Neurological Hx

Front 1

Major Symptoms of Neuro

Back 1

1. Pain – back, neck or facial pain or headache.
2. Seizures, syncope and odd behaviours (‘funny turns’)
3. Dizziness and vertigo
4. Tremor
5. Disturbances of:
o Cognition
o Speech or swallowing
o Vision, hearing or smell
o Gait
o Limb power, sensation or coordination
o Bladder or bowel control

Front 2

Timeline

Back 2

RAPID: more likely vascular
SLOWLY-progressing; more likely tumour, neurodegenerative
RECURRENT: episodes such as migraine and epilepsy

Front 3

Localisation

Back 3

- cerebrum
cerebellum
spinal cord
peripheral nerve
NMJ
Muscles

Front 4

Hx from a patient with Limb Sx

Back 4

- suggests spinal cord
- bowel & bladder Qus
- Sensory & Motor Sx
- loss of balance & Falls
- Incoordination
- Tone

Front 5

Bowel or Bladder involvement

Back 5

Suggest spinal cord or cauda equina
BLADDER:
-LMN; loss of small urine with coughing, straining (stress incontinence)
-UMN: urge incontinence

BOWEL: either constipation or diarrhoea. Faecal incontinence is most often seen in LMN disease

ERECTILE DYS: most commonly due to local vascular disease but spinal cord lesion could be the cause (eg young men with MS)

Front 6

Sensory Sx

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- paraesthesiae
- numbness
- hyperaesthesia (more acutely than normal)

Front 7

Motor Sx

Back 7

Weakness
stiffness
Loss of coordination
Movement Disorders

Distinguish between UMN & LMN

Front 8

Loss of balance and falls

Back 8

- can be due to;
- loss of coordination
- sensory abnormalities and
- muscle weakness. Assess the frequency of falls, the
resultant injuries and whether mobility aids are required.

Front 9

Incoordination

Back 9

may be due to an
- upper motor neurone lesion,
- a movement disorder or
- to sensory loss.
Impaired fine movements in the absence of other symptoms are often seen in Parkinson disease.

Front 10

Tone

Back 10

- complaint of leg stiffness (spasticity) UMN or with movement disorders (PK)

Front 11

Associated Conditions INC Risk

Back 11

- STROKE
- peripheral neuropathy
- medications

Front 12

Syncope

Back 12

- due to reduced cerebral blood flow
2 important forms:
1. VASOVAGAL: -impaired vascular tone in blood vessels (abdo and LL) + reduced HR. Resulting BP drop is gradual seconds to mins, and thus patients have recollection of Sx's prior to fall. INCLUDE: tunnel vision, roaring in ears... it may also be involved in an ACUTE convulsion. recovery within SECONDS!

2. CARDIAC: abrupt cessation of CO (arrhythmia..). Rapid loss of consciousness, patients rarely recall preceding events and OFTEN injury themselves as they collapse. Rapid recovery once circulation is restored

Front 13

Seizures

Back 13

-Primary Generalised: abrupt, no recollection, witness Hx is essential. Followed by 20mins of confusion.

- focal seizures; can then spread. Sx at first related to the area the focal seizure arises from. As it spreads the patient loses awareness, stops laying down new memories and may go on to have a generalised seizure. The commonest site of origin is the hippocampus and seizures in this area are associated with memory disturbance (déjà- vu), olfactory hallucinations and disturbances of visceral sensation (nausea and/or odd feelings in the chest or upper abdomen).

Front 14

Comparison of Seizure and Syncopy

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best comparision is
1. the preceding Sx and memory of it
2. Duration of post-collapse amnesia

- also tonic clonic contractions

Front 15

Activities to avoid

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What common activities should the patient avoid (harm to self or others)? Drowning is the
commonest cause of death in epilepsy. Also consider driving, working at heights and use of
machinery

Front 16

Dizziness

Back 16

non-specific term refers to light-headedness, generalised feeling unwell such as in anaemia

Front 17

Vertigo

Back 17

- specifically assoc. with disorders of the membranous labyrinth or its neuro connections.
- CARDINAL feature is illusion of movement (i OR the world was spinning).
- it could also be linear vertigo (i was pushed sideways or the world dropped underneath me).

- vertigo is made worse by head movements and so patients will attempt to limit movement

Front 18

Patterns of vertigo

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1. Benign positional vertigo: brief (seconds to minutes) recurrent episodes of vertigo precipitated by
head movement are usually due to crystalline debris in the semi-circular canals. Looking upwards
or rolling over in bed typically provokes this.
2. Acute labyrinthine vertigo: acute damage to the membranous labyrinth (usually viral in young
people and vascular in the elderly) is associated with intense rotatory sensation accompanied by
nausea. The symptoms settle over a period of days. During the acute phase, the patient is very
unwell and very reluctant to move his or her head.
3. Recurrent labyrinthine vertigo: patients with Menière disease get periods of recurrent vertigo that
last for hours or days. Theses are frequently associated with tinnitus and reduced or distorted
hearing.
4. Acute non-labyrinthine vertigo: vertigo may be the presenting symptom of a brainstem stroke.
Patients with acute non-labyrinthine vertigo have symptoms similar to those with acute
labyrinthine vertigo, plus other symptoms due to brain stem damage – weakness, sensory loss,
diplopia or facial weakness.

Front 19

Mental State Exam

Back 19

Tests facets of Higher mental function
OBSERVE: their appearance, behaviour, patterns of speech, and interactions with others.
TEST: orientation, memory, attention and registration and enquiring about perceptual disturbances and in some cases, disorders of thought.

- picks up pschyatric conditions with no abnormal brain structures BUT some thought processes may NOT be revealed by MSE

Front 20

MMSE

Back 20

used for declining cognition (alzheimers..)
- culturally and educationally specific

Front 21

Delirium

Back 21

Delirium is an acute reversible deterioration of mental function due to an imposed stress. It most
commonly occurs in patients with an underlying cognitive abnormality, but a severe stress (e.g.
meningitis, hyperthermia) may produce delirium in a previously normal person.

Front 22

Causes of Delirium

Back 22

hypoxia, infections, medications, metabolic disorders, stroke, sensory impairment, constipation and
urinary retention. Rapid recognition of delirium is important because it is often related to reversible
conditions and earlier intervention leads to better outcomes

Front 23

Distinguishing Features of Delirium

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Disturbances of consciousness and attention, with sudden onset and fluctuating cognitive status, are the major features that distinguish delirium from other causes of impaired cognitive function

Front 24

Confusion Assessment Method (CAM)

Back 24

commonly used tool to identify delirium.
1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking or altered level of consciousness.

Front 25

Acute onset neurological problems DDx?

Back 25

- cerbrovascular disease (stroke Sx occur over minutes or when the patient wakes from sleep)
- convulsions
- eg seizure headache of subarachnoid haemorrhage

* precipitating or warning events may be present

Front 26

Precipitating or Warning events

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- may be localising (auditory hallucinations, an unusual smell or taste, loss of speech, or motor changes) or non-localising (e.g. a feeling of apprehension).

Front 27

Questions for Stroke or TIA?

Back 27

1. What have you noticed has been wrong?
2. How quickly did it come on? How long ago?
3. Has it improved or gone away now?
4. Have you ever had a stroke before? How did that affect you?
5. Have you had high blood pressure or cholesterol (risk factors)?
6. Are you a diabetic (risk factor)?
7. Do you smoke (risk factor)?
8. Is there a history of strokes in the family?
9. Have you had palpitations or been told you have atrial fibrillation?
10. Have you been treated with blood-thinning drugs such as aspirin or warfarin?

Front 28

Dx: sudden onset weakness on one side of the body followed by resolution and a sever headache

Back 28

hemiplegic migraine

without headache think TIA

Front 29

Dx: very gradual onset muscle weakness

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muscle abnormality

Front 30

Subacute onset (hrs-days)

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occurs in inflammatory disease (meningitis, cerebral abscess or Guillain-Barre)

Front 31

Dx: Chronic

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-tumour (weeks - months)
- degenerative process (months-years)

Front 32

Hx and Physchial try to determine

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- diffuse or localised
- levels of the NS involved

Front 33

HPI: detailing other neurological problems?

Back 33

1. Can you tell me what has been happening to you?
2. Are you right- or left-handed?
3. Have you had problems with headaches?
4. Have you been dizzy or had problems with your balance?
5. Have you noticed trouble with your speech?
6. Have you had problems with your vision?
7. Have you had weakness in an arm or leg?
8. Have you ever had a seizure or a blackout?
9. Have you ever had a head injury?
10. Have you had any back problems?
11. Have you had any scans of your brain or spinal cord?
12. What medications have you been taking?
13. Have you had high blood pressure?
14. Is there a history of neurological or muscle problems in the family?
15. Do you drink alcohol?

Front 34

Questions for Headache?
SOCRATES

Back 34

1. What is it like, e.g. dull, sharp, throbbing or tight?
2. Where do you feel it—at the front or back, on one side or in the face?
3. How severe is it and how long does it last?
4. Has it begun very suddenly and severely?—Subarachnoid haemorrhage
5. Do you get any warning that it is about to start, e.g. flashing lights or zigzag lines in your
vision?—Migraine
6. Is it associated with sensitivity to light (photophobia)?—Migraine
7. Do you feel drowsy or nauseated?—Raised intracranial pressure
8. Is the pain on one side over the temple and have you had any blurred vision?—
Temporal arteritis
9. Is the pain worst over your cheek bones?—Sinusitis
10. Are the attacks likely to occur in clusters and associated with watering of one eye?—
Cluster headache
11. Is there a prolonged feeling of tightness over the head but no other symptoms?—
Tension headache
12. Did you drink large amounts of alcohol last night?—Hangover

Front 35

Different types of headache?

Back 35

- neck stiffness (occiput pain; cervical spondylosis)
- cotial headache; durin intercourse close to orgasm
- ICP headache; worse in the morning and is assoc. with drowsiness/vomiting
- Meningitis; fever, stiff neck
- temporal arterities: tender temporal a, blurring vision, unilateral headache, jaw claudication or pain
- Acute sinusitis; pain or fullness behind he eyes or ver cheeks
- tension; common, tightness, bilateral (no assoc. Sx)

Front 36

Causes of pain in the face?

Back 36

- trigeminal neuralgia
- TMJ arthritis
- glaucoma
- cluster headaches
- temporal arteritis
- psychiatric disease
- aneurysm of internal carotid or post. comm.
- superior orbital fissure syndrome

Front 37

Faints and Fits DDx

Back 37

- both can cause clonic jerks
- Epilepsy causes ABRUPT loss of consciousness which may be preceded by an aura
- both cause incontinence
- epilepsy may bite their tongues
- WITNESS is important (generalised seizure vs focal sx- eg one arm may indicate a focal lesion- tumour, abscess...

Front 38

Simple v complex partial

Back 38

simple no LOC
complex LOC

Front 39

Main Children

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idiopathic abscence seizures (petit mal) episode of LOC followed by staring

Front 40

Questions to ask syncope or dizziness?

Back 40

1. Have you lost consciousness completely? How long for?
2. Do you black out or feel dizzy when you stand up quickly?—Postural hypotension
3. How often have episodes occurred?
4. Was the sensation more one of spinning?—Vertigo
5. Did the episode occur during heavy exercise or when you got up to pass urine at night?
Exercise—suggests a left ventricular outflow tract obstruction such as aortic stenosis. Pass
urine at night—micturition syncope
6. Have you injured yourself?
7. Do you get any warning?—A feeling of nausea and being in a stuffy room suggests a
vasovagal episode; a strange smell or feeling of deja-vu suggests an aura and therefore a
seizure
8. Have you passed urine during the episode?—Seizure
9. Have you bitten your tongue?—Seizure
10. Has anyone seen an episode and noticed jerking movements (tonic-clonic
movements)?—Makes a seizure more likely but can also occur with cardiac syncope
11. Do you wake up feeling normal or drowsy? Normal—cardiac syncope. Drowsy—
seizure
12. What medications are you taking—any antihypertensive medications, cardiac antiarrhythmic
drugs or anti-epileptic drugs?

Front 41

Other causes of LOC

Back 41

- TIA to brainstem
- Hypoglycaemia; sweating, weakness, confusion
- Hysteria

Front 42

Dizziness

Back 42

1. true vertigo; sense of motion surrounding or head itself

Front 43

Vertigo CAUSES:

Back 43

Assoc. Sx: n/v, pallor, sweating, headache
PERIPHERAK VESTIBULAR LESIONS:
A. benign postioning vertigo; precipitated by change in head position due to crystals in the saccule and utricle
B. Vestibular neuronitis; non-positional vertigo due to inflammation of the acoustic nerve with normal hearing
C. acute labyrinthitis; assoc. with hearing loss

D. OTHER CAUSES;
1. ototoxic drugs (aminoglycosides- deafness or tinnitus)
2. Meniere's disease; >50yrs, triad of episodic vertigo & tinnitus and progressive deafness
3. Acoustic neuroma (patients also have deafness & tinnitus)
4. Central causes such as vertebrobasilar TIAs, assoc. with diplopia, visual loss and ataxia
5. RARE: internal auditory artery occlusion

Front 44

Ambylopia

Back 44

blurred vision

Front 45

Disturbance of Gait

Back 45

page 376 talley

Front 46

Disturbed Sensation or weakness in limbs

Back 46

- pins and needles may indicate nerve entrapment or peripheral neuropathy
- median nerve the pain can extend to the shoulder but parasthesia remains only in the fingers

Front 47

Sx of Muscle Disorders

Back 47

wasting, decreased tone, and the reflexes are reduced or
absent.

Front 48

Sx of NMJ disorders

Back 48

generalised weakness, which worsens with repetition. The reflexes and tone are often normal

Front 49

Non-organic weakness (e.g. due to hysteria)

Back 49

causes a non-anatomical pattern of weakness in association with normal tone and power and, unless
there has been prolonged disuse, normal muscle bulk

Front 50

Tremor definitions

Back 50

- rhythmical movement
SLOW 3-5Hz
RAPID 10Hz
RESTING during muscle relaxation
INTENTION during deliberate movement more pronounced towards the end of the action
PHYSIOLOGICAL tremor when holding posture or slow movements (exaggerated in thyrotoxicosis, beta agonist, caffeine, fright or flight)
BEGNIGN; inherited tremor and thats it

Front 51

Rates of tremors

Back 51

3-5Hz Parkinson's
4-7Hz Essential/familial
8-13Hz Physiological

Front 52

Akithesia

Back 52

Motor restlessness; constant semi-purposeful
movements of the arms and legs

Front 53

Asterixis

Back 53

Sudden loss of muscle tone during sustained
contraction of an outstretched limb

Front 54

Athetosis

Back 54

Writhing, slow sinuous movements, especially of
the hands and wrists

Front 55

Chorea

Back 55

Jerky small rapid movements, often disguised by
the patient with a purposeful final movement: e.g.
the jerky upward arm movement is transformed
into a voluntary movement to scratch the head

Front 56

Dyskinesia

Back 56

Purposeless and continuous movements, often of
the face and mouth; often a result of treatment
with major tranquillisers for psychotic illness

Front 57

Dystonia

Back 57

Sustained contractions of groups of agonist and
antagonist muscles, usually in flexion or extremes
of extension; it results in bizarre postures

Front 58

Hemiballismus

Back 58

An exaggerated form of chorea involving one side of the body: there are wild flinging movements which can injure the patient (or bystanders)

Front 59

Myoclonic Jerk

Back 59

A brief muscle contraction which causes a sudden
purposeless jerking of a limb

Front 60

Myokymia

Back 60

A repeated contraction of a small muscle group;
often involves the orbicularis oculi muscles

Front 61

Tic

Back 61

A repetitive irresistible movement which is
purposeful or semi-purposeful

Front 62

Tremor

Back 62

A rhythmical alternating movement

Front 63

Medical History

Back 63

- meningitis or encephalitis
- head or spinal injuries
- Hx of epilepsy
- previous operations
- STDs (HIV or syphillis)
- risk factors for cerebrovascular disease

Front 64

Medications Hx

Back 64

1. Anti-HT
2. Anti-platelet/ Anti-coag
3. Statins
4. Major tanquillisers
5. Nitrates & sildenafil
6. Deafness (Amino, A, F)
7. Peripheral neuropathy (A, I, M)
8. Non-PK tremor
9. Dysphagia (bisphos)
10. Confusion & loss of memory
11. Seizures (lignocaine)

Front 65

Social Hx

Back 65

- smoking
- occupation (exposure to toxins)
- EtOH

Front 66

Family Hx
- Inherited Neurological Conditions
X linked

Back 66

- colour blindness
- Duchenne’s and Becker’s muscular dystrophy,
- Leber’s* optic atrophy

Front 67

Autosomal Dominant

Back 67

- Huntington’s chorea,
- tuberose sclerosis,
- dystrophia myotonica

Front 68

Autosomal Recessive

Back 68

- Wilson’s disease,
- Refsum’s† disease,
- Freiderich’s ataxia,
- Tay-Sachs’‡ disease

Front 69

Increased Incidence in family

Back 69

Alzheimer's disease