Neuropsychiatry Module 2010-2011

History and Topical Diagnosis in

Neurology

Dr Jofizal Jannis Sp.S(K)

Dr. Darma Imran SpS
Department of Neurology
Faculty of Medicine University of Indonesia
 Learning objectives

• The importance of history taking in

neurology
• Topical diagnosis in nervous system
• Clinical method
• Clinical Case
 Introduction
• We enter medicine for many different reasons but
two most frequently reasons : we love humanity and
science.

• Patients and family want a doctor with :

– A doctor who is caring and who will understand the
patients’ problems and who will listen, advise and support
both the patients and their families.

• Our job is not simply about making a diagnosis, it is

about helping and caring for patients with their
medical problems.
 History
• History taking is usually your first contact with
the patient
• It is establishes the foundation for your future
relationship with the patient and their family.
• It is a time when you begin to build :
– trust, confidence and authority.
 History taking requires :
1. time,
2. skill,
3. concentration
4. experience
5. tact and diplomacy
6. patience.

your only lack is only on point 4

 Coma
• Coma history (from relatives or attendants)
– Onset of coma (abrupt, gradual)
– Recent complaints (headache, focal weakness,
vertigo etc)
– Recent injury
– Previous medical illnesses (e.g., diabetes, renal
failure, heart disease)
– Previous psychiatric history
– Access to drugs (sedatives, psychotropic drugs)
 The onset of coma
• Sudden onset :
– In a previously healthy, young patient : drug poisoning,
subarachnoid hemorrhage, or head trauma
– In the elderly : cerebral hemorrhage or infarction.

• Gradual onset :
– A history of premonitory signs, including focal weakness
such as dragging of the leg or complaints of unilateral
sensory symptoms or diplopia, suggests a cerebral or
brainstem mass lesion.
– Most patients with metabolic disorders
 Case 1
• A 50 year old man with a sudden lost of
counsciouness while in the meeting at his
office
• Physical examination :
• Blood pressure 200/110 mmHg
• GCS E1M4V1=6
• Pin point pupil
–Where is the possible lesion
Brain lesion : pons
Changes in pupils in patients with lesions at different
levels of the brain that cause coma
 Case 2
Sheet B1

• A 40 year old man

with left lower limb
and upper limb
weakness :
–Where is the
possible lesion
 Case 3
Sheet B1

• A 30 year old man,

compos mentis but
had an all-four
limb weakness :
–Where is the
lesion ?
 Case 4
• A 73-year-old woman had a 4-days history of fever, nausea, and
vomiting.
• she awoke on the third day and found it difficult to walk to the
bathroom, by the afternoon she had difficulty in swallowing

• Physical examination :
– Vital sign normal, E3M6V5.
– Pupils were equal and constricted from 3 to 2 mm with light,
– Diplopia when try to look to the left side
– left-sided facial numbness
– left lower motor neuron facial weakness.
– the tongue deviated to the right
– the left limbs were clumsy comparing to her right side
 Case 4 : question
1. Did the patients had a neurological problem ?
– mention her deficits
2. Where is the lesion (anatomical diagnosis)
 Case 4 : answer
• Left abducens palsy (N. VI)
• Left facial palsy (N. VII)
• Left trigeminal (sensory) nerve deficit (N.V)
• Left hypoglossal palsy (N XII)
• ………………………..

• Where is the lesion ?

 Case 4 : answer

Look at
your C1
sheet

Peter Duus.2005
page65
 Case 4 : question
• Is it possible to have brain stem lesion and at
the same time retain relatively good
consciousness ?
 Case 4 : answer
Look at your A1 and A2 sheet

Plum 2007 page29-30

 Case 5
• History
– A 28 year-old man was riding a motor cycles, when suddenly he
crash to another motor cycle approaching from the side.
– Luckily After the accident he is alert, with out a significant injury.
– Further inquiry from the doctor , revealed that in the past 6 several
times he bumped into something in his side while walking.
– He also complaint that he can not get an erection since 3 month
ago.

• Physical examination :
– Vital sign normal
– Visual acuity normal
– Confrontation visual field testing : peripheral visual field lost on both side

What is his problem ? Eye problem or

Neurological problem ? Or both ?
 Case 5 : answer

Peter Duus.2005
page 131
 Case 5 : answer
• What are the possible pathology underlying
this case ?
 Clinical method

• Through case 1 - 5 we already exercise clinical

method to understand patients problem
 Clinical method

This is an orderly series of steps, as follows:

1. Symptoms and signs
2. Anatomic diagnosis
3. Pathologic and etiologic diagnosis
4. Prognosis and treatment
 Symptoms and signs
• The fundamental steps in diagnosis always
involve the accurate elicitation of symptoms
and signs and their correct interpretation in
terms of disordered function of the nervous
system.

• Most often when the diagnosis is wrong, it will be

found later that the symptoms were incorrectly
interpreted in the first place.
 Symptoms and signs
• History and physical examination.
– symptoms and physical signs considered relevant
to the problem at hand are interpreted in terms of
physiology and anatomy :
• identifies the disorder(s) of function
• pathophysiology -pathogenesis
• the anatomic structure(s) that are implicated.
 Conclusion

• Neurology is not a difficult subject, enjoy

taking care of your patients sign and
symptoms and give a solution to their
problem.
 Thank you

• Dr Jofizal Jannis Sp.S(K)

• Dr. Darma Imran SpS

• Dep of Neurology Faculty of Medicine

University of Indonesia
• correspondence
darma_imran@yahoo.com
 Hemiparesis
Phys reflexes↑
Patho reflexes ↑ Quadry/paraparesis
Phys reflexes
Cranial nerve palsy Path reflexes 
Cortical brain fc dist Sensory level
Autonom disturb

Monoparesis
Phys reflexes ↓
No path reflexes
Radiks Sensory ~ dermatome segment

Paralysis asendens
Symmetry GBS
Neuromuscular junction KPR -/-

Fluctuate, recurrent
Muscle Proxymal > distal Activity influences
Gower sign Palpebra, dysphagi-
Duck gait disphonia
No sensory disturbances
Miastenia Gravis