Acute Onset vascular/ convulsion

Aura plus unconscious major seizure/ partial complex seizure

Hemiplegia/ dysphagia/ difficulty in speech stroke/ cerebrovascular event or
Transient Ischemic attack (TIA) if resolved within 24 hours
TIA vs Hemiplegic Migraine no headache vs headache (may be absent in elderly,
causing a difficulty in distinguishing between both)
Subacute Onset inflammatory disorders
Meningitis, cerebral abcess or Gullian-Barre syndrome
Gradual Onset - muscle
Muscle abnormality such as myopathy
Chronic
Tumor/ degenerative
Non-specific
Metabolic/ toxic disorders
Localized/ diffuse
Cerebral hemispheres/ brainstem/ spinal cord/ peripheral nerves
Headache
Unilateral headache preceded with flashing lights/ zig-zag lines associated with
photophobia + aura classical migraine/ common migraine (without aura)
Pain over one eye associated with lacrimation, rhinorrhea, and forehead flushing for
few weeks a few times a year cluster headache
Headache over occiput + neck stiffness cervical spondylosis
Headache during intercourse near to orgasm coital headache; sudden, severe
headache lasting 15 minutes/persist in a milder form for several hours in middle
aged man with NO nausea and neck stiffness
Dramatic, instantaneous onset of severe headache that is initially localized but
becomes generalized in association with neck stiffness sub-arachnoid
hemorrhage (may occur during sexual intercourse)
Generalized headache with drowsiness/ vomiting raised intracranial pressure
Generalized headache + photophobia + fever + stiff neck of gradual onset
meningitis
Persistent unilateral headache over temporal area + tenderness over temporal
artery + diplopia temporal arteritis associated with jaw claudication and loss of
weight

Headache with pain behind the eyes/ cheeks/ forehead acute sinusitis
Morning headaches worsened by cough idiopathic intracranial hypertension
(especially in obese patients, visual loss may occur)
Bilateral over frontal, temporal and occipital described as sensation of tightness for
hours which recurs often Episodic/ tension-type headache (no nausea, vomiting
weakness or parenthesis)
Migraine vs Tension-type headache Pulsatile, 4-72 hOurs, Unilateral, Nausea and/
or vomiting, Disabling in migraine
Face Pain
Trigeminal neuralgia, temporomandibular arteritis, psychiatric disease, aneurysm of
internal carotid/ posterior communicating artery, superior orbital syndrome
Faints and Fits
Syncope vs epilepsy
Aura + loss of consciousness + urine and fecal incontinence + bitten tongue
tonic-clonic seizures (major seizure)
Generalized/ localized (focal lesion: tumor or abscess)
Impaired consciousness complex partial seizures
Non- impaired consciousness simple partial seizures
Brief episodes of loss of awareness associated with staring Idiopathic absence
seizures in children
Drop attacks, patients fall with no loss of consciousness TIA
Loss of consciousness hypoglycemia with report of sweeting, weakness and
confusion
Slump to ground with apparent fluctuations in level of consciousness for a
prolonged period hysteria
Dizziness
Vertigo (sense of motion) vs dizziness
Vertigo with or without hearing loss
Visual disturbances
Diplopia/ amblyopia/ photophobia/ visual loss
Deafness
Unilateral- tumors, trauma, vascular disease
Bilateral- environmental exposure, degeneration, toxicity, infection, Menieres
disease, brainstem diseases

Conduction deafness- wax, otitis media, otosclerosis, or Pagets disease

Gait
Altered sensation/ weakness in limbs
UMN lesion vs LMN lesion vs muscle disease vs disease at neuromuscular junction
vs non-organic weakness
UMN
Increase tone
Increased
peripheral
reflexes
No muscle
wasting

LMN
Reduction in tone
Decreased reflexes

Fasciculation
Muscle wasting

Muscle disease
Reduction in tone
Decreased/ absent
reflexes

Disease of NMJ
Normal tone
Normal reflexes

Muscle wasting

Tremor & involuntary movements

Speech and Mental Status
Neck stiffness
Resistance in neck flexion due to spasm of extensor muscles meningism
Resistance in Neck rotation cervical spondylosis, after cervical fusion, Parkinsons
disease, and raised intracranial pressure, especially if impending tonsillar herniation
Kernigs sign
Flex each hip, then attempt to straighten knee, resistance due to spasm in
hamstrings meningitis due to inflammatory exudate around lumbar spinal roots
Brudzdinski sign
Spontaneous flexion of hip when neck is flexed meningism
Fever + neck stiffness + headache meningitis
Handedness
Orientation
Place, Person, Time
Delirium (acute, reversible) vs Dementia (chronic, irreversible)
Cranial nerves
Patient sitting with legs hanging off the floor
Acromegaly, Pagets disease (tibia bowing), basilar invagination, ptosis, proptosis,
pupillary inequity, slew deviation of eyes and facial asymmetry

Scalp for craniotomy scars and skin for neurofibroma

Capillary or cavernous hemangiomas Sturge-Weber syndrome associated with
intracranial venous hemangioma of the leptomeninges and seizures
Herpes zoster appears with nerve distribution, diagnostic help in painful rash
CN I- tested if patients complains of anosmia/ loss of taste
Rash/ deformity of external nose
Speculum + nose elevation to examination of nasal vestibule
Test each nostril with common essences, avoid pungent substances because
noxious stimuli is detected by CN V
Nasal passages examination for polyps/ mucosal thickening
Causes of bilateral anosmia
-

URTI
Smoking
Aging
Ethmoid tumors
Basal skull fracture/ frontal fracture/ post-pituitary surgery
Congenital agenesis of olfactory bulb in Kallmans syndrome/
Hypogonadotropic hypogonadism
Meningioma of olfactory groove
Meningitis

Causes of unilateral anosmia

-

Head trauma with no fracture

Early meningioma

CN II
Curtain drawn across one eye + spontaneous return of vision amaurosis fugax
Flickering spot at center of visual field scintillating scotoma
Negative visual symptoms (unable to see something) vs positive visual symptoms
(seeing weird things)
Visual acuity- Snellens test, 6m, each individual eye tested separately, acuity
improve via pin-hole (refractive error), unable to read largest letter number of
fingers hand movement light perception
Bilateral blindness of rapid onset
-

Bilateral occipital lobe infarction

Bilateral occipital lobe trauma
Bilateral optic nerve damage
Hysteria

Sudden blindness in one eye

Retinal artery/ vein occlusion

Temporal arteritis
Non-arteritic ischemic optic neuropathy and optic neuritis/ migraine

Bilateral blindness of gradual onset

-

Cataracts
Acute glaucoma
Macular degeneration
Diabetic retinopathy
Bilateral optic nerve damage

Visual field- confrontation

-

disappearance and reappearance of red pin central scotoma

wash out red color optic nerve pathology

Fundoscopy
-

+20 lens and ask patient to gaze into distance to prevent pupil reflex
contraction look at cornea, iris then lens for corneal ulcers or undulation of
the rim of iris or opacities of the lens (cataracts) rack ophthalmoscope to 0
to shift focus to fundus search for optic disc
Loss of normal depression leading to blurring of margins papilledema
raised ICP
Presence of pulsation in retinal veins rule out papilledema
Papilledema + demyelination of anterior part of optic nerve papillitis
Papillitis causes loss of vision while papilledema does not
Pale white optic disc optic atrophy
Note for hypertensive or diabetic retinopathy changes note hemorrhage/
exudates

CN III,IV, VI
Pupils
-

Patients looks at object at intermediate distance, observe for size, shape,

equality and regularity
Ptosis
Ectropion
Light reflex, light source brought form side, pupil shone with light will
constrict briskly and other pupil will constrict together (consensual response)
Move torch in arc fashion between eyes, afferent pupillary defect ( affected
eye will dilate paradoxically after a short time when the torch is shone from
normal eye to affected eye optic atrophy/ severely reduced visual acuity
Accommodation, patient looks into the Dianne and a white hat pin is brought
to 30 cm in front of the nose of the patient, there will be contrition of pupils.
Absent light reflex + intact accommodation --> midbrain lesion (Argyll
Robertson pupil of syphillis)/ ciliary ganglion lesion (Adies pupil)/ Parinauds
syndrome
Failure of accommodation--> midbrain lesion / cortical blindness

Eye movement
-

failure of eye movement --> double vision (Diplopia) and nystagmus

Strabismus/ squint
Concomitant/ incomitant squint
Concomitant squint common in children / idiopathic / intracranial mass
Strabismus is associate with Diplopia but one of the image may be
suppressed especially in children and lead to amblyopia
Assess voluntary movement of eye Look up, look down, look left and look
right
Ask patient to follow hat pin in a H movement
Ask patient to follow hat pin in a X movement
Diplopia, position of false image to take not (side by side or Up and down)
False image is pale and less distinct
Mononuclear Diplopia --> astigmatism, myopia, dislocated lens, cataract or
hysteria
If there is any muscle weakness, individual eyes must be assessed

3rd nerve lesion features

-

Complete ptosis, divergent strabismus and dilated pupil unreactive to light

but consensual response reflex is still intact
Exclude 4th nerve lesion
Causes :
Central: vascular lesion in brain stem, tomorrow, and demyelination
Peripheral: compressive lesion aneurysm)