Neurological History Taking

Question 1

Presenting complaints?

Answer 1

1. headache
2. muscle weakness
3. visual disturbance
4. change in other senses
5. dizziness
6. speech disturbance
7. dysphagia
8. fits, faints, funny turns, involuntary movements
9. abnormal sensations
10. tremor

Question 2

Headaches?

Answer 2

Different to usual headaches? Acute/chronic?
Speed of onset?
Single/recurrent?
Unilateral/bilateral?
Associated symptoms (e.g. aura
with migraine)?
Any meningism?
Worse on waking (increased ICP)? Decreased conscious level?

Question 4

Muscle weakness?

Answer 4

Speed of onset?
Muscle groups affected?
Sensory loss?
Any sphincter disturbance?
Loss of balance?
Associated spinal/root pain?

Question 5

Visual disturbance?

Answer 5

e.g. blurring, double vision (diplopia), photophobia, visual loss
Speed of onset?
Any preceding symptoms?
Pain in eye?

Question 6

Change in other senses?

Answer 6

Hearing, smell, taste?
- Abnormalities are not always due to neurological disease, consider ENT disease.

Question 8

Dizziness?

Answer 8

Illusion of surroundings moving (vertigo)?
Hearing loss/tinnitus?
Any loss of consciousness?
Positional?

Question 8

Speech diturbance?

Answer 8

Difficulty in expression, articulation, or comprehension (can be difficult to determine)?
Sudden onset or gradual?

Question 9

Dysphagia?

Answer 9

Solids and/or liquids?
Intermittent or constant?
Difficulty in coordination?
Painful (odynophagia)?

Question 10

Fits/faints/‘funny turns’/involuntary movements?

Answer 10

Frequency?
Duration?
Mode of onset?
Preceding aura?
Loss of consciousness?
Tongue biting?
Incontinence?
Any residual weakness/confusion? Family history?

Question 11

Abnormal sensations?

Answer 11

E.g. numbness, ‘pins & needles’ (paraesthesiae), pain, odd
sensations
Distribution?
Speed of onset?
Associated weakness?

Question 13

How do you assess the cognitive tate of the patient?

Answer 13

Mini-Mental State Exam

Question 14

Past medical history?

Answer 14

meningitis/encephalitis
head/spine trauma
seizures
previous operations
risk factors for vascular disease (AF, hypertension, hyperlipidemia, diabetes, smoking)
recent travel - especially exotic destinations
Is there any chance that the patient is pregnant

Question 15

Drug history?

Answer 15

anticonvulsant/antipsychotic/antidepressant medication
psychotropic drugs (e.g. ecstasy)
medication with neurological side-effects (e.g. isoniazid which can cause a peripheral neuropathy)

Question 16

Social and family history?

Answer 16

What can the patient do/not do, ie activities of daily living (ADLs)?
What’s the Barthel Index score?
Any family history of neurological
or psychiatric disease?
Any consanguinity?
Consider sexual history, eg syphilis.

Question 17

What is a cramp?

Answer 17

• This is painful muscle spasm
• Leg cramps are common at night or after heavy exercise, and in patients with renal impairment or on dialysis
• Cramp can signify salt depletion

Question 18

Cramp and neurological disease?

Answer 18

Forearm cramps suggest motor neuron disease

Question 19

What is parasthesiae?

Answer 19

Pins and needles’, numbness/tingling, which can hurt or ‘burn’ (dysaesthesia)

Question 20

What are the causes of parasthesiae?

Answer 20

1. Metabolic - increased Ca2+ (perioral); increased PaCO2; myxedema; neurotoxins (tick bite; sting)
2. Vascular - arterial emboli; Raynaud’s; DVT; high plasma viscosity
3. Anti body-mediated - paraneoplastic; SLE; ITP. Infection, rare: Lyme; rabies. Drugs, ACE-i
4. Brain - thalamic/parietal le
   sions
5. Cord - MS; myelitis/HIV; B12; lumbar fracture
6. Plexopathy/mono neuropathy - cervical rib; carpal tunnel; sciatica
7. Peripheral neuropathy - glove & stocking, e.g. DM; CKD
8. paroxysmal neuropathy - migraine; epilepsy; phaeochromocytoma
9. take travel history, consider infection, e.g. strongyloides

Question 21

What is a tremor?

Answer 21

Tremor is rhythmic oscillation of limbs, trunk, head, or tongue.

Question 22

Types of tremor?

Answer 22

1. resting
2. postural
3. intention

Question 23

Resting tremor?

Answer 23

• worst at rest
  e.g. from parkinsonism (±bradykinesia and rigidity; tremor is more resistant to treatment than other symptoms)
• It is usually a slow tremor (frequency of 3–5Hz)
• typically ‘pill-rolling’ of the thumb over a finger

Question 24

Postural tremor?

Answer 24

• worst if arms are outstretched. Typically rapid (8–12Hz)
• May be exaggerated physiological tremor (eg anxiety, hyperthyroidism, alcohol, drugs), due to brain damage (eg Wilson’s disease, syphilis) or benign essential tremor
• This is often familial (autosomal dominant) tremor of arms and head pre
  senting at any age. Cogwheeling may occur but there is no brady kinesia

Question 25

Intention tremor?

Answer 25

• worst on movement, seen in cerebellar disease, with past pointing and dysdiadochokinesis
• No effective drug has been found.

Question 26

CNS causes of facial pain?

Answer 26

Migraine, trigeminal, or glossopharyngeal neuralgia (p457) or from any
other pain-sensitive structure in the head or neck. Post-herpetic neuralgia: nasty
burning-and-stabbing pain involves dermatomal areas aff ected by shingles (p404);
it may aff ect cranial nerves V and VII in the face. It all too often becomes chronic
and intractable (skin aff ected is exquisitely sensitive).

Question 27

Vascular and non-neurological causes?

Answer 27

Neck—cervical disc pathology.
Bone/sinuses—sinusitis; neoplasia.
Eye—glaucoma; iritis; orbital cellulitis; eye strain; AVM.
Temporomandibular joint—arthritis or idiopathic dysfunction (common).
Teeth/gums—caries; broken teeth; abscess; malocclusion.
Ear—otitis media; otitis externa.
Vascular/vasculitis—arteriovenous fi stula; aneurysm; or AVM at the cerebellopon
tine angle; giant cell arteritis; SLE