Chapter 2 neurological history

- Pivotal questions
o Where is the lesion
o What is the pathology
- Past history does not make a diagnosis only increases likelihood
- Principles of neurological history taking
o Monophasic or intermittent
 Monophasic
 Onset, progression, duration
o Onset
 Sudden
 Vascular – embolism, SAH
 Electrical – Epileptic seizure or arrhytmia
(brady/tachy/complete heart block)
 Mechanical – trauma
 Subacute
 Infective - meningitis
 Inflammatory – MS, neuropathy
 Metabolic – hyponatremia, coma
 Chronic
 Neoplastic - tumors
 Degenderative – cervical spondylitic
myelopathy
 Chronic endocrine – hypothyroidism,
cushings
 Chronic inflammatory – chronic
inflammatory demyelinating
 Exceptions
 Diplopia – begins suddenly but not always
vascular or mechanical
 Neoplastic – can develop ery fast
 Vascular – can be slow
 When onset cannot be established
 On awakening, when external stimulus is
applied.
 Instead elcit whether symtpoms have
progressed since first noticed
 Site of disorder (nature and distribution)
o Nature – clarify exactly
 Weakness – loss of strength
 Diplopia – actually see 2 bjects, vertical or horizontal
 Dizzy – lightheaded or room is spinning
 Slurred speech – dysarthria like drunk, or difficulty
finding words/saying words (dysphasia
o Localising
 Part of the nervous system
  Unilateral vision loss – ipsilateral eye or
optic nerve
 Temporal field loss – chiasm
 Hemianopia – optic radiation or occipital
cortex
 Vertical – brainstem, midbrain (3rd or 4th
cranial nerve), very rarely due to local
muscle problems
 Horizontal diplopia – pons, CNVI or MLF
 Pill rolling – basal ganglia
 Variability with exercise
o Lambert eaton improves,
o MG gets worse
 Impairment of speech – usually cortex on
dominant side
 Involvement of pathway
 Vertigo – vestibular system
 Weakness – between cortex and muscle
 Sensation – peripheral nerve and cortex
o Propriocception – tightness of skin
o Spinothalamic – inability to feel
temperature
 Wasting or fasciculation – LMN from
anterior horn
o Distribution
 Pattern of weakness – one limb -> whole limb or
part of limb (CNS vs PNS)
o Nonspecific
 Dysarthria
 Anosmia
 Exacerbation from heat and exercise
 Ataxia
 Pain
 Urinary or lower bowel sphincter – in women can be
due to gynaecological problems rather than
neurological problems
 Dusphagia
o Patterns of weakness
 Sudden onset weakness confined to one limb – CNS
rather than PNS
 Weakness in hand or forearm – C7,C8, T1, median,
ulnar or radial nerve
 Weakness in upper arm or shoulder - C5, C6 nerve
root, axillary, MCT, suprascapular nerve
 Weakness in leg – L2,3,4, nerve root orfemoral
nerve
  Weakness in lower part of leg – L5, S1, sciatic,
common peroneal or posterior tibial nerve
 Hemiparesis arm and leg with no facial involvement
– very likely upper motor neuron problem,
contralateral hemisphere > contralateral
brainstem >> ipsilateral spinal cord around C5
 Paraparesos – Spinalcord or LMN lesion such as
peripheral neuropathy
 Quadriparesis – Cervical spinal cord problem above
C5 >> peripheral neuropathy or muscle disease
 Other facts
o Family Hx
o Past MedHx
o Coesistent medical problems
o Medication Hx
o Social Hx
o Suggested framework
 When were you last well
 First symptom you noticed? Exactly which part of body involves
 Gotten worse?
 Repeat for all symptoms
 Family history of similar problems
 Medical problems in past year
 Medication
 Anyone who lives with you