Neurological History Taking Flashcards
Identify ways to optimise communication with a patient during history taking.
- Quiet environment, minimise distractions
- Ensure hearing aid works properly if present
- Ensure you are speaking clearly and articulately
- Ensure patient can see you and your mouth
- Possibly use paper/pen if needed
Identify areas in which history taking and examination overlap.
Observations: state of health, mode of dress, age, eye contact, mood, abnormal movements (e.g. tics)
Content of conversation: level of education, intelligence, mood.
Articulation of speech (dysarthria), dysphasia
What is the relevance of knowing whether a patient is R or L handed ?
If R sided weakness, L hemisphere dominance, which means that is where language is located in their brain.
Clinically, this means that if a patient comes in with R sided weakness you expect language might be affected (given that they are R handed), so might expect dysphasia.
Define presenting complaint.
Symptom that has brought the patient to the doctor
Why should you record the presenting complaint in the patient’s own words ?
Patient’s don’t always use terminology to mean what you think it means
Identify ways patients might word a presentation of benign position vertigo.
The dizziness started suddenly when I was in bed and rolled over
Feels like I am on a roundabout lasts a couple minutes then settles
OK if I keep my head still but if I look up suddenly it can start again
Identify the commonest neurological symptoms.
- Headache
- Blackout/funny turn
- Dizziness
- Numbness/sensory change
- Movement/walking problems • Memory problems
- Visual symptoms
Identify a possible neurological cause for the following presenting complaint:
Increasing difficulty doing up buttons.
Also state possible questions to clarify whether that is the actual cause.
Parkinson’s
Ask:
changes in handwriting? (small handwriting is sign of Parkinson’s)
any tremor at rest?
any differences in the way you walk ?
What are the main systems which can be involved in blackouts, fits, faints and funny turns ? Give a specific example of cause of those for each system.
CV (e.g. postural hypotension)
Neurological (e.g. seizures in epilepsy)
It’s orientation week…at the Principal’s reception your parents are listening to wise words being spoken (lots of them!). There are no seats (to encourage mingling) and wine is being served. One of the mothers falls to the floor. What is the likely cause ?
Postural hypotension
What is epilepsy due to ?
Abnormal, excessive paroxysmal discharge of
cerebral neurons
Identify tests which can be undertaken for epilepsy.
- Sodium, glucose, magnesium, urea
- Neuro imaging
- Electroencephalogram
BUT MAY ALL BE NORMAL IN EPILEPSY
Diagnosis of fits, faints and funny turns can be difficult. What types can be used to aid in this diagnosis ?
- Description from witness
- If recurrent, ask to record the event (smartphone)
- Describe the most recent episode
Identify questions to answer about a patient’s most recent episode of fits, faints and funny turns, in order to help determine a diagnosis.
• What was happening immediately before? • What factors might have lowered the seizure threshold? • What position was the patient in? • Any prodromal symptoms? • What happened during the episode? • After?
Identify possible factors which can lower the seizure threshold.
Antidepressants, tranquillisers, lack of sleep, alcohol, fever
State a common associated feature of headaches.
Nausea
Identify a type of headache.
Tension headache
What are possible time courses/evolution of symptoms for headaches.
- Sudden e.g. “thunder clap” headache (suggests subarachnoid hemorrhage)
- Recurrent (but well between episodes)
- Deterioration over hours
- Relapsing / remitting
- Deterioration over weeks / months
What is the commonest cause of fatigue.
Chronic fatigue syndrome
What are possible signs/symptoms which can be meant by “weakness” ?
Chronic aesthenia
Fatigue
Specific muscle weakness
(problem may be in the muscle or in the nerve supply to the muscle, focal weakness suggest neurological origin)
Describe the ice pack test.
Myasthenia Gravis patients: when ice pack on eye, eye opens (ice allows greater conduction in neuromuscular junction)
Identify tests for proximal and distal muscle weakness respectively.
Proximal muscle weakness (steroid drugs, or excess steroids due to Cushing’s disease)
- rising from sitting
- drying hair
Distal muscle weakness
- standing on tip toes
- fine finger movements
Identify questions to ask a patient who presents with weakness.
What activities are they finding difficult (e.g. walking ?)
• Has the distance they can manage changed?
• Why? What makes them stop?
• What about hills?
• One leg or both legs?
• Any sensory symptoms including pain?
• Any urinary symptoms? (spinal cord problems often present with urinary symptoms)
Identify possible causes of abnormal movement in a patient.
Too little movement: Parkinson’s (slowing of movement, stiffness)
Too much movement:
Chorea (fidgety jerks)
Choreoathetosis (decreased tone rapid, writhing changes in movement, can present due to overtreatment of Parkinson’s)
Identify sensory disorders.
Sensory loss
Paraesthesia: “feels like a tight bandage wrapped around my leg”
Allodynia (sense of pain as a result of different sensory stimulus (eg touch causes pain)
Complete sensory loss is likely to be of functional origin (hysterical sensation loss, i.e. psychological)
Identify a chronic illness which can result in neurological impairment.
Diabetes
How can you diagnose a neurological issue in a younger patient ?
Think milestones:
- was there any evidence of developmental delay ?
- 1 to walk and 2 to talk normally
- also think birth history (premature birth?)
What questions may we ask about drugs for a patient presenting with a neurological issue ?
PRESCRIBED DRUGS
What treatment(s) are they on?
Are they compliant?
Is it optimal?
Could it be the cause of the problem?
Is there any interaction between the drugs?
Is the patient thinking of becoming pregnant?
NON PRESCRIBED DRUGS
- What other drugs are you taking?
- How often, how much, how long?
- Tell me about your pattern of drinking alcohol
- What symptoms do you have if you don’t take drugs / drink?
Identify important questions to ask as part of a systems enquiry to a patient presenting with neurological problems.
Psychological…depressed?
Autonomic nervous system…bowel, bladder function, sexual dysfunction, light headedness?
Recent infection?
True or False: there is a genetic component to many neurological disorders.
True
Identify important questions to ask as part of the social history segment to a patient presenting with neurological problems.
- Who is at home?
- Home circumstances
- Are home circumstances contributing to medically unexplained symptoms?
- Occupational history
Identify cranial nerve screening questions.
- Change in your sense of smell?
- Vision? Double vision?
- Dry eyes? Dry mouth? Change in taste?
- Hearing? Dizziness?
- Change in voice?
- Articulation?
True or False: is it often important to record negatives when documenting a history.
True (documenting negatives are just as important as documenting positives)
How should you conclude a history documentation ?
Summary, differential diagnosis, and action plan
What factors are important when deciding on a differential diagnosis ?
Age Gender Pattern of onset Risk factors Relative incidence (common things are common)
Define medically unexplained symptoms. What proportion of all symptoms can these make up ?
Symptoms that are non-organic in origin (don’t fit a pattern underpinned by anatomy and physiology)
30%
What are important components of an action plan (as part of the documentation of a history).
What the patient wants
Investigations considered
Treatment considered
State questions to determine whether a patient has altered cognitive ability. What should you do if a patient has apparent altered cognitive ability ?
Is the patient orientated? Memory function?
May be apparent but confirm and document with objective assessment
Identify assessment tools for cognitive assessment.
- 4AT
- Mini Mental State Examination (MMSE)
- Addenbrookes Cognitive examination (ACE III, ACE mobile)
Briefly describe the 4 As Test as an assessment tool for cognitive assessment.
4 As Test is the (rapid), initial assessment for delirium and severe cognitive impairment:
- Alertness (Excessively sleepy ?)
- AMT4 (can patient state age, DOB, place, current year)
- Attention (can patient state the months of year in backwards order, starting at December)
- Acute change or fluctuating course (evidence of significance change in alertness, cognition, other mental function recently)
Define delirium.
• Mental confusion that can happen if someone becomes medically unwell (“acute confusional state”)
How common is delirium in hospital ?
Common 1:10 hospital patients
Identify a possible trigger of delirium.
Constipation
How is delirium treated ?
Treat the underlying cause
Briefly describe the ACE III, ACE mobile assessment tool for cognitive assessment.
• About 20 minutes to do • Scored out of 100 • 5 cognitive domains: – Attention – Memory – Verbal fluency – Language – Visuospatial abilities
