Its a detailed description of how to manage a neurosurgical long case. A proper comprehensive history taking and examination technique based on the FCPS II exam pattern in Pakistan

1. NEUROSURGERY LONG CASE
HISTORY AND EXAMINATION
TECHNIQUE
DR. FARRUKH JAVEED
Final Year Resident

2. Time/Duration
• Total time 60 mins
• History and examination 30 mins
• Viva 30 mins

3. History & Examination – 30 mins
• History 10-12mins (11)
• Examination 18-20mins (18)
• Finalization 1-2mins (1)

4. History and examination – time breakage
History –
11mins
Introduction
and PCs –
2mins
HOPC – 4mins
Intracranial
Review –
2mins
Systemic
Review –
1min
Past, Personal
and Family –
2mins

5. History and examination – time breakage
Examination –
18 mins
GPE – 2mins
MMSE & Lobe
Signs – 4mins
Cranial Nerves
– 6mins
Cerebellar
Signs – 2mins
Limbs
Examination –
4mins

6. HISTORY TAKING…!

7. Introduction
• Name: Age: Sex:
• Handedness:
• Marital Status:
• Occupation:
• Resident:
• Admitted via:
• Date of admission:

8. Presenting Complaints
• Direct question for the presenting complaints.
• Ask if any of the following occurs other than the presenting
complaints:
• Headache
• Loss of consciousness
• Seizures
• Visual Changes
• Hearing loss/change
• Motor weakness/problem with balance
• Speech difficulty/change

9. HOPC
• Detailed history (questionnaire) of the individual presenting
complaints.
• Ask specifically for the following:
• Any history of head or spine trauma
• History of T.B or contact to T.B
• Weight loss

10. Headache
• Since when are you having this headache?
• Does it start all of a sudden or was it gradual?
• Specifically where does this headache occur? (point)
• Is it intermittent or continuous?
• If intermittent, how often does it occur?
• How long does it last?
• Is there a specific time in the day when it occurs?
• What type of pain? (Aching, throbbing, burning etc)
• How severe is the pain? Does it affect your daily routine or sleep pattern?
• Does the pain radiate anywhere?
• What are the exacerbating factors? Does it increase on straining, coughing, sneezing or bending down?
• What are the relieving factors?
• Is it associated with nausea/vomiting, fever, diplopia or visual disturbances, neck rigidity, vertigo?
• Have you ever had such kind of a pain before?
• Is the headache preceded by any blinking lights or certain smells or tinnitus or sounds?

11. Nausea/Vomiting
• Have you ever felt nauseous? Is it accompanied by vomiting?
• How many times have you vomited uptil now? How many times per
day (if regular)?
• Is it projectile?
• What’s the color and consistency?
• Is there any blood in the vomitus?
• What is the quantity?
• Does it have a bad odour?
• Is it associated with severe headache or vertigo?

12. Seizures
• Have you ever had fits or lost consciousness?
• What were you doing at the time?
• Were you unconscious during the episode or were you aware of what was going on?
• How long were you unconscious?
• Did it start from a specific body part or was It generalized from the beginning?
• Was there someone with you at the time? Were you hurt?
• Was it associated with:
i) Frothing from the mouth
ii) Rolling over of the eyes
iii) Urinary incontinence
iv) Tongue biting
• Did you remember the event after regaining consciousness?
• Did you feel very lethargic/ weak/ drowsy after the event?
• Did you see any strange lights or see hear any strange sounds before the seizure?
• How many episodes of fits have you had?
• Have you previously taken any consultation or treatment for it?

13. Visual Loss/Impairment
• Since when are you having visual problems?
• Is it blurring of vision or are you seeing double?
• Was this visual impairment gradual or sudden?
• Is it progressive?
• Is it unilateral or bilateral?
• Is it total or partial visual / field loss?
• Was it painless or painful?
• Is it associated with headache or vomiting?
• Is it associated with any hallucinations or aura?
• Can you move the eyes comfortable in all directions?

14. Neurological Deficit/Weakness
• Do you feel difficulty in moving your limbs?
• Upper or lower limbs? Right or left side?
• Was It sudden or gradual in onset?
• Does it involve the whole limb or only certain parts (i.e proximal or distal)?
Which part was affected first?
• Is the weakness static or progressive?
• Do you feel numbness/ paresthesia in the affected limb?
• Is it associated with dystonic movements or focal fits?
• How much does it affect your daily life?
• Can you feel touch or pain when pricked?
• If lower limb affected, can you walk with or without support?
• Are the movements painful?

15. Speech Disorder
• Since when is he having this problem?
• Was it sudden or gradual?
• Is he having any difficulty in finding words he wants to say?
• Does he mean to say something sometimes and the wrong word comes out unintentionally?
• Does the patient often use made up words?
• Does the patient have a hard time forming sentences?
• Does the patient put made up words and real words together into sentences that do not make
sense?
• Does the patient have difficulty understanding what others are saying and give inappropriate
responses?
• Is this more pronounced in a noisy place or in a group?
• Does the patient have difficulty in understanding jokes?
• Does he stammer?
• Does he have difficulty in forming words or expressing himself?

16. Hearing Loss/Change
• Since when are you having this problem?
• Was it sudden or gradual?
• Unilateral or bilateral?
• How did he notice it?
• Is it associated with any ear pain or discharge?
• Is there any tinnitus?
• Any history of hearing strange sounds?
• Does the patient have difficulty in balancing himself while walking?
• Does he feel like the world is spinning?
• If there is a sense of vertigo and the patient falls, which side does he tend to fall towards more often?
• Is there any facial numbness or tingling?
• If so, is it constant or does it come and go?
• Does the patient experience any weakness on any side of the face? (Inability to close the eyes fully or smile)?
• Is there any change in the taste?
• Any difficulty in swallowing?
• Any hoarseness or change in voice?

17. Intracranial Review
• Frontal (Fits, Motor weakness, Aggressiveness, Speech, Urinary
incontinence), Temporal (Memory, Seizures with aura), Parietal (Dressing,
Forgetting home, difficulty with calculations), Occipital (Sparks).
• Ant 3rd V (Drop attacks), Post 3rd V (Looking up), Pituitary (Change in
hands/feet size, loss of libido, nipple discharge, infertility, menstrual
irregularity, hyperpigmentation), Thalamus (Heat & Cold Intolerance),
Hypothalamus ( Micturition,  Eating).
• Post fossa (Drunken gait, Tremors, Truncal ataxia).
• Smell CNI, Vision CNII, Diplopia CNIII CNIV CNVI, Facial sensory loss CNV,
Brain stem (Facial weakness CNVII, Swallowing CNIX CNX CNXI, Nasal
regurgitation of water).

18. Systemic Review
• GIT: Vomiting, Abdominal pain, diarrhea/constipation
• Respiratory: Dyspnea, cough, hemoptysis
• Cardiovascular: chest pain, palpitation, fatigue
• Genitourinary: dysuria, frequency, urgency, incontinence
• Musculoskeletal: joints pain

19. Past History
• Previous hospitalization
• Any history of blood transfusion
• Past medical
• Past surgical
• Drug intake
• Any allergy

20. Family, Personal & Socioeconomic History
• Family Hx of any brain lesion, spine lesion, T.B, HTN, Diabetes. Ask
about the parents, siblings and children.
• Personal Hx: Sleep changes, weight loss, any addiction
• Socioeconomic Status: Type of job, no. of family members

21. Examination….!

22. General Physical Examination
• Vitals:
• BP: HR:
• R/R: Temp:
• Subvitals:
• A, Cy, Cl, D, Ed, J, K
• Lymph Nodes: Thyroid:
• Hyperpigmentation: Hyperostosis:
• Café au Leit: Others:
• Signs of meningeal irritation

23. Mini-mental Score Examination
• Orientation to time(5)
• Orientation to place(5)
• Repeat three objects(3)
• Spelling WORLD backward(5)
• Recall three objects(3)
• Recognize objects(2)
• Recognize idiom(1)
• Three-step command(3)
• Do what’s written e.g. “Close your eyes”(1)
• Copy a design(1)
• Write a sentence(1)
TOTAL SCORE = 30
Good Score ≥ 24
Cognitive impairment ≤ 23
mild 19–23
moderate 10–18
severe ≤ 9

24. Lobe Signs
• Frontal: attention, concentration, abstraction, judgment, planning,
frontal gaze, pronator drift, speech. Glabellar, rooting, sucking, grasp,
palmomental.
• Temporal: memory, hearing.
• Parietal: finger agnosia, astereognosis, right/left differentiation,
complex task.
• Occipital: vision

25. Cranial Nerves
• CN I: Torch examination, Check smell bilateral with patient’s eyes closed.
• CN II: Pupil (size, shape, symmetry), Acuity, Pupillary reflexes (direct and
consensual), Swinging light test, Accommodation, Color vision, Visual field,
Fundoscopy.
• CN III:
• CN IV: Ptosis, Eye movements.
• CN VI:

26. Cranial Nerves
• CN V: Sensory(light touch, pinprick), Motor(masseter, temporalis), Reflexes(jaw jerk,
corneal)
• CN VII: Inspect asymmetry, Facial movements (raise eyebrows, close eyes, blow cheeks,
smile, whistle, close lips), EAM, Hearing change, Taste change.
• CN VIII: Torch examination, Whisper, Rinne’s, Weber’s, Turning test, Vestibulo-Ocular reflex.
• CN IX and X: Torch examination, Assess soft palate & Uvula, Gag reflex, Cough, Swallow.
• CN XI: Shrug, Rotate against resistance.
• CN XII: Inspect tongue (wasting, fasciculations), Protrusion, Power.

27. Cerebellum
• Nystagmus
• Hypotonia
• Rebound Phenomenon
• Pendular Knee Jerk
• Heel Shin
• Romberg
• Dysdiadochokinesia
• Pastpointing
• Scanning Speech
• Intention Tremors
• Tandem Walking
• Ataxia (Gait & Posture)

28. Upper limbs
• General appearance (Position/Deformity, Scars, Wasting,
Fasciculations, Tremor)
• Sensations (Light touch, Pinprick, Vibration, Proprioception)
• Tone
• Power
• Deep tendon reflexes.
Right Upper Left Upper
Bulk
Tone
Power
Reflexes

29. Lower Limbs
• General appearance (Position/Deformity, Scars, Wasting,
Fasciculations, Tremor)
• Sensations (Light touch, Pinprick, Vibration, Proprioception)
• Tone
• Power
• Deep tendon reflexes.
• Clonus
• Planters.
Right Upper Left Upper
Bulk
Tone
Power
Reflexes
Clonus
Plantars

30. Viva
1. Present history and examination
2. Summary
3. Localization of the lesion with
justification
4. Differential Diagnosis with
justification
5. Investigations
6. Counseling
7. Treatment options
8. Surgical indication
9. Surgical options
10. Pre-requisites for surgery
11. Surgical steps
12. Principal of surgery
13. Complications and management
14. Post-op care/follow-up
15. Any other adjuvant treatment
16. Rehabilitation
17. Recent advances

31. The best way to predict the future
is to create it.