A. Bulk
B. Tone - normal, spastic, rigid, paratonia
C. Strength (MRC scale 0 - 5)
0 = no movement or contraction
1 = flicker (i.e., contraction, no movement)
2 = markedly weak, cannot overcome gravity
3 = moderately weak, can just overcome gravity
4 = mildly weak, cannot overcome resistance
5 = normal strength
In the upper extremities, check shoulder adduction
and abduction; elbow flexion and extension; wrist
flexion and extension; finger extension and flexion;
interossei
In the lower extremities, check: hip flexion, extension,
adduction and abduction; knee flexion and extension;
ankle dorsiflexion, plantar flexion, inversion and
eversion; toe dorsiflexion and plantar flexion.
D. Involuntary movements (fasciculations, tremor,
chorea, dystonia, etc.)
Reflexes
A. Muscle stretch reflexes (0 - 4 scale) - biceps,
brachioradialis, triceps, quadriceps, ankles
0 = absent
1 = hypoactive
2 = normal active
3 = brisk active
4 = pathologically brisk (associated with pathologic
spread and/or clonus)
B. Cutaneous reflexes
1. Babinski
2. Abdominal, cremasteric (if necessary)
C. Primitive reflexes or "Frontal release" signs
1. Snout, suck, palmar mental, gabellar (if necessary)
Sensation
A. Pin/temperature (small fiber - spinothalamic tract) -
check all four extremities
B. Vibration, joint position sense (large fiber - dorsal
columns) - check all four extremities
C. Cortical sensation
1. Stereognosis
2. Graphognosis
3. Double simultaneous stimulation
Coordination and Gait Testing
A. Rapid alternating movements
B. Finger nose finger
C. Heel to shin
D. Gait
E. Tandem gait
F. Romberg sign
Other (if necessary)
A. Neurovascular Exam
1. Carotid and ocular bruits
2. Facial pulses
B. Straight leg raising
C. Nuchal rigidity
D. External evidence of trauma
LABORATORY DATA
The laboratory data should be listed. It needs to be
complete, accurate and organized. Laboratory data may
include blood tests, CSF studies, EKG, radiology and any
clinical neurophysiology (e.g., EMG, EEG). Attention
should be given to any abnormal results.
ASSESSMENT, PROBLEM
LIST AND PLAN
The patient assessment should summarize the key points
from the history and physical followed by a problem list
and plan. The first problem listed should be the problem
that has resulted in the patient being admitted to the
hospital or the reason for referral. This problem should
be followed by an assessment that lists and discusses
the most likely diagnoses for the problem. In the
neuroscience clerkship, it is essential to discuss the
localization of the problem within the neuraxis. The
resultant discussion should demonstrate your skills in
integrating clinical information from the patient. The
discussion should include management plans that includes
plans for further rational diagnostic studies,
treatments and patient education.
Judgement should be used in the degree of detail
provided about other active problems. The plan may vary
depending if the patient is seen on the ward, the
consult service or in the outpatient clinic. In the
modern day, it is often important to consider discharge
planning early, especially for anticipated
rehabilitation or skilled nursing needs. Likewise, it is
essential to identify the primary care physician and
ensure they are kept informed.
VERBAL PRESENTATION
The ability to clearly present a case is one of most
important skills to master during the core clerkships.
The challenge is to be precise and to the point.
Pertinent positives and negatives need to be mentioned;
the remainder can be included in the written note. The
focus of the presentation is the history of present
illness. After the history, the listener will have
internally generated a list of questions and hypotheses
which can then be further narrowed from information
gleamed by the physical examination. A busy service
could not operate if every patient presentation took an
hour. Once mastered, the entire neurologic history and
physical examination should be able to be presented in
the range of 5-10 minutes.
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