NEUROLOGICAL HISTORY-TAKING

BYDR. MANOJ KUMAR MAHATA

DM PDT NEUROLOGY

PRE-REQUISITEAlertness of patient Informant Insight of patient regarding illnessDoctor-patient relationship PROFORMAPatient particulars ( name, age , sex, occupation, area of

residency, handedness)Presenting illnessPast illness- medical/ surgicalPersonal history- toxin exposure, birth historyFamily historyTreatment history

GOAL OF HISTORY TAKINGFirst priority is to identify the region of nervous system

that is likely to be responsible for the symptomsSite of the lesionNature of the lesion BASIC DESCRIPTIONSiteSeverityOnset ( acute, subacute, chronic )Duration FrequencyPrecipitating/ Relieving factorsTime of occurrence

COMMON PRESENTATIONS

HeadacheVisual disturbancesLoss of consciousnessSeizureSpeech disorderMotor disorderSensory disorderCranial nerve disorderAlteration of state of mind Autonomic disorderSphincter disorder

HEADACHE

SiteSeverityOnset ( sudden/ gradual )FrequencyDurationCharacterTime of occurrence ( e.g.morning )Precipitating factors ( stooping / coughing )Relieving factorsAssociated features ( vomiting, visual disturbances )

First attack or presence of previous attacks - worst headache (SAH) - persistent ( secondary headache)Age of onset - childhood to young adulthood ( primary headache) - older than 50 yrs ( secondary headache)Activity at onset of headache - Valsalva maneuver ( SAH, CSF leak) - changes in posture (supine - ↑ICP , upright –

low CSF pressure headache) - head trauma

- exercise – can precipitate migraine

Characteristics of headache - severe headache : SAH both primary & secondary HA may be

mild to severe

- timeframe : rapid onset – SAH, ICH gradual onset – migraine(mins to days) SDH, GCA(days to months)

- duration - location - quality : pounding/throbbing- migraine boring sharp- cluster HA

- Associated symptoms : • Fever , diaphoresis , chills & rigor• nausea & vomiting – migraine, ↑ICP,

posterior fossa lesion• Photophobia & phonophobia – migraine or

meningeal process • Neck stiffness – meningeal process• Changes in consciousness• Focal neurological symptoms

VISUAL DISTURBANCES

Impairment of vision

Diplopia

Hallucinations ( formed / unformed)

IMPAIRMENT OF VISIONMaybe caused by problem in media or due to nerve damageMonocular• acute transient – Amaurosis fugax• subacute – maybe painful or painless - optic neuritis - AION – arteritic or non arteritic - leber optic neuropathy• Chronic – due to optic nerve compression usually painless

Binocular abrupt onset – ON – Devic’s disease, Foster Kennedy

syndrome partial field loss – chiasmal damage, migraine,

degenerative disease

DIPLOPIAMONOCULAR - due to aberration in ocular mediaBINOCULAR – vertical/ horizontal diplopia constant/ intermittent diplopiaASSOCIATED SYMPTOMS eye pain – orbital conditions - distributed in V1 – cavernous

sinus / SOF headache - ↑ICP, brainstem localisation

HALLUCINATIONS due to migraines

LOSS OF CONSCIOUSNESSHead injury – recent / previousSudden collapse – ICH , SAHLimb twitching ,incontinence – epilepsy/post-

tictalAlcohol/ drug abuseCardiovascular/ respiratory/ genitourinary

disorderAcute/ gradual – mass lesionMetabolic – diabetesPsychiatric disorder - hysteria

HISTORY OF SEIZURES

• Obtain a description of the seizure/s:• From patient and witness (NB blackouts, faints, fits,

loss of consciousness)• What happens at the onset of the fit?• What happens during the fit?• Does the patient fall or remain standing or sitting?• How does the fit end?• Confusion or other post-ictal symptoms?

• Is there incontinence, any injury or tongue biting?• Frequency of seizures?• When do the seizures occur?• What medication is taken?• History of past/ current medication, compliance and

response to medication

HISTORY OF SEIZURES

• Change in seizure pattern• Family history of seizures• Head trauma or brain illness

(especially in adult onset epilepsy)• Birth history

(especially in early onset seizures)

HISTORY OF SEIZURES

SYNCOPE

• Fainting or LOC resulting from recoverable loss of adequate blood supply to the brain

• Vasovagal syncope - provoked by emotionally charged event e.g venepuncture

• Cardiac syncope - sudden decline in cardiac output and hence cerebral perfusion e.g severe aortic stenosis or heart block

SEIZURE AND SYNCOPE

• Features helpful in distinguishing the two: Seizure Syncope1) Aura + -2) Cyanosis + -3) Tongue-biting + -4) Post-ictal confusion,headache and amnesia + -5) Rapid recovery - +

SPEECH DISORDER

• Onset• Frequency• Duration• Difficulty in articulation – dysarthria• Difficulty in expression• Difficulty in understanding

MOTOR DISORDER

Lack of co-ordination – balance Weakness – unilateral / bilateral - progressive/static - distal/proximal(ability to lift objects,

grip strength, arising from chair/bed, climbing stairs)

- painful/ painless - diurnal variations Involuntary movements like twitching, jerks etc Wasting Limb stiffness Gait abnormalities – limping, leg dragging, waddling

SENSORY DISORDER

PainTingling/ numbnessLoss of sensation Trophic changes – ulcer/ neuropathic joint

CRANIAL NERVE DISORDER Loss of smell, vision, taste Difficulty in mastication , loss of sensation over face Deviation of angle of mouth; facial asymmetry;

epiphora Deafness/ tinnitus – unilateral/ bilateral Vertigo Balance/ staggering – direction Nasal intonation or regurgitation Difficulty in deglutition Change of voice Wasting of tongue / dysarthria Difficulty in neck movements

CHANGE IN MENTAL STATEChanges in memory ( short / long term)Alertness/ drowsinessLoss of spatial orientationChanges in mood, affect, loss of spontaneityAbility to carry out daily routine activities

Autonomic disorder

• Palpitation• Abnormal sweating• Abnormal skin temperature• Impotence• Bladder dysfunction• Nocturnal diarrhoea• GI dysfunction- vomiting• Orthostatic hypotension

SPHINCTER DISORDERDifficulty in control – incontinence/ retentionUrinary retention ( spinal cord compression or

trauma)Loss of awareness of bladder distension ( damage

to frontal lobe)Frequency, urgency, urge incontinence ( damage to

pons or spinal cord)Overflow incontinence ( lmn)

Medical illnesses

• DM, hypertension, dyslipidemia• Valvular heart disease• Malignancy• Coagulopathy• Collagen vascular diseases• Endocrinopathies• Infectious diseases like HIV

FAMILY HISTORYHypertension , heart disease – stroke Inherited disorder ( NF, Wilson’s Ds, CMT )Detailed family history often necessary in polygenic

disorders such as MS, migraine, and epilepsies.

PERSONAL HISTORYDrug abuse – prescribed or illicitToxin exposure like alcohol, environmental or

industrial neurotoxinsBirth history

Drug history

• h/o sedatives, antidepressants and other psychoactive medications in acute confusional state

• Aminoglycosides use in neuromuscular disorder• Anticancer drugs in peripheral neuropathy• Immunosuppressive agents in encephalopathy• Excessive vitamins uses• OCPs, antihypertensives, anti-coagulants

THANK YOU