Neuro History Taking Flashcards
Give some examples of presentations which can localise neurological lesions.
Cerebral hemispheres = higher mental function, vision, motor weakness, loss of cortical sensation according to pattern
Brainstem = specific cranial nerves affected
Cerebellum = cerebellar signs
Spinal cord = loss of sensation and motor weakness according to level +/- bladder dysfunction, Brown-Séquard syndrome, syringomyelia
Nerve roots = specific dermatomes/myotomes affected
Nerve plexuses = complex motor and sensory disturbances
Peripheral nerves = glove and stocking distribution of sensory loss, individual nerve palsies
Neuromuscular junction = ptosis, diplopia, bulbar dysfunction (speech and swallowing), limb weakness, fatiguability, NO sensory loss
Muscle = proximal weakness, NO sensory loss
What are some important things to observe in a neurological examination?
Gait
Speech:
- articulation
- quality
- content
Involuntary movements:
- tremor
- tics
- choreas
- orofacial dyskinesias
+ third party information useful for assessing levels of consciousness and intellect
What are some important questions to ask in a neurological history?
Distribution of symptoms
Circumstances of event
Precipitating factors
Mode of onset (sudden = vascular until proven otherwise)
Progression (worsening = brain tumour, improving = stroke)
Systematic neurological enquiry:
- headache
- loss of consciousness
- fits
- problems with speech or swallowing
- bladder problems
- diplopia
- muscle weakness
- sensory loss
- clumsiness
- mental or cognitive difficulties
Give examples of terminology used by patients which need to be clarified.
“Gradual” (precise timeline)
“Blackout” (loss of consciousness v.s. loss of vision)
“Dizziness” (vertigo - sensation of spinning relative to their surroundings; presyncope - light-headedness or faint; unsteadiness in legs; anxiety)
“Weakness” (loss of strength or power; difficulty using limb; numbness; fatigue; general lack of energy; dyspraxia)
“Numbness” (lack of sensation; abnormal sensation e.g. pins and needles)
“Blurred vision (reduced visual acuity; diplopia; oscillopsia)
What is oscillopsia? What can it be caused by?
Moving visual field
Paraneoplastic syndrome
Give some differentials for temporary loss of consciousness.
Syncope:
- postural hypotension
- reflex (vasovagal or situational)
- cardiac
Seizure
Hypoglycaemia
Non-epileptic attack disorder
Other e.g. ascending aortic aneurysm, PE, aortic dissection
What are some discriminating features for temporary loss of consciousness?
Eye witness account (e.g. seizures)
Situation (e.g. situational vasovagal syncope)
Phases (pre-, intra-, and post-)
Stereotypy (epilepsy)
Serious injury
Prolonged post-ictal confusion (epilepsy)
Aura (partial seizure)
Precipitating events
Psychogenic seizures last longer than epileptic seizures (excluding status epilepticus)
Cardiac syncope:
- no prodrome
- 45yrs+
- history of abnormal ECG
- history of heart disease e.g. ventricular arrhythmia, congestive cardiac failure
Contrast the presentation of fits and faints.
WARNING:
- fits = 50%+ have some aura
- faints = felt faint/light headed, blurred/darkened vision
ONSET:
- fits = sudden, any position
- faints = only occurs sitting or standing, avoidable by change in posture
FEATURES:
- fits = eyes open, rigidity, falls backwards, convulses
- faints = eyes closed, limp, falls forwards, minor twitching only (if unable to fall flat),
RECOVERY:
- fits = confused, headache, sleepy, focal deficit (e.g. Todd’s palsy)
- faints = pale, washed out, sweating, cold or clammy
OTHER:
- fits = tongue biting, loss of bladder control
- faints = loss of bladder control rare
Give some general differentials for headaches.
PRIMARY:
- tension type headache (TTH)
- migraine
- cluster headache
- other
SECONDARY:
- trauma
- raised ICP
- inflammation
- drugs
- neoplasia
- infection
- vascular
- metabolic
- toxins
How can the severity of a headache be assessed?
Ask patient what they do when they get the headache
e.g. sleep in a dark quiet room v.s. pacing, crying, punching the walls
Contrast the differentials for acute and chronic headaches.
ACUTE:
- meningitis, encephalitis, other infections (+ neck stiffness, rash, photophobia, fever)
- subarachnoid haemorrhage (“thunder clap”; very severe and rapid, no longer than a minute)
- post-coital
- migraine
- cluster headache
- acute angle closure glaucoma
+ focal neurology, N&V, recent onset or change in character
CHRONIC:
- temporal arteritis
- migraine
- analgesic abuse
- tension type headache
- Paget’s disease
- raised ICP (present on waking, worse if lying down, exacerbated by valsalva/bending/cough, papilloedema
How can a morning headache be differentiated from a headache caused by raised intracranial pressure?
Raised intracranial pressure:
- present on waking
- improves when they sit up
Morning headache:
- not present on waking
- lasts longer
What is the presentation of a migraine?
Prodrome (hrs-days)
Aura immediately before the headache)
Pain
Postdrome
What is the presentation of cluster headaches?
Severe pain (some patients suicidal)
Short-lived (less than 1hr)
Unilateral, around eye
Episodic (daily for weeks)
+ nasal congestion, rhinorrhoea, ptosis, conjunctival infection
Contrast the presentation of migraines and tension headaches.
Pain:
- migraine = throbbing, pulsating
- tension headache = dull, pressure, tight band around the head
Photo/phonophobia:
- migraine = typical
- tension headache = rare
Location:
- migraine = deep stabbing pain in the temple or eye, usually unilateral, can change sides
- tension headache = generalised, usually bilateral, may be more intense; affects scalp, forehead, temples, and neck
Severity:
- migraine = moderate to severe
- tension headache = mild to moderate
Duration:
- migraine = 4-24hrs
- tension headache = can remain several days, fluctuates
Triggers:
- migraine = stress or relief of stress, sleeping too much/too little, foods, alcohol, odours, motion
- tension headache = stress
Aura/prodrome:
- migraine = scintillating scotoma (flickering lights), pins and needles, weakness, vertigo
- tension headache = none
Nausea and vomiting:
- migraine = common
- tension headache = rare
Give some examples of differentials for dizziness.
Vertigo:
- peripheral = benign paroxysmal positional vertigo, vestibular neuritis, Ménière’s disease
- central = migraine, drugs, cerebellar disease/brainstem disorders
Loss of balance:
- Parkinson’s disease
- peripheral neuropathies (loss of proprioception)
Presyncope
Anxiety
Other e.g. anaemia, hypoglycaemia
What is the general presentation of vertigo?
Occurs when moving the head
Temporal pattern of weakness
Hearing loss/tinnitus
Short duration
Fullness in ear
Nausea and vomiting
Headache
Precipitating events e.g. salt
Aura with no headache
What is the presentation of benign paroxysmal positional vertigo?
Abrupt onset
Short-lived (10-15s)
Precipitated by head movement
e.g. turning in bed, looking up, bending down
Onset delayed by a few seconds
Risk factors:
- vestibular neuronitis
- head injury
- age
What are some questions to help localise and formulate differentials for weakness?
Mode of onset
Distribution:
- proximal v.s. distal
- upper limbs affected early indicates central cord involvement (e.g. syringomyelia)
- resp. muscle weakness indicates problem with high cervical cord, NMJ, phrenic nerves, muscle, Guillain-Barré
Duration
Muscle appearance:
- wasting
- twitching
- increased bulk
Progression: short-term (e.g. fatiguability), intermittent, long-term, improvement
Other neurological involvement:
- sensory loss/tingling
- dysphagia
- bladder dysfunction
- dysarthria
- visual disturbance
- vertigo
Pain
Family history
Drug history/exposure to toxins
Systemic disease
note: bulbar weakness + ptosis indicates myasthenia gravis
note: fatiguable weakness = test by doing multiple tests of power in order to demonstrate reduced power over time
What are some of the questions to keep in mind when taking a neurological history?
Where is the lesion?
Is it a characteristic syndrome?
What is the pathological process?
Give some examples of causes of confusion.
- sepsis —> delirium
- dehydration —> delirium
- hypoglycaemia
- meningitis/encephalitis —> RICP
- alcohol (& alcohol withdrawal)
- drugs
- Wernicke’s encephalopathy
- hypoxia
- metabolic
- stroke
- head injury
- post-ictal seizure
