Nervous System

Cerebellar Function Assessment

Romberg Test:

• Patient stands upright with arms relaxed at sides and feet together.
• With eyes closed, observe for significant swaying or loss of balance.
• Positive test suggests proprioceptive dysfunction.

Tandem Gait Test:

• Patient walks a straight line using a normal gait.
• Then instructed to walk heel-to-toe in a straight line.
• Positive test if patient loses balance, veers off course, or is unable to complete the task.

Neurological Examination Techniques

Kernig’s Test:

• With the patient lying down, flex one hip at a time to a 90° angle.
• Attempt to straighten the leg while keeping the hip flexed.
• Positive if pain or resistance occurs.

Brudzinski’s Sign:

• Gently bend the patient’s neck forward, bringing the chin toward the chest.
• Positive if the patient reflexively bends the hips and knees to reduce discomfort.

Nuchal Rigidity Test:

• Instruct the patient to attempt touching the chin to the chest.
• Inability due to pain or stiffness indicates a positive result.

Cerebellar Function and Neurological Assessment

Coordination (Diadochokinesia)

Rapid Alternating Movements:

• Have the patient place their forearms on their thighs and rapidly alternate between supination and pronation.

Heel-to-Shin Test:

• With the patient lying supine and legs extended, instruct them to place one heel on the opposite knee and slide it down the shin.
• Repeat with the other leg.

Sensory Function

Assess Sensation:

• Vibration, temperature, and sharp vs. dull touch.

Stereognosis:

• Ask the patient to identify a familiar object by touch alone.

Graphesthesia:

• Trace a number or letter on the patient’s palm and ask them to recognize it.

Motor Function

Gait Assessment:

• Observe normal walking patterns and assess for muscle atrophy in the legs.

Pronator Drift Test:

• Ask the patient to extend both arms forward, palms up, and close their eyes.
• Observe for any downward drifting over 5–10 seconds.

Deep Tendon Reflexes:

• Quadriceps (knee-jerk reflex)
• Achilles tendon (ankle-jerk reflex)
• Plantar reflex (Babinski’s sign)

Cranial Nerve Overview

Mnemonic for Function: Some Say Marry Money, But My Brother Says Big Brains Matter More (Sensory, Motor, Both)

Cranial Nerve Breakdown:
I (S) – Olfactory → Sense of smell (one nose)
II (S) – Optic → Visual acuity, fields, fundoscopy (two eyes)
III (M) – Oculomotor → Moves eyes up, down, and medially (CN 3 helps you look up)

IV (M) – Trochlear → Moves eyes downward and inward
V (B) – Trigeminal → Sensation to forehead, cheeks, and jaw; controls jaw clenching
VI (M) – Abducens → Moves eyes laterally (side to side)
VII (B) – Facial → Facial expressions: raise eyebrows, close eyes, puff cheeks, and smile
VIII (S) – Vestibulocochlear (Acoustic) → Hearing and balance (Rinne & Weber test)
IX (B) – Glossopharyngeal → Speech, swallowing, and gag reflex
X (B) – Vagus → Controls digestion, defecation, and heart rate (helps stick out tongue)
XI (M) – Accessory (Spinal) → Shoulder shrug and head movement
XII (M) – Hypoglossal → Tongue movement (stick out tongue)

Cranial Nerve Mnemonic for Eye Movement

Which cranial nerves control eye movement?

• CN III, IV, and VI – “They make the eyes do the tricks!”

3-Minute Neurological Assessment

Balance & Coordination:

• Stand still with eyes closed → Romberg test
• Open eyes and walk heel-to-toe in a straight line → Tandem gait
• Walk on tiptoes → Tests plantar flexion strength
• Walk on heels → Evaluates dorsiflexion power

Motor & Reflex Testing:

• Close eyes → Perform Pronator Drift test, followed by Finger-to-Nose
• Open eyes → Mimic piano playing (assesses pyramidal function)
• Rapid tapping or alternating hand movements (tests coordination)
• Close eyes tightly → Facial nerve (CN VII)
• Open eyes → Observe pupillary reflex (CN II, III)
• Smile → Facial nerve (CN VII)
• Stick out tongue → Hypoglossal nerve (CN XII)
• Move tongue rapidly → Assesses pseudobulbar palsy

Cranial Nerve & Sensory Testing:

• Test visual fields using confrontation (CN II)
• Assess eye movements (CN III, IV, VI)
• Check Babinski reflex (assesses upper motor neuron function)
• Perform fundoscopy (examine optic nerve and retina)

Migraines

Headache Type	Symptoms	Triggers	Acute Treatment	Preventive Measures
Migraine without Aura	Throbbing pain, typically behind one eye, sensitivity to light and sound, nausea/vomiting. Lasts 4-72 hours.	Red wine, MSG, aspartame, menstruation, stress.	Ice pack on forehead, rest in a dark, quiet room. Triptans, Tigan suppositories.	TCAs, beta-blockers for episodic migraines (<14 days/month).
Migraine with Aura	Same as above, but preceded by visual disturbances (scotomas, flashing lights, halos).	Foods high in triptans, more common in teenage to middle-aged females.	Same as migraine without aura.	Same as migraine without aura.
Trigeminal Neuralgia (CN V)	Sudden, intense, sharp, stabbing pain affecting one cheek.	Triggered by cold food, cold air, talking, touch, or chewing. Common in older adults.	Carbamazepine (Tegretol) or phenytoin (Dilantin). Monitor serum levels.	Long-term use of Tegretol or Dilantin, monitor for drug interactions.
Cluster Headache	Excruciating “ice-pick” pain behind one eye and temple, tearing, rhinorrhea, ptosis, and miosis (Horner’s syndrome).	Occurs at the same time daily in clusters for weeks to months, primarily affects middle-aged males.	First-line therapy includes subcutaneous sumatriptan and 100% oxygen at 12 L/min via non-rebreather mask. Intranasal 4% lidocaine may be used as an adjunct, but it is not a primary treatment.	Avoid alcohol. Episodes often resolve spontaneously but can be distressing.
Temporal Arteritis (Giant Cell Arteritis)	Unilateral temporal pain with scalp tenderness, indurated and warm artery, possible amaurosis fugax (temporary blindness).	Associated with polymyalgia rheumatica (50% of cases), occurs in older adults.	Immediate referral to ED or ophthalmologist. Lab: ESR. High-dose steroids.	Temporal artery biopsy is the gold standard for diagnosis. Risk of permanent blindness if untreated.
Tension Headache	Dull, continuous, bilateral “band-like” pressure. May be accompanied by trapezius muscle tightness.	Stress, common in adults.	NSAIDs, Tylenol, hot showers, massage, relaxation techniques.	Stress management, yoga, massage, biofeedback.

Common Medications for Headache Management

Acute Treatment:

• NSAIDs → May cause gastrointestinal discomfort, ulcers, kidney damage, and increased blood pressure in hypertensive patients.
• Triptans → Can trigger nausea and, in rare cases, acute myocardial infarction. Use cautiously in those with cardiovascular conditions. Avoid within 24 hours of ergot derivatives and 14 days of MAOIs.
• Analgesics (e.g., Acetaminophen) → Risk of liver toxicity. Not effective for prevention; must be taken daily for prophylaxis.

Preventive Therapy:

• Tricyclic Antidepressants (TCAs): Amitriptyline or imipramine may be used at half the typical dose. Common side effects include drowsiness, dry mouth, and confusion—especially in older adults.
• Beta-Blockers: Daily propranolol or atenolol may help prevent migraines. Avoid use in patients with 2nd or 3rd-degree heart block, asthma, COPD, or bradycardia.
• Antiepileptics (e.g., Topiramate): Often requires gradual dose titration. Contraindicated in patients with a history of kidney stones.
• CGRP Inhibitors: Newer injectable monoclonal antibodies (e.g., erenumab, fremanezumab) offer effective migraine prophylaxis for patients with frequent or refractory migraines. These are generally well-tolerated and represent a more targeted treatment option.

Concussion Overview

Common Symptoms:

• Head pain, memory impairment, disorientation, vertigo, tinnitus, nausea, and vomiting.

Return to Activity:

• Must successfully complete a structured evaluation before resuming sports or physical exertion.

Potential Complications:

• Increased risk of subdural hematoma following head trauma.

Headaches

Primary Headaches	Secondary Headaches
Occur independently, not linked to other medical conditions.	Result from underlying health issues or external causes.
Includes migraines, tension headaches, and cluster headaches. More common.	Caused by factors such as brain tumors, intracranial bleeding, increased intracranial pressure (ICP), medications (e.g., nitroglycerin), meningitis, or giant cell arteritis.

Red Flag Headaches

Systemic Symptoms:

• Fever, unexplained weight loss
• Risk factors: HIV, cancer, pregnancy, anticoagulant use, hypertension

Neurological Signs & Symptoms:

• New-onset symptoms: Confusion, altered consciousness, impaired alertness, neck stiffness, hypertension, papilledema, cranial nerve dysfunction
  • Exceptions: Photophobia & phonophobia may be acceptable
• Unequal pupil sizes

Onset Characteristics:

• Sudden, severe, “thunderclap” headache (possible subarachnoid hemorrhage)
• Triggered by exertion, sexual activity, coughing—suggestive of increased intracranial pressure (ICP)

Age Considerations:

• Higher concern in individuals over 50 or under 5 years old

Headache History:

• Less concerning if patient has a prior history of similar headaches
• “Worst headache of my life”—must rule out subarachnoid hemorrhage

Potential Causes to Rule Out:

• Subarachnoid or acute subdural hemorrhage
• Leaking aneurysm
• Bacterial meningitis
• Increased intracranial pressure (ICP)
• Brain abscess or tumor

Brain Damage

• Apraxia – Impaired ability to carry out purposeful movements despite intact motor function.
• Broca’s Aphasia (“Nonfluent Aphasia”) – Patient understands speech and can read but struggles with forming words and sentences; speech is fragmented or effortful.
• Wernicke’s Aphasia (“Fluent Aphasia”) – Patient speaks easily but has difficulty understanding language; speech may lack meaning, and reading/writing abilities are often affected.
• Frontal Lobe Damage – Impacts intelligence, personality, and cognitive function; may cause memory loss, dementia, and difficulty learning new information.

Headache Assessment

Patient History

• Location – Where is the pain?
• Description – What does it feel like?
• Patient Behavior – Are they lying in the dark in discomfort, or casually reading?
• Duration – How long does it last?
• Accompanying Symptoms – Any other issues present?

Physical Examination

• Vital Signs – Blood pressure and pulse
• Palpation – Check the head, neck, shoulders, and spine
• Auscultation – Listen for bruits

Key Considerations

• If a new headache develops after age 35, further testing is warranted.

When Imaging is Justified

• Symptoms suggest a red flag headache
• Changes in pattern, frequency, or intensity
• Headache worsens despite treatment
• Presence of unexplained neurological signs
• Pain is always localized to the same side
• Headache triggered by exertion, coughing, or intercourse
• New onset after age 50
• Associated symptoms: fever, stiff neck, papilledema, cognitive decline, or personality changes

Mini-Cog Assessment

• Immediate Recall – Repeat three words
• Clock Drawing Test – Assess for accuracy (normal vs. abnormal)
• Delayed Recall – Repeat the three words again
• Scoring:
  • 0-2 → Indicative of dementia
  • 3 or higher → Unlikely to have dementia

Mini-Mental State Examination (MMSE)

• Orientation – Assess awareness of time, place, and situation
• Short-Term Memory – Recall three unrelated words
• Attention & Calculation – Spell “WORLD” in reverse or subtract 7s from 100
• Delayed Recall – Repeat the previously given words
• Writing Task – Compose a simple sentence
• Visual-Spatial Skills – Copy a geometric design
• Language Assessment – Observe for signs of aphasia (difficulty in speech or language comprehension)

Headache Differential Diagnosis:

• Sinusitis – Associated with nasal congestion or facial pressure
• Temporal Arteritis – Symptoms include jaw pain while chewing, fever, vision disturbances, and tenderness in the temple region***
• Optic Pathway Lesion (Pituitary Tumor) – May present with visual field deficits
• Intracranial Lesion – Blurred vision when bending forward
• Brain Tumor – Headache accompanied by nausea and vomiting
• Optic Neuritis – Sudden loss of vision in one eye
• Pheochromocytoma – Characterized by excessive sweating and rapid heartbeat
• Pseudotumor Cerebri* – Temporary vision changes due to increased intracranial pressure

Condition	Cause	Signs & Symptoms	Diagnostics	Treatment	Concerns
Acute Bacterial Meningitis	Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae	High fever, severe headache, stiff neck, meningismus, rapid mental status changes, nausea/vomiting, photophobia, petechial rash, worsening to lethargy, confusion, and coma.	Lumbar puncture (↑ WBC, ↑ protein, ↓ glucose), CT/MRI, CBC, CMP, coagulation panel, blood cultures ×2, Gram stain & CSF culture.	Report to Health Dept. Infants: Ampicillin + 3rd-gen cephalosporin. Adults: 3rd-gen cephalosporin + Chloramphenicol. >50 yrs: Amoxicillin + 3rd-gen cephalosporin. Prophylaxis for close contacts with rifampin or ceftriaxone.	Fatal if untreated.
Temporal Arteritis (Giant Cell Arteritis)	Autoimmune vasculitis affecting temporal artery.	Sudden headache on one temple (often in older adults), scalp tenderness, indurated/red/tender artery, jaw pain, abrupt visual changes (amaurosis fugax).	Elevated ESR & CRP.	Urgent referral to ophthalmologist or ED. Temporal artery biopsy (gold standard). High-dose steroids (40-60 mg/day). Add PPI for ulcer prevention and bisphosphonates for bone health.	Risk of permanent blindness. Mean diagnosis age: 72. More common in women. 30% of patients with polymyalgia rheumatica are at high risk.
Stroke (CVA)	Embolic (clot) or hemorrhagic (bleeding).	Embolic: Sudden speech issues, facial weakness, hemiparesis. Hemorrhagic: Severe headache, nausea/vomiting, nuchal rigidity, history of poorly controlled hypertension.		Call 911, assess ABCs. Risk factors: A-fib, hypertension, aneurysm, anticoagulants, stimulants, sickle cell disease, diabetes, smoking, oral contraceptives.	Higher prevalence in Black, Hispanic, and Indigenous populations.
Chronic Subdural Hematoma (SDH)	Bleeding between dura and arachnoid membranes.	History of head trauma, headache, gradual cognitive decline (apathy, somnolence, confusion). More common in older adults and those on anticoagulants or aspirin therapy.
Subarachnoid Hemorrhage (SAH)	Head trauma.	Sudden, severe “worst headache of life,” photophobia, nausea/vomiting, meningeal irritation (+Brudzinski & Kernig signs), altered consciousness. Elderly: often due to falls. Younger adults: often from motor vehicle accidents.			Sentinel headache (warning sign) can occur days to weeks before rupture.
Migraine (With or Without Aura)		Gradual onset throbbing headache, often behind one eye, worsens over hours, may last 2-3 days, may become bilateral. Aura symptoms: Paresthesia, halos, metallic taste, hyperosmia, scotomas. Positive family history. In children, migraines may present as abdominal pain.	Migraine Without Aura: – Headache 4-72 hrs. – 2+ symptoms (unilateral, pulsating, moderate/severe, aggravated by routine activity). – 1+ additional symptom (nausea/vomiting, photophobia, phonophobia). – At least 5 attacks. Migraine With Aura: – At least 2 attacks with aura (visual/sensory/motor symptoms). – Develops over 5-20 min, headache follows within 60 min.	Rest in a dark, quiet room, apply ice, avoid triggers (MSG, alcohol, caffeine, stress, bright lights, menses, skipping meals). Abortive treatment: Triptans, NSAIDs, antiemetics. Prophylactic treatment: Beta-blockers, TCAs, anticonvulsants (avoid in history of kidney stones). Supplements: Butterbur, feverfew, magnesium.	Triptan contraindications: Ischemic heart disease, CVA/TIA, hypertension, diabetes, obesity, males >40, hyperlipidemia. Risk of serotonin syndrome with SSRIs/SNRIs. Avoid within 2 weeks of MAOI use or in combination with ergots. Avoid estrogen-progestin contraceptives in migraine with aura due to stroke risk.

Condition	Cause	Signs & Symptoms	Diagnostics	Treatment	Concerns
Basilar or Hemiplegic Migraine		Stroke-like symptoms, focal neurological deficits, resembles TIA.		Avoid estrogen-containing medications.
Polymyalgia Rheumatica (PMR)		Bilateral morning stiffness and aching in shoulders, neck, hips, and torso (difficulty raising arms or fastening bra).	↑ ESR, ↑ CRP.	Symptoms typically respond quickly to oral steroids.	High risk of developing temporal arteritis. More common in individuals over 50.
Trigeminal Neuralgia (Tic Douloureux)	Compression of CN V by an artery or tumor.	Unilateral facial pain along one of the trigeminal nerve branches, often near the nasal border and cheeks. Pain triggered by chewing, cold foods, or exposure to cold air. Type I: Sudden, extreme, shock-like pain lasting seconds to minutes. Type II: Persistent, aching, burning facial pain of lower intensity.	MRI/CT to rule out tumor, vascular compression, or multiple sclerosis.	First-line: High-dose anticonvulsants (carbamazepine, phenytoin). Additional options: Muscle relaxants, gabapentin.	More common in women, peak incidence in the 60s.
Bell’s Palsy	Dysfunction of CN VII due to viral infection, autoimmune disorder, or pressure from a tumor/blood vessel.	Rapid-onset facial paralysis within 24 hours, difficulty chewing/swallowing on affected side, inability to fully close eyelid, decreased tear production.	Rule out: Stroke (CVA), TIA, mastoid infection, bone fracture, Lyme disease, tumor.	High-dose corticosteroids (taper over 10 days). If herpes suspected: Acyclovir (Zovirax). Eye protection: Lubricating drops and nighttime patch to prevent corneal damage.	Corneal ulceration, potential for permanent neurological deficits or facial weakness in prolonged cases.
Cluster Headache	Idiopathic.	Sudden, severe, one-sided headache with recurrent episodes of “ice-pick” pain behind the eye. May include tearing, nasal congestion, ptosis. Occurs in clusters (multiple attacks per day for weeks/months).		Acute: 100% oxygen (12 LPM for 15 minutes), sumatriptan (Imitrex). Prophylaxis: Verapamil.	Higher suicide risk. More common in men.
Tension Headache	Emotional or psychological stress.	“Band-like” or squeezing headache, dull and constant. May be associated with neck muscle tension. Can last several days.	Prevention: Regular sleep/exercise, stress management (yoga, tai chi, therapy).	NSAIDs, OTC analgesics (Excedrin). Avoid: Narcotics and butalbital (habit-forming, increases rebound headaches).
Rebound Headache	Overuse of abortive medications, NSAIDs, aspirin, narcotics.	Chronic, daily headaches with irritability, depression, and insomnia.		Discontinue offending medications or gradually taper off.
Transient Ischemic Attack (TIA)	Temporary ischemia affecting the brain, spinal cord, or retina.	Sudden-onset speech difficulties, unilateral weakness, dizziness, vertigo, balance issues, slurred speech (aphasia). Longer duration increases risk of permanent damage.	Imaging: CT/MRI within 24 hours.	Emergency referral to ED. Consider hospitalization if: – First-time TIA – TIA lasting >1 hour – High risk of embolism (A-fib) – Symptomatic carotid stenosis >50% – Hypercoagulable state – Recurrent TIAs – High ABCD2 score.	Up to 20% will have a stroke within 90 days.
Carpal Tunnel Syndrome (CTS)	Compression of the median nerve.	Gradual onset numbness, tingling, and burning in the thumb, index, and middle fingers. Weak grip, difficulty lifting objects. Acroparesthesia: Nighttime awakening due to hand numbness/burning. History of repetitive wrist movements.	Tinel’s sign: Tapping on the wrist elicits tingling. Phalen’s test: Wrist flexion for 60 seconds causes numbness/tingling. Additional: EMG, nerve conduction studies.	Prevention: Limit repetitive motions, take breaks, stretch, strengthen hands. Treatment: Elevation, volar wrist splint in neutral position.	Increased risk with: Repetitive motion jobs, hypothyroidism, pregnancy, obesity.

Condition	Cause	Signs & Symptoms	Diagnostics	Treatment	Concerns
Vertigo	Not a diagnosis – a symptom of vestibular dysfunction.	Sensation of spinning, tilting, swaying, nausea/vomiting, and postural instability. Can occur as a single episode or recur. Peripheral (vestibular system): Severe nausea/vomiting, recurrent episodes lasting <1 min. Central (brainstem/cerebellum): Prolonged nystagmus, impaired gait, single episode lasting minutes to hours.	If patient can focus on a stationary object and vertigo resolves, outpatient management is possible. Otherwise, refer. Benign Paroxysmal Positional Vertigo (BPPV): Brief, recurrent episodes triggered by movement, caused by calcium debris in semicircular canals. Diagnosed with Dix-Hallpike maneuver.	Treatment: Antihistamines (meclizine, Dramamine), benzodiazepines (alprazolam, lorazepam), and time.
Polyneuropathy		Symmetric burning pain, weakness, and sensory loss. Progression varies; often affects lower extremities first, symptoms begin distally and spread proximally.			Common risk factors: Diabetes, alcohol abuse.
Tremors		Parkinson’s Disease: Chronic, progressive disorder, onset ~70 years. Key features: Resting tremor (“pill-rolling”), bradykinesia, rigidity. First-line treatment: Levodopa – refer to neurology. Essential Tremor: Most common tremor; often familial (50% autosomal dominant). Occurs with action, affects hands, forearms, head, voice, chin, and lips (legs are rarely affected). First-line treatment: Beta-blockers.
Multiple Sclerosis (MS)	Immune-mediated inflammatory disease causing CNS demyelination.	Typically affects young adults. Symptoms include abnormal limb sensation, visual disturbances, diplopia, motor dysfunction, gait instability, and acute neurological episodes.	Gold standard: MRI.	Refer to neurology.
Dementia	Progressive cognitive decline (most commonly due to Alzheimer’s, followed by Lewy body dementia).	Gradual deterioration in memory, executive function, attention, learning, perception, and social awareness. Deficits must interfere with daily functioning and independence.	Differentiate between dementia, delirium, and depression. Cognitive assessment: MMSE score <24 suggests dementia. Identify contributing factors: Medications (analgesics, anticholinergics, psychotropics, sedatives). Labs: CBC, CMP, B12, folate, TSH, UA, RPR, HIV. Imaging: CT/MRI. Screen for depression.	Monitor for safety concerns: – Driving ability – Financial decision-making – Wandering risk – Living alone Other concerns: Caregiver burnout, polypharmacy, family conflicts, elder abuse, risk of injury.
Delirium	Medication effects, substance use, drug interactions, abrupt withdrawal, infections, electrolyte imbalances, chronic illness (heart/renal failure).	Acute, reversible cognitive impairment lasting hours to days. Symptoms include agitation, irritability, combative behavior, short attention span, memory loss, and disorientation.		Identify and address underlying causes: Infection, metabolic disturbance, medication effects.	Sundowning Syndrome: Common in both delirium and dementia. Symptoms worsen in the evening—agitation, confusion, combativeness—then resolve by morning. Management: Avoid dark, quiet spaces, keep a radio on, minimize furniture changes.