06-09-23 –Neurological History Taking

Question 1

Learning outcomes

Answer 1

• To demonstrate an understanding of how patients with GI problems present
• To demonstrate an understanding of the causes of common GI symptoms
• To understand how different body systems inter-relate
• To be able to ask relevant GI questions in a medical history

Question 2

Watch lecture for practise questions

Question 3

What are the 6 stages of the traditional medical model?

Answer 3

• 6 stages of the traditional medical model:
1) History
2) Examination
3) Investigation
4) Diagnosis
5) Treatment
6) Follow up

Question 4

What are the 5 stages of the Roger Neighbour Inner Consultation Model 1987?

Answer 4

• This model asks the same questions as the traditional method, but in a different order

• 5 stages of the Roger Neighbour Inner Consultation Model 1987:

1) Connecting
• Building rapport
• Identifying patients views beliefs and expectations

2) Summarising
• Explaining back to the patient what they have told you
• Allow for correction/development of ideas and understanding

3) Handing over
• Agreeing on doctor’s and patient’s agendas
• Involves negotiating and influencing shared management plan
• Giving ownership and responsibility of management plan to patient

4) Safety netting
• Providing advice on what to do if things get worse
• Could be a follow up, advice, or referral
• For the benefit of both doctor and patient
• Ensures ill patients stay in the medical system

5) Housekeeping
• Looking after yourself as a doctor e.g coffee or going for a walk
• Ensures you can provide a high level of care for every patient you see

Question 5

What are the 7 stages for the structure of history taking?

Answer 5

• 7 stages of history taking:
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)

Question 6

How do you start the presenting complaint section (PC) of history taking?

What do you then do?

What is it important to do when doing this?

Answer 6

• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?

• It is then important to get a description of symptoms from the patient
• It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest

Question 7

What is it important to establish during history of presenting complaint (HPC)?

What is it important to do during this section?

How can patient conversation be facilitated?

What 2 questions should be constantly be thinking in HPC?

What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?

Answer 7

• During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
• Is it important to allow the patient to speak, and not jump in during this section
• Also important to facilitate the patient giving their account by asking a mix of open and close questions
* Be constantly thinking:
1) What are the possible diagnoses?
2) What else do I need to know to help decide which diagnosis is the correct one?

• Useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section:
  • S – Site – location of pain
  • O – Onset – when the pain started, what is sudden or gradual?
  • C – Character – shooting, stabbing, dull ache, throbbing pain
  • R – Radiation – see if pain radiates away from source
  • A – Associated symptoms – give examples
  • T – Timing – pain worse at a particular time? Is it constant or intermittent?
  • E – exacerbators/relievers – What makes the pain better/worse
  • S – severity – pain on a 1-10 rating

Question 8

What 4 questions we ask about systemic upset?

What can systemic upset indicate?

Answer 8

• 4 questions we ask about systemic upset:
1) Change in appetite
2) Weight loss
3) Fever – probably means infection
4) Tiredness / lethargy

• Systemic upset could indicate malignancy

Question 9

What 4 questions should we ask about Timing?

Answer 9

• 4 questions should we ask about Timing:

1) When did it happen? (date, time)

2) Is it still happening now? (on going)

3) How long did it last for? (mins/hours/days/weeks/months/years)

4) How often is it occurring (one off, once a day, once a week etc.)

Question 10

How is severity graded?

Answer 10

• Severity is graded using a Use a 0-10 rating scale
• 0 = no pain
• 10 = worst pain ever had

Question 11

HPC.

What are 11 examples of common neurological presentations?

Answer 11

• HPC
• 11 examples of common neurological presentations:
  1) Altered cognitive ability
  2) Memory loss
  3) Fits, faints & funny turns
  4) Headaches
  5) Dizziness & vertigo
  6) Weakness or movement disorders
  7) Numbness or sensory disorders
  8) Disturbed / loss of consciousness
  9) Visual impairments
  10) Functional neurological symptoms
  11) Specific cranial nerve questioning / presentations

Question 12

What is confabulation?

What are 2 conditions where we may see confabulation?

Answer 12

• Confabulation is a type of memory error in which gaps in a person’s memory are unconsciously filled with fabricated, misinterpreted, or distorted information
• There is often no intent to deceive
• 2 conditions where we may see confabulation:

1) Korsakoff’ssyndrome - a memory disorder that results from vitamin B1 deficiency and is associated with alcoholism

2) Alzheimer’s dementia

Question 13

What are 10 examples of cranial nerve screening questions?

Answer 13

• 10 examples of cranial nerve screening questions:
  1) Change in your sense of smell?
  2) Vision?
  3) Double vision?
  4) Dry eyes?
  5) Dry mouth?
  6) Change in taste?
  7) Hearing?
  8) Dizziness?
  9) Change in voice?
  10) Articulation? (Dysarthria and aphasia)
• Aphasia occurs due to brain damage that affects the ability to express and understand speech.
• Dysarthria, on the other hand, is a condition that affects the muscles necessary for speech. It does not affect the ability to understand language

Question 14

Why might we ask the patients preferred hand?

Answer 14

• We may ask the patients preferred hand to understand how they are personally affected by their condition

Question 15

How can pattern recognition we used to identify Parkinsons?

Answer 15

• How pattern recognition we used to identify Parkinsons:
• Parkinsons can affect fine motor and gross motor control
• PC: Increasing difficulty doing up buttons (fine motor)
• Have you noticed any changes in your writing? (Fine motor) – writing becomes small and spidery
• Any differences in the way you walk? (Gross motor) – patients can present with difficult turning

Question 16

What is the difference and vertigo?

What are 3 signs of benign paroxysmal positional vertigo?

Answer 16

• “dizziness” is an umbrella term that covers a spinning, lightheaded, unbalanced or woozy sensation.
• The term “vertigo” is a specific form of dizziness in which you experience a spinning sensation – you either feel like your surroundings are moving around you, or that you’re moving
• 3 signs of benign paroxysmal positional vertigo:
  1) The dizziness started suddenly when I was in bed and rolled over…
  2) Feels like I am on a roundabout…lasts a couple minutes then settles
  3) OK if I keep my head still but if I look up suddenly it can start again

Question 17

What are 3 potential causes of fits, faints, and funny turns?

How can we differentiate between the 3?

Answer 17

• 3 potential causes of fits, faints, and funny turns:

1) Cardiovascular origin?
* Chest pain?
* SOB?
* Feeling faint and going clammy and sweaty?

2) Endocrine origin?
* Type 1 diabetic?
* High glucose
* DKA?

3) Neurological origin?
* History of epilepsy?
* Warning symptoms? E.g unusual smell or taste
* Seizure activity?
* Recovery phase?

Question 18

What are 3 additional pieces of information that can be used to diagnose the cause of fits, faints and funny turns?

Answer 18

• 3 additional pieces of information that can be used to diagnose the cause of fits, faints and funny turns:
  1) Good history from patient
  2) A description from witness
  3) If recurrent think of asking to record the event (smartphone)

Question 19

What are 9 questions to ask regarding fits, faints & funny turns?

Answer 19

• 9 questions to ask regarding fits, faints & funny turns:
  1) Describe the most recent episode
  2) What was happening immediately before?
  3) If known epilepsy / seizures any factors that might have lowered the seizure threshold?
  4) What position was the patient in?
  5) Any prodromal symptoms?
  6) What happened during the episode?
  7) After?
  8) Tongue biting?
  9) Urinary incontinence?

Question 20

Headache: Primary syndromes (3 in picture):
* Onset
* Duration
* Pain location
* Associated features

Answer 20

Question 21

Headache: Primary syndromes (3 in picture):
* Onset
* Duration
* Pain location
* Associated features

Answer 21

Question 22

What 3 questions can be asked regarding ‘weakness’?

Answer 22

• 3 questions can be asked regarding ‘weakness’:

1) What does the patient mean…chronic “aesthenia” “fatigue” or specific muscle weakness.
* Aesthenia - generalized weakness that can be produced by a lesion of the cerebellum

2) What activities are they finding difficult?

3) Is the problem in the muscle or in the nerve supply to the muscle?

Question 23

What is the ice pack test used for? What is myasthenia gravis? What does it most commonly affect?

Answer 23

• The ice pack test is used to diagnose myasthenia gravis
• It can be identified through unilateral ptosis (eye lid drooping), which is rectified using an ice pack
• Myasthenia gravis is a rare long-term condition that causes muscle weakness.
• It most commonly affects the muscles that control the eyes and eyelids

Question 24

What should we look for regarding weakness?

What are 3 examples of patterns used to identify weakness?

Answer 24

• Regarding weakness, we should look for patterns
• 3 examples of patterns used to identify weakness:

1) Focal weakness suggests neurological origin
* Focal weakness usually denotes asymmetry or predominance of upper versus lower extremities

2) Proximal muscle weakness (think steroids? Polymyalgia?)
* Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips
* E.g difficulty rising from sitting and drying hair

3) Distal muscle weakness
* Difficulty standing on tip toes and fine finger movements

Question 25

What are 5 questions we may ask about walking?

Answer 25

• 5 questions we may ask about walking:
  1) Has the distance they can manage changed?
  2) What makes them stop?
  3) What about hills?
  4) One leg or both legs?
  5) Any sensory symptoms?

Question 26

What 3 questions may we ask about abnormal movement?

What is Chorea?

What is Choreoathetosis?

Answer 26

• 3 questions may we ask about abnormal movement:

1) Too much or too little movement?

2) Too little movement - E,g. Parkinson’s disease - slowing of movement, stiffness

3) Too much movement
* Chorea – “fidgety jerks”
* Choreoathetosis - decreased tone and rapid, writhing changes in movement (consider over treatment of PD)

Question 27

What are 2 examples of sensory disorders?

What should we consider if there is complete sensory loss?

With sensory disorders, what can help us reach a diagnosis?

Answer 27

• 2 examples of sensory disorders:

1) Paraesthesia
* Abnormal sensory symptoms; e.g. tingling, prickling, pins & needles, burning
* Sciatica is an example of this

2) Allodynia
* Perceives pain in the absence of a painful stimulus
* If there is complete sensory loss, it can be neurological, but we should also consider functional origin, where we can find a specific cause

• With sensory disorders, we should also think about patters e.g:
• “Wake up in the middle of the night with ache and numbness in my thumb and first two fingers”
• Which nerve?
• What is the problem?

Question 28

What should we think about with neurological conditions in younger patients?

Answer 28

• With neurological conditions in younger patients, we should think about milestones
• Was there any evidence of developmental delay?
• 1 to walk & 2 to talk
• Also think birth history

Question 29

What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?

What is the 10-part mnemonic for PMH?

Answer 29

• Information about previous illnesses during PMH:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion

• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke

Question 30

PMH.

What is an example of a chronic illness that may result in neurological impairment?

Answer 30

• PMH
• Diabetes is an example of a chronic illness that may result in neurological impairment (can cause peripheral neuropathy)

Question 31

What 4 types of drugs are considered during Drug history (DH)?

What are the 5 things considered when documenting a drug in drug history?

What must be asked regarding allergies?

What is an important allergy to keep in mind?

What is the difference between allergies and adverse effects?

Answer 31

• 4 types of drugs considered during drug history:
1) Prescribed medication
2) Over the counter medication
3) Herbal medication
4) Consider illicit drug use (recreational)

• 5 things considered when document a drug in drug history:
1) Name of drug
2) Dose
3) Route (e.g oral, intramuscular, per rectum)
4) Frequency
5) Duration

• We want to know why they are taking it and if they are takng it correctly
• Regarding allergies, we must ask “are you allergic to anything/any medicines that you know of?
• Elastoplast/latex allergies are important to keep note of
• Adverse effects are expected known side effects of drugs, and are not the intended therapeutic purpose of the drug
• Allergies to medicine are adverse drug reactions mediated by an immune response
• Medicine that can cause adverse effects (e.g stomach upset) can still be prescribed, but it depends on the severity of the effects.

Question 32

What are 6 reasons we ensure accurate medication history?

Answer 32

• 6 reasons we ensure accurate medication history:
1) Improves patient safety
2) Reduces medication errors / near misses
3) Reduces missed doses in hospital
4) Reduces delays to treatment
5) Savings to NHS from prevented errors
6) Improves therapeutic outcomes

Question 33

What are 6 golden rules of medication history taking?

Answer 33

• 6 golden rules of medication history taking:

1) Be structured – methodically collect current meds, allergies and previous adverse drug reactions

2) Engage with the patient whenever possible but find out who knows best about meds – carer?

3) Use more than one source of information to accurately confirm a patient’s medication history.

4) Be alert to use of high-risk medicines (e.g. warfarin, insulin, methotrexate) as accuracy critical in these cases.

• Warfarin can increase haemorrhage risk
• Methotrexate is on a weekly dose, not a daily dose, so a lot of room for error

5) Women of childbearing age – ask about prescribed contraception

6) Are they taking part in any clinical trials?

• Clinical trial medication use/dosage may not appear on medication list

Question 34

What question can we use to start drug taking history?

What 9 questions might we ask about each drug?

Answer 34

• To start drug taking history, we can ask “Which medicines are currently prescribed for you to take?”

• 9 questions might we ask about each drug:
1) Name of medicine?
2) Do you know what it is for?
3) What is the dose/strength?
4) What is the route?
5) Number of tablets or puffs or dose units taken?
6) Type/Form – device type? E.g spacer, auto inhaler
7) How often do you take this?
8) Any recent changes to dose / frequency?
9) Do you think you have any side effects with any of these medications?

Question 35

What are 9 other sources of information we can use about a patient’s medicines?

Answer 35

• Other sources of information we can use about a patient’s medicines:

1) Patient or family/friends/carers

2) Patient’s own medicines – can ask to see their medicines/dosette box

3) Repeat prescription slips/other lists – need to make sure its up to date

4) GP surgery staff / letter/ printout

5) Previous hospital notes/letters

6) Community pharmacy

7) Emergency Care Summary (ECS) Scotland only. (called Summary Care Record in England)

8) MAR chart – Medication Administration Records from care homes, prepared by Pharmacy

9) Substance misuse services – e.g. for methadone doses
• Methadone isn’t prescribed by general practise, but by substances misuse services
• Sometimes, dosage isn’t included, so we may have to contact them to get this information

Question 36

What are 3 questions we may ask concerning allergies?

What else can we do?

What are 3 ways of asking about adverse side-effects?

Answer 36

• 3 questions we may ask concerning allergies:
1) Are you allergic to any medicines?
2) What happened when you had these medicines?
3) Have any medicines caused a rash or difficulty breathing in the past?

• We can also check other sources of information

• 3 ways of asking about adverse side-effects:
1) Have any medicines recently been stopped and if so why?
2) Have you ever had a medicine stopped because the Dr thought it was making you worse?
3) Have you ever stopped a medicine because you felt unwell?

Question 37

What is intentional non-adherence?

What are 4 reasons for unintentional non-adherence?

Answer 37

• Intentional non-adherence– definite decision to not take medicine(s)

• 4 reasons for unintentional non-adherence:
1) Physical dexterity e.g cant reach medicine
2) Reduced vision
3) Cognitive impairment
4) Poor understanding e.g not being taught to use an inhaler properly

Question 38

What is the purpose of asking about family history (FH)?

What are 4 questions that may be asked?

What may be useful during this section?

What disease might we want to specifically ask about regarding the CV system?

What degree of relative are we most interested about?

What age range are we looking at?

Answer 38

• Asking about family history may give clues about possible genetic pre-disposition to illness

• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?

2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?

3) Do you have any children? How old are they? Are they well/any illnesses?

4) Are there any health problems that run in your family?

• We want to ask if any 1st degree relatives (parents, siblings, children) have a history of cardiovascular disease at a young age
• 1st degree male relative less than 55 years
• 1st degree female relative less than 65 years
• May be useful to draw a family tree

Question 39

FH.

How is family history linked to neurological disorders?

Answer 39

• FH
• There is a genetic component to many neurological disorders
• We must ask and document

Question 40

What are the various aspects of social history (SH) asked about?

Answer 40

1) Employment
• Are you working at the moment?
• May I ask what you do?
• What does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise

2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)

3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week

4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
• This is one of the most important sections, as we want to ensure the patient has access to what they need to live in their home

5) Other questions to consider:
• Exercise/diet
• Do they have any hobbies or interests?
Do they have any pets?
• Do they drive?

Question 41

What is system enquiry?

What is the purpose of the system enquiry portion of an interview?

What are 7 systems that may be asked about?

What are symptoms we may look for?

Answer 41

• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool

• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS (respiratory) – cough, mucus, shortness off breath
3) GI – change in bowels, abdominal pain
4) GU (genitourinary) – urinary systems, change in water works, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance, changes in weight
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits, collapses

Question 42

What are 3 questions we ask to address ideas, concerns, and expectations of the patient?

Answer 42

• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?

Question 43

What is the purpose of summarising to complete a history taking?

What is important that needs to occur throughout the session?

Answer 43

• Summarising:
• Helps to clarify points
• May highlight questions you haven’t asked or misunderstanding
• Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
• Brings up relevant features in the remainder of history
• Brings up relevant positives/negatives from systems enquiry

• It is important to explain and gain consent for examination as appropriate

Question 44

What is documentation?

How do we conclude documentation?

Answer 44

• Documentation is not a verbatim record of what the patient has told you
• Filtered and critically analysed record
• Often important to record negatives
• Conclude with a summary, differential diagnosis & action plan
• Remember confidentiality

Question 45

What % of symptoms are medically unexplained?

When should this be considered?

Answer 45

• 30% of symptoms can be non-organic (medically unexplained) in origin
• If the symptoms don’t fit a pattern underpinned by anatomy & physiology consider this option.

Question 46

When should we consider cognitive assessment.

What are 4 examples of cognitive assessment?

Answer 46

• With possible altered cognitive function / cognitive impairment, consider cognitive assessment
• 4 examples of cognitive assessment:

1) 4 As test (rapid, initial screen for delirium)

2) Mini Mental State Examination (MMSE)

3) Montreal Cognitive Assessment (MOCA)

4) Addenbrookes Cognitive examination (ACE III)

Question 47

Describe the 4 As cognitive assessment test (in picture)

Answer 47

Question 48

What is MoCA?

What are its advantages?

Answer 48

• MoCA is the Montreal Cognitive Assessment (2005)
• Its advantages are that it is better at identifying mild levels of impairment and has less bias from ethnicity / age/ education

Question 49

How long does the ACE III cognitive assessment take?

How is it scored?

What are the 5 cognitive domains ACE III tests?

Answer 49

• The ACE III cognitive assessment takes about 20 minutes to do
• It is scored out of 100
• 5 cognitive domains ACE III tests:
  1) Attention
  2) Memory
  3) Verbal fluency
  4) Language
  5) Visuospatial abilities

Question 50

What is delirium?

How common is it in hospital patients?

How should it be treated?

Answer 50

• Delirium is acute confusion that can happen if someone becomes medically unwell (“acute confusionalstate”)
• It is common - 1:10 hospital patients
• There are predisposing factors and triggers
• Treat the underlying cause

Question 51

What factors do we think about with differential diagnosis concerning the CNS?

Answer 51

• Factors we think about with differential diagnosis concerning the CNS:
• The neurological system is logical so think logically!
• Age, gender, pattern of onset
• Risk factors
• Relative incidence…common things are common
• Assess probability