Neurological History Taking Flashcards
What things should you do to optimise communication before or at the start of a patient interview?
- Quiet environment minimise distractions
- Is hearing aid working or in?
- Are you speaking clearly & articulately
- Can the patient see you & your mouth (masks/clear visors)
- Do you need a pen and paper
- Is carer available ?
Online;
- Can you see/hear me
- Who else is in room, is that ok?
- Professional setting plain wall, lighting
- Confirm patient ID
What is dysarthria and dysphasia?
Dysarthria - Articulation of speech
Dysphasia - Difficulty to use or understand words
Why would asking what hand write with be useful in a neurological history?
Can show what hemisphere you have speech issues in
Although some left handed people use left side of brain so not always accurate, and 90% population right handed
What is benign positional vertigo?
Inner ear pathology where the room is physically spinning for someone (different to light headed)
Position it happens in is important as well
SOCRATES
What common neurological presentations do we usually see? The negatives are as important as the positives!
Altered cognitive ability - Confusion or memory loss (has carer noticed?)
Fits, faints and funny turns
Headache
Dizziness
Weakness or movement disorders affecting motor
Numbness or sensory disorders
Visual impairments (sight, smell, hearing) - affecting cranial nerves
What are some important questions asked in the presenting complaint ?
- Increased difficultly in doing up buttons? (fine motor skills - could be Parkinson’s)
- Have you noticed any changes in your writing?(Micrographia - small clustered writing that trails off at end)
- Any differences in the way you walk?
What is important in taking a history of fainting from a patient?
You need to work out if it is cardiovascular, endocrine or neurological so you can ask associated questions
What is important in taking a history of epilepsy from a patient?
Epilepsy is recurrent seizures so we need to do a series of tests, CT, MRI, EEG, ECG (heart) and bloods (electrolyte disturbance) to try and confirm which system is causing it
- even if these are all fine can still be epilepsy as reoccurring
How his epilepsy described?
An abnormal, excessive paroxysmal discharge of cerebral neurons
If possible what can be handy to get a patient to do when they are experiencing episodes?
Record it or write it down, more info the better!
- What happened before
- What factors might have lowered the seizure threshold
- What position was patient in
- Any proximal symptoms
- What happened during episode
- What happened after?
What questions would we ask around headache ?
SOCRATES
Site - show me where?
Onset - When did start?
Character - What kind of pain?
Radiation - Does it go anywhere else?
Associated symptoms ?
Timing
Exacerbates or reliving factors ?
Severity - Pain scale
What would a headache described as a sudden thunder clap be?
Subarachnoid haemorrhage - Send to hospital as have to rule out
What would a headache described as recurrent (but well between episodes) be?
Tension headache over stressful times
What would a headache described as gradually getting worse be?
Tumours cause headaches to get worse
What questions would we ask about the timing and evolution of symptoms ?
- Sudden e.g thunder clap headache?
- Recurrent (but well between episodes)
- Deterioration over hours
Relapsing/remitting - Deterioration over weeks/months
What questions would we need to clarify when patient is mentioning weakness ?
Do you mean chronic asthenia (diminishing strength and energy) or fatigue or specific muscle weakness?
What activities do you find difficult? (activities of daily living)
(Need to work out if problem is in muscle or in the nerve supply to muscle)
Is it focal weakness (neurological origin), proximal muscle weakness (think steroids) - standing up or doing hair. Is it distal muscle weakness standing on tips of toes or finger movements?
Any issues with walking; distance (why?), has to stop, hills, one or both legs, sensory issues
Abnormal movements?;
Too much or too little movement?
Too little - e.g Parkinson’s
Too much - Chorea - fidgety jerks - could be lined to Huntington’s
Choreoathetosis, decreased tone, rapid writhing changes in movement (consider over treatment Parkinson’s)
What is an easy way to test for Myasthenia Gravis on a ward?
Ice pack test
What would you ask a patient if they mention sensory issues?
Paraesthesia - like a tight bandage around mu leg
Allodynia - abnormal perception of pain, e.g gentle touch
Complete sensory loss is likely to be of a functional origin e.g - spinal cord injury
If a patient is experiencing ache and numbness in thumb and first two fingers what would you expect?
Carpal tunnel from median nerve compression
Think what nerve?
What is problem?
What question would you want to ask yourself when asking for the past medical history of a neurological case?
What chronic illnesses may result in neurological impairment?
Hospital admissions, operations, significant illnesses, things they see GP about
Sensory change affecting hands and feet - diabetes
Risk factors can help show what looking for, and patients don’t perceive these as illnesses
Younger patients milestones, any delays, birth history normal?
What questions would you ask a neuro-patient about drugs?
- What treatments are you on?
- Do you comply with these?
- Are they the best treatment for you?
- Could they be the cause of the problem?
- Any interaction of drugs (focal migraines can be associated with the pill contraception)
- Is patient thinking of becoming pregnant
- Any allergies
Non prescribed drugs;
- What others? (Ibuprofen increase haemorrhage)
- How often, how much, how long?
- Tell me about your pattern of drinking alcohol (increase haemorrhage)
- What symptoms do you have if you don’t take drugs for drink?
Systems enquiry questions?
Psychological, depressed?
ANS - bowel, bladder, sexual dysfunction, light headedness
Recent infection?
What family history questions would you ask?
Genetic component to many nerve disorders, must ask and document!
Siblings, parents, children
Social history?
Who is at home?
Home circumstances?
Are home circumstances contributing to medically unexplained symptoms?
Occupational history
What are your cranial nerve screening questions?
Change in sense of smell?
Vision? double vision?
Dry eyes? Dry mouth? Change in taste?
Hearing? Dizziness?
Change in voice?
Articulation?
How should you analyse the info?
Where is the lesion??? What is causing it?
Upper, lower, cranial nerve, cardiological
What should you do at the end of a consultation?
Make an action plan for yourself and patient
What questions would you ask yourself about a patients cognitive ability and how would you assess this?
Is the patient orientated?
Memory function?
May be apparent but confirm and document with objective assessment like 4A’s test (rapid, initial screen for delirium) or Addenbrookes cognitive examination (ACE III) Or MoCA (Montreal cognitive assessment)
What is delirium?
Mental confusion that can happen if someone becomes medically unwell
“acute confusional state”
Common in 1:10 hospital patients
Think predisposing factors, tiggers (covid?), treat underlying cause, manage
Tell me about the MoCA (Montreal cognitive assessment)
No copyright!
Better at identifying mild levels of impairment
Less bias ethnicity/age/education
Tell me about the Addenbrookes cognitive examination (ACE III)
About 20 mins to do, scored out 100
5 cognitive domains:
- attention
- memory
- verbal fluency
- language
- visuospatial abilities
What is confabulation and important to remember about it?
Its when a patient presents false information with great authority and certainty. often autobiographical; in nature
Important - Not intent to deceive, genuinely believes this
Associated with;
- Korsakoff’s syndrome
- Alzheimer’s dementia
