Lecture 1- Introduction

Question 1

MAIN CHIEF COMPLAINT

Answer 1

• try to describe the nature of the problem in a word or phrase
• find out if your understanding of the complaint is the same as the patients
• clearly outline area of complaint

Question 2

HISTORY OF PRESENTING ILLNESS

Answer 2

• SOCRATES
• S: clearly delineate
• C: neurological complaints are typically not just pain
• A: if pain is main complaint ask about other common neurological complaints. If neuro complaints in the MC, ask about pain. Ask about fever is there is any suspicion of infection

Question 3

NEUROPATHIC PAIN

Answer 3

• results from direct injury if nerves
• compression
• stretching
• severing
• terminology related to NP
• dysesthesia: abnormal sensation in response to stimulus
• hyperesthesia: increased sensitivity to touch
• hyperalgesia: increased sensitivity to pain
• allodynia: perception of innocuous stimulus as painful

Question 4

PAST MEDICAL HISTORY

Answer 4

• enquire about chronic illnesses such as hypertension and diabetes
• medications: are these essential to enquire about with neuro complaints
• vaccinations: meningococcal meningitis
• diet:
• B1 deficiency (causes alcoholic polyneuropathy)
• Excessive B6 (causes polyneuropathy)
• B12 deficiency (causes malabsorption and pernicious anaemia which lead to corticospinal and posterior column degeneration and dementia)

Question 5

PSYCHOSOCIAL HISTORY

Answer 5

• Alcohol abuse
• withdrawal seizures
• polyneuropathy

Question 6

FAMILY HISTORY

Answer 6

Severe neurological symptoms are inherited:

• Huntington disease (autosomal dominant)
• Wilson’s disease (autosomal recessive)
• Duchenne muscular dystrophy (x-linked recessive)
• Some motor neuron diseases (can be autosomal dominant, recessive or x-linked)

Question 7

REVIEW OF SYSTEMS

Neurological questions

Answer 7

• difficulty with memory, mood and attention
• seizures or loss of consciousness
• episodes of dizziness or vertigo
• difficulty with or slurred speech
• numbness, weakness or pins and needles
• tics or tremors

Question 8

REVIEW OF SYSTEMS

Answer 8

• screening questions for diabtes under endocrine if your concerned:
• polydipsia
• polyuria
• nocturial
• screening for risk of a potential stroke under CVS
• chest pain
• palpitations
• SOB
• Orthopnea
• stroke

Question 9

COMMON NEUROLOGIC MAIN COMPLAINTS

Answer 9

• confusion
• dizziness
• weakness
• numbness
  ( patients may describe their complaint as being a “spell”, this signifies that the condition is episodic)

Question 10

LOCALISING THE LESION: GENERAL PRINCIPLES

Answer 10

• one lesion being most likely, not multiple
• hemispheric lesions (one cortex)
• brainstem lesions ( crossed deficit: one side of body and other side of face)
• spinal cord lesion (bilaterally below)
• diabetic polyneuropathy (bilateral, symmetric, glove and stocking distribution)
• myopathy (bilateral, symmetric, proximal weakness in large muscle groups)

Question 11

FOCUSSED EXAMINATION: OBSERVATION

Answer 11

Observe the patients for any visible neurological deficits e.g tics and tremors

Question 12

FOCUSSED EXAMINATION: MENTAL STATUS EXAM

Answer 12

• level of consciousness
• establish if cognitive function is normal
• the standardised mini mental state exam

Question 13

FOCUSSED EXAMINATION: VITAL SIGNS

Answer 13

• temperature: elevation in encephalitis, meningitis or myelitis
• respiratory rate: Cheyenne-stroke breathing ( alternating respiration patterns of deeper, shallower with possible periods of apnoea, seen in severe CVA (brainstem), encephalitis, raised ICP)
• blood pressure (chronic hypertension is risk factor for stroke, acute hypertension seen in ischemic stroke and Subchondral haemorrhage)

Question 14

FOCUSSED EXAMINATION: HEENT

Answer 14

• HEENT:
• check for ptosis( drooping of eyelid, lesion of levator palpebrae), *physiologic anisociria (1mm difference in sides),
• accomodation/near response
• pupillary dilation

Question 15

FOCUSSED EXAMINATION: NECK

Answer 15

• test for meningeal irritation
• Kernot sign: resistance to passive knee extension while hip flexed
• Brudzinski sign: involuntary hip and knee flexion accompanying passive neck flexion

Question 16

PATIENT IDENTIFYING DATA: AGE!!!

Answer 16

Middle-aged:
- epilepsy
- multiple sclerosis
- Huntington disease 
Older age:
- Alzheimer disease
- Parkinson disease 
- Brain tumours 
- Stroke