CNS History Taking

ID:

Name age sex marital status nationality occupation address

Source or referral: (OPD, PHC, self, policeetc)

Presenting complaint:

*In patients own words What brought you to hospital? When did it first begin? (duration) Which part of the body is affected? (location)

History of presenting complaint:

How long do the symptom/symptoms last for? Is it localized or widespread? Is it sudden, rapid or gradual in onset? Are the symptoms static or deteriorating? Are there any aggravating or relieving factors? (For example, worsening of symptoms with hot environments eg: sauna, hot bath or hot weather in demyelinating disorders, called Uhthoff's sign) Does anything trigger the symptoms? (eg: exercise, sleep, posture or external stimuli such as light or smell?) Is there history of trauma or infection Is there any exposure to drugs or toxic substances More specific questions: For headache ask: Location: Unilateral (migraine), periorbital (glaucoma/uveitis), parietal/occipital (tension), neck (meningitis or subarachnoid hemorrhage) Quality: throbbing (vascular), intermittent jabbing (trigeminal neuralgia), pressure (sinus) Radiation

Severity (rate from 1-10) Timing (worse in a.m. or p.m.) Constant vs. intermittent Is it the worst headache ever? Specific associated symptoms: dysesthesias, aura For altered mental status ask: Associated seizure activity For weakness, unsteadiness, stiffness or clumsiness ask: Progressive or recurrent? Generalized or focal? Is there loss of strength Is there associated pain For vertigo ask: *Differentiate between true vertigo and lightheadedness! Present at rest or affected by positional changes For seizures ask: Previous history of seizures? Frequency motor activity aura Loss of consciousness post-ictal confusion External etiology (triggers/trauma?) What are the associated symptoms? May include: Visual disturbance Psychological changes - eg, agitation, tearfulness, depression or elation, sleep disturbance For children, ask about performance at school Nausea or vomiting Numbness, pins and needles, cold or warmth Seizures Headaches Weakness Biological functions: sleep, appetite /weight, bowel habits, libido Treatments if received, response, side effects, compliance Visits to native or faith healers. Impact of the illness on his/her daily function (work, friends, family) Safety assessment review of major psychiatric illness symptoms

Past psychiatric history:

Previous episodes previous treatments (medications, ECT, Psychotherapy) history of self or other harm

Past medical history

Some neurological problems can present years after a causative event Enquire about other medical problems, past and present, surgeries (These may give clues to the diagnosis. For example: A person in atrial fibrillation may be producing multiple tiny emboli. There may be vascular problems or recurrent miscarriage to suggest antiphospholipid syndrome. There may be diabetes mellitus.) Ask about any infections, convulsions or injuries (RTA, trauma) in infancy, childhood or adult life Particularly ask about head or spinal injury, meningitis or encephalitis Pregnancy, birth and neonatal health: Any illness or infection during pregnancy Difficult / complicated labor Need to stay in the hospital after delivery

Personal history:

Childhood: Milestones (at what started sitting, walking, talking) separation from mother Schooling: Start and finish Grades Relation with schoolmates & teachers. Social history: Smoking Drinking habits (Alcohol is a significant neurotoxin, both centrally and peripherally.) Ask about drugs including prescribed, over-the-counter and illicit. Ask about accommodation and financial situation Occupational history: Ask about occupation and what it involves About continuity and changing jobs, relation with workmates & seniors, promotions, dismissal, retirement (There may be exposure to toxins. Is there prolonged visual work which may predispose to tension headache or migraine? The job may involve driving but the patient has admitted to convulsions. He may work at heights or in a dangerous environment.) Marital history: Ask about marital status and *domestic violence (Has there been recent bereavement or divorce which may have affected symptoms?) Number of children Ask about sexual orientation and consider the likelihood of sexually transmitted infection - eg, syphilis, HIV

Family history
Parents : age, health, occupation, relation with patient siblings: age, order, health, occupation, relation with patient Family history of mental illness, substance abuse, epilepsy Family atmosphere: harmonious / disrupt / relaxed / tense / controlling / over involving? (For example: A cousin with Duchenne muscular dystrophy or Becker's muscular dystrophy would be very important for a boy who cannot run like his peers. Huntington's chorea is a familial disease that does not present until well into adult life. A family history of, for example, type 2 diabetes mellitus, cerebral aneurysm, neuropathies, epilepsy, migraine or vascular disease may be important.)

Systematic enquiry

Review all the systems from head to toe Loss of weight and appetite (may suggest malignancy) Gain in weight (may have precipitated diabetes mellitus.) Polyuria (may suggest diabetes mellitus. Difficulty with micturition or constipation may be part of the neurological problem but was not volunteered in the general history. In men, enquire about erectile dysfunction.)