Neurological History Taking Flashcards
Presenting complaints?
- headache
- muscle weakness
- visual disturbance
- change in other senses
- dizziness
- speech disturbance
- dysphagia
- fits, faints, funny turns, involuntary movements
- abnormal sensations
- tremor
Headaches?
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?
Muscle weakness?
Speed of onset?
Muscle groups affected?
Sensory loss?
Any sphincter disturbance?
Loss of balance?
Associated spinal/root pain?
Visual disturbance?
e.g. blurring, double vision (diplopia), photophobia, visual loss
Speed of onset?
Any preceding symptoms?
Pain in eye?
Change in other senses?
Hearing, smell, taste?
- Abnormalities are not always due to neurological disease, consider ENT disease.
Dizziness?
Illusion of surroundings moving (vertigo)?
Hearing loss/tinnitus?
Any loss of consciousness?
Positional?
Speech diturbance?
Difficulty in expression, articulation, or comprehension (can be difficult to determine)?
Sudden onset or gradual?
Dysphagia?
Solids and/or liquids?
Intermittent or constant?
Difficulty in coordination?
Painful (odynophagia)?
Fits/faints/‘funny turns’/involuntary movements?
Frequency?
Duration?
Mode of onset?
Preceding aura?
Loss of consciousness?
Tongue biting?
Incontinence?
Any residual weakness/confusion? Family history?
Abnormal sensations?
E.g. numbness, ‘pins & needles’ (paraesthesiae), pain, odd
sensations
Distribution?
Speed of onset?
Associated weakness?
How do you assess the cognitive tate of the patient?
Mini-Mental State Exam
Past medical history?
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
Drug history?
anticonvulsant/antipsychotic/antidepressant medication
psychotropic drugs (e.g. ecstasy)
medication with neurological side-effects (e.g. isoniazid which can cause a peripheral neuropathy)
Social and family history?
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.
What is a cramp?
- 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
Cramp and neurological disease?
Forearm cramps suggest motor neuron disease
What is parasthesiae?
Pins and needles’, numbness/tingling, which can hurt or ‘burn’ (dysaesthesia)
What are the causes of parasthesiae?
- Metabolic - increased Ca2+ (perioral); increased PaCO2; myxedema; neurotoxins (tick bite; sting)
- Vascular - arterial emboli; Raynaud’s; DVT; high plasma viscosity
- Anti body-mediated - paraneoplastic; SLE; ITP. Infection, rare: Lyme; rabies. Drugs, ACE-i
- Brain - thalamic/parietal le
sions - Cord - MS; myelitis/HIV; B12; lumbar fracture
- Plexopathy/mono neuropathy - cervical rib; carpal tunnel; sciatica
- Peripheral neuropathy - glove & stocking, e.g. DM; CKD
- paroxysmal neuropathy - migraine; epilepsy; phaeochromocytoma
- take travel history, consider infection, e.g. strongyloides
What is a tremor?
Tremor is rhythmic oscillation of limbs, trunk, head, or tongue.
Types of tremor?
- resting
- postural
- intention
Resting tremor?
- 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
Postural tremor?
- 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
Intention tremor?
- worst on movement, seen in cerebellar disease, with past pointing and dysdiadochokinesis
- No effective drug has been found.
CNS causes of facial pain?
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).
Vascular and non-neurological causes?
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
