a guide for neurology history taking

1. NEUROLOGICAL
HISTORY-TAKING
BY
DR. MANOJ KUMAR MAHATA
DM PDT NEUROLOGY

2. PRE-REQUISITE
Alertness of patient
Informant
Insight of patient regarding illness
Doctor-patient relationship
PROFORMA
Patient particulars ( name, age , sex, occupation,
area of residency, handedness)
Presenting illness
Past illness- medical/ surgical
Personal history- toxin exposure, birth history
Family history
Treatment history

3. GOAL OF HISTORY TAKING
First priority is to identify the region of nervous
system that is likely to be responsible for the
symptoms
Site of the lesion
Nature of the lesion
BASIC DESCRIPTION
Site
Severity
Onset ( acute, subacute, chronic )
Duration
Frequency
Precipitating/ Relieving factors
Time of occurrence

4. COMMON PRESENTATIONS
Headache
Visual disturbances
Loss of consciousness
Seizure
Speech disorder
Motor disorder
Sensory disorder
Cranial nerve disorder
Alteration of state of mind
Autonomic disorder
Sphincter disorder

5. HEADACHE
Site
Severity
Onset ( sudden/ gradual )
Frequency
Duration
Character
Time of occurrence ( e.g.morning )
Precipitating factors ( stooping / coughing )
Relieving factors
Associated features ( vomiting, visual
disturbances )

6. 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

7. 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

8. - 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

9. VISUAL DISTURBANCES
Impairment of vision
Diplopia
Hallucinations ( formed / unformed)

10. IMPAIRMENT OF VISION
Maybe caused by problem in media or due to nerve
damage
Monocular
• 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

11. DIPLOPIA
MONOCULAR - due to aberration in ocular media
BINOCULAR – vertical/ horizontal diplopia
constant/ intermittent diplopia
ASSOCIATED SYMPTOMS
eye pain – orbital conditions
- distributed in V1 – cavernous
sinus / SOF
headache - ↑ICP, brainstem localisation
HALLUCINATIONS
due to migraines

12. LOSS OF CONSCIOUSNESS
Head injury – recent / previous
Sudden collapse – ICH , SAH
Limb twitching ,incontinence – epilepsy/post-
tictal
Alcohol/ drug abuse
Cardiovascular/ respiratory/ genitourinary
disorder
Acute/ gradual – mass lesion
Metabolic – diabetes
Psychiatric disorder - hysteria

13. 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?

14. • 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

15. • 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

16. 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

17. SEIZURE AND SYNCOPE
• Features helpful in distinguishing the two:
Seizure Syncope
1) Aura + -
2) Cyanosis + -
3) Tongue-biting + -
4) Post-ictal confusion,
headache and amnesia + -
5) Rapid recovery - +

18. SPEECH DISORDER
• Onset
• Frequency
• Duration
• Difficulty in articulation – dysarthria
• Difficulty in expression
• Difficulty in understanding

19. 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

20. SENSORY DISORDER
Pain
Tingling/ numbness
Loss of sensation
Trophic changes – ulcer/ neuropathic joint

21. 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

22. CHANGE IN MENTAL STATE
Changes in memory ( short / long term)
Alertness/ drowsiness
Loss of spatial orientation
Changes in mood, affect, loss of spontaneity
Ability to carry out daily routine activities

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

24. SPHINCTER DISORDER
Difficulty in control – incontinence/ retention
Urinary 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)

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

26. FAMILY HISTORY
Hypertension , 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 HISTORY
Drug abuse – prescribed or illicit
Toxin exposure like alcohol, environmental or
industrial neurotoxins
Birth history

27. 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