HISTORY TAKING

Dr.Ahmed Gaber Ass. Prof of Neurology Ain Shams University

OBJECTIVES
To reach a final diagnosis: 1. Where is the lesion? (Anatomical vs physiological) i.e focal /systemic 2. What is the lesion? = where + onset course and duration see table 1

Dr. Ahmed Gaber

Mental Process
During this course the following will be done for each test (history- examination): 1. Objectives 2. How can I do it 3. Interpretation

Dr. Ahmed Gaber

HISTORY

PERSONAL HISTORY
Name Age Sex Residence Occupation Marital status and children Special habits, dietary habits Handedness

Dr. Ahmed Gaber

COMPLAINT
Patients own word Most distressing symptom which brought him to medical advice

Dr. Ahmed Gaber

FAMILY HISTORY
Consanguinity Similar condition Other neurological disorders Other congenital anomalies Hypertension DM

Dr. Ahmed Gaber

PAST HISTORY

Similar attack Trauma, Fever, OM Cardiac, Hypertension, DM, TIA Allergy, Vaccination, Vasculitis (orogenital ulcers) TB, Bilharzias,$,Malignancy Surgery, Drugs,Toxic substances, irradiation Menstrual history, contraception, abortions Perinatal and developmental
Dr. Ahmed Gaber

HISTORY OF PRESENT ILLNESS

ONSET, COARSE, DURATION

Consciousness, HCF, Epilepsy Speech ORGANIZATION Cranial Nerves Start by patients C/O Motor system Chronological order within Sensory system and pain each system After finishing each system Sphincters start the following system Cranium, spine by chronological order Stretch Increase ICT, Headache Hypothalamic + Autonomic Other systems
Dr. Ahmed Gaber

ONSET

ACUTE

INSIDUOUS

GRADUAL

Dramatic

Sudden

Rapid

Dr. Ahmed Gaber

COARSE

Regressive Stationary Intermittent Remittent/Exacerb

Dr. Ahmed Gaber

Progressive

Consciousness
Alertness Vs Awareness Continuous Vs episodic Associated Phenomena

Convulsions Headache Sleep disturbance Focal deficit Arrhythmias Drug intake Systemic illness Fever

Dr. Ahmed Gaber

Alertness
Fully Awake Sleepy Drowsy Stuperous Comatose

Glascow scale definition No eye opening to verbal command No motor response better than weak flexion Incomprehensible sounds in response to pain

Dr. Ahmed Gaber

Awareness
Attentive, Oriented Apathy (slow) Ill sustained attention Inattentive Confusion Disoriented Delerious (confused + irritable /hallucination)
Dr. Ahmed Gaber

Orientation (T, P, P) Attention: (ill sustained, apathy, bradyphrenia) Memory (anterograde, retrograde) Thinking Hallucination Mood

EPISODIC

STEREOTYPY

NO STEREOTYPY

EPILEPSY

SYNCOPE

MIGRAINE

DELERIUM

TIA

NOCT

NARCOLEPSY

Dr. Ahmed Gaber

CONTINUOUS

AWARENESS

AROUSAL

LATERALIZING SIGNS

DIFFUSE SIGNS

NO NON LATERALIZING LATERALIZING LATERALIZING SIGNS

Hemispheric ParietoOccipital

Encephalitis ICT

Metabolic Toxic ICT

Dr. Ahmed Gaber

Hemispheric Brain Stem Diencephalic

Deepened Awareness

EPILEPSY OBJECTIVES
Is he epileptic What type of epilepsy What is possible etiology Evaluate seizure variables Medication history

Dr. Ahmed Gaber

IS HE EPILEPTIC
Two Unprovoked Seizures Behvioral Phenomena What is Seizure? Excessive Neuronal Discharge
Cerebral Origin Paroxysmal Stereotyped Recurrent Unprovoked (usually)

Dr. Ahmed Gaber

WHAT TYPE OF EPILEPSY?

TYPES

CLINICAL

SYNDROMATIC ETIOLOGICAL

Generalized

Acute Symptomatic

Isolated Cryptogenic

Epilepsies

Partial

Dr. Ahmed Gaber

Idiopathic

Cryptogenic

Symptomatic

Partial Epilepsy Secondary Generalized

Simple

Complex

Motor

Aura (Subjective SPS)

Sensory

Dialeptic

Special Sensory

Automatisms

Autonomic

Simple

Psychic

Complex

Ictal Core phenomena

Dr. Ahmed Gaber

Post ictal State

Generalized Epilepsy

GTC

Absence

Myoclonic

Atonic

Tonic
Dr. Ahmed Gaber

Spasms

Epilepsy Variables
Frequency (Singlets, clusters, status) Diurnal Variation Cataminal Stress Provocation Medical History

Dr. Ahmed Gaber

HPI
Consciousness, HCF, Epilepsy Speech Cranial Nerves Motor system Sensory system and pain Sphincters Cranium, spine Stretch Increase ICT, Headache Hypothalamic + Autonomic Other systems
Dr. Ahmed Gaber

SPEECH

Language DYSPHASIA

Articulation DYSARTHRIA

EXPRESIVE

GLOBAL

RECEPTIVE

Nominal Dysphasia

Litteral Paraphasia

Word Salad

Word Finding Difficulty

Telegraphic speech

Symantic Paraphasia

Dr. Ahmed Gaber

Word Finding Difficulty

Dr. Ahmed Gaber

CRANIAL NERVES

Dr. Ahmed Gaber

OLFACTORY
HOW TO ASK
Diminished olfaction Change in quality of olfaction Abnormal olfaction not present

FINDINGS & INTERPRETATION

Anosmia: Bilateral (not significant), unilateral (signify a lesion any where in the pathway) Parosmia (abnormality in olfactory cortex) Olfactory hallucinations mostly epileptic in uncus, orbitofrontal surface

Dr. Ahmed Gaber

Interpretation
Anosmia Bilateral Unilateral

Local

Parkinsonism

Focal

Dr. Ahmed Gaber

OPTIC
How to ask? VA Optic n Color vision-- Macula Field of vision-- retino cortical pathway Blurring of vision -- non specific, migraine Visual hallucinations, illusions: complexity , coloring, hemifield -- epileptic, migraine, psychotic
Dr. Ahmed Gaber

FINDINGS & INTERPRETATION

Dec VA

Loss of Color Vision

Field Defect

Visual il usions

Viisual Hallucinations

Acute

Chronic

Optic Neuritis

To one side

Concentric

Occipital Cx

Il formed

Wellformed

Optic Neuritis Error of refraction (pain on eye mov) Optic neuritis

Hemianopia Quadrantanopia

Papil edema

Flashes, patterns animals, persons Black and white coloured may be hemifield both fields

Dr. Ahmed Gaber

Occipital

Post temporal

OCCULO MOTORS

Diplopia

Ptosis

Dazzling

Squint

Binocular/Mono

Partial/Complete

Divergent

HZ/ Vertical

Correctability

Convergent

Direction

Fatigue

Headache

Dr. Ahmed Gaber

DIPLOPIA
Direction of maximum separation between images is the side of nerve lesion False image= Outer image
Horizontal Images Double vision + Single Eye Closure

Corrected

Non Corrected

Binocular Diplopia

Monocular Diplopia

Oblique Images

On Looking Down words

Local Eye Cause

Occipital cortex Lesion

Divergent Squint

Convergent squint

No Squint

Occulomotor n
Dr. Ahmed Gaber

Trochlear nerve

Medial rectus (3 rd)

Abducent n

Median Long Bundle

SQUINT
SQUINT

Divergent

Convergent

Unilateral or Bilateral Occulomotor

Unilateral or Bilateral Abducent

DAZLING:

Dilated pupils due to third nerve lesion

Dr. Ahmed Gaber

PTOSIS
Ptosis Bilateral Eye Lid Pufffiness Unilateral

WeaK Orbicularis Occuli

Intact Orbicularis Oculi

Lid Oedema

Correctable

Non correctable

Myogenic, MNJ

Neurogenic

Horner Syndrome

Occulomotor

Diurnal Variation

No diurnal Variation

Nuclear third lesion

Never Complete ptosis May be complete ptosis

Myasthenia Gravis

Myopathy

Dr. Ahmed Gaber

TRIGEMINAL

Mastication/Biting/ Mouth Deviation

Wasting/ Fasciculations

Facial Sensations

Superficial
Dr. Ahmed Gaber

Deep

Neuralgia

INTERPRETATION
Motor Weak biting Bilateral atrophy Mouth deviation Unilateral atrophy

Bilateral LMNL
Systemic

Unilateral LMNL
Focal MND Extraxial

FSH
Myotonic Dyst
Dr. Ahmed Gaber

Intraaxial

SENSORY IRRITATION DESTRUCTION

Burning, electric
Division

See exam
Whole n

V3

TG Neuralgia

TG Neuralgia

Migrainous Neuralgia
R Structural Pathology
Dr. Ahmed Gaber

Not V3

Structural Pathology

FACIAL NERVE
HOW? Eye closure Eye brow elevation Epiphoria Dry eye, eye burning Mouth deviation Driplling of saliva Food accumulation Taste Hyperacusis Fasciculations and wasting Emotional expression CORRECTION BY EMOTION RELATION TO THE SIDE OF WEAKNESS

Dr. Ahmed Gaber

FACIAL N Abnormality

VOLUNTARY

ASSOCIATIVE

LMNL

Reduced

No Correction by emotions Contralateral to limb Wk Lost Glabellar

Extrapyramidal

UMNL

Exagerated

Corrected by emotions Epsilateral to Limb Wk Intact Glabellar

BIL Pyramidal
Dr. Ahmed Gaber

VESTIBULOCHOCLEAR N
HOW? A. Choclear Tinnitus Deafness Auditory hallucinations: formed, illformed B. Vestibular Vertigo Dissociation Phenomena
Dr. Ahmed Gaber

VIII

Choclear

Vestibular

Irritation

Destruction

VERTIGO

PN Tinnitus

Deafness

Epileptic

CX Hallucination

Central BSTem

Peripheral

Migrainous Dr. Ahmed Gaber

IX, X
Nasal tone Nasal regurgitation Choking Dysphagia Hoarseness, dysphonia Emotional lability

Dr. Ahmed Gaber

INTERPRETATION
Three Levels: Neurological vs Mechanical ( Mechanical More to solid) If Neurological , Myogenic Vs neurogenic (Neurogenic more to fluid, Myogenic either) If Neurogenic Bulbar Vs Pseudo Bulbar
Dr. Ahmed Gaber

Neurogenic IX, X Bulbar Severe Pseudo bulbar Less

No
Nasal Regurge Atrophy, fascic No
Dr. Ahmed Gaber

Emotional Lability
NO NO Brisk Jaw

XI
HOW? Head tilt Shoulder depression Head falling back or forward Fasciculation or atrophy in neck

Dr. Ahmed Gaber

MOTOR

Dr. Ahmed Gaber

XII
HOW? Dysarthria tongue syllables Movement of food by tongue Tongue deviation unable to protrude tongue Wasting , fasciculation of tongue

Dr. Ahmed Gaber

MOTOR SYSTEM
UMNU P EP CLL LMNU

Dr. Ahmed Gaber

Objectives
Where UMNL / LMNL

Dr. Ahmed Gaber

HOW?
Weakness? (P, LMN) Ataxia? (Cll) Involuntary Movements? (EP)

Dr. Ahmed Gaber

WEAKNESS

Distribution

Tone

State

Fasciculations

Laterality

UL/LL

P/D

F/E

Abd/Add

Dr. Ahmed Gaber

TONE
Hypotonia UMNL Cerebellar Caudate/chorea LMNL

Hypertonia

Massive UMNL
Shock Stage

Spasticity

Rigidity

Parietal Lobe hypotonia

Dr. Ahmed Gaber

Weakness

Hemiparesis

Quadreparesis/ Paraparesis

Monoparesis

P Dist D>P Abd>Add F>E LL E>F UL DF> PLF

Subcortical UL><LL

Capsular UL=LL

B Stem Cll/ CN
Dr. Ahmed Gaber

Weakness

Hemiparesis

Quadreparesis/ Paraparesis

Monoparesis

P>D

D>P

Muscle

LMNL

UMNL

AHCs

PN

Focal Spinal

Roots

AHCs

Brain stem

Roots Dr. Ahmed Gaber

Parasagittal

Weakness

Hemiparesis

Quadreparesis/ Paraparesis

Monoparesis

P>D

D>P

AHCs

LMNL

UMNL

Roots

PN

Cortical

AHCs

Dr. Ahmed Gaber Roots

ATAXIA
Objectives Cerebellar or Sensory ataxia

Dr. Ahmed Gaber

How?
NO weakness Vertigo or not Ataxia or not Sensitivity to dark
Basin sign Dark room Night time

Gait deviation Intention tremor Speech change

Dr. Ahmed Gaber

BALANCE DISORDER

VESTIBULAR

EXTRAPYRAMIDAL

COORDINATION

Vertigo

Propulsion Retropulsion Postural ref

Correctable (Sensory)

Continuous (Cerebellar)

Dr. Ahmed Gaber

INVOLUNTARY MOVEMENTS
Akinetic rigid syndrome /dyskinetic syndrome

Dr. Ahmed Gaber

Akinetic Rigid

Bradykinesia/ Bradyphrenia

Hypertonia

Tremor-- Static

Autonomic

Balance disturbance Postural

Dr. Ahmed Gaber

Depression

DYSKINESIA Distribution Axial/Acral UL/LL D/P Segmental Focal Precipitation Rest/ Spontaneous Action Startle Kinetic Intetion kinetic

Postural

Generalized
Hemi Overflow Rate/Rhythm
Dr. Ahmed Gaber

Task/Position specific
Isometric Stimulus sensitive Time/Day

Stereotypy

DYSKINESIA

Stereotyped Shock Like Single, clusters Myoclonus

Non Stereotyped Proximal, Rapid, Pseudopurposive Chorea Distal, Slow, Snake like

Regular/Rhythmic

Tremor

Athetosis
Maintained, Spasm, Posturing
Dr. Ahmed Gaber

Irregular

Tics

Dystonia

SENSORY SYSTEM

PAIN CC Site Radiation +/When Autonomic

SENSORY SYSTEM What??

SUPERFICIAL

DEEP

Burning Heat/Cold Dysthesia

Tingling

Numbness Narrow Band

Dr. Ahmed Gaber

Broad Tight band Swelling Soft ground Rhombergism

SENSORY SYSTEM Where??

Dermatome= Root

PN

Radicular Pain

Level=SP Cd
Dr. Ahmed Gaber

Hemihypothesia =Cranial

Dermatome

S. Level

HEMI

Dr. Ahmed Gaber

PN

Radiculopathy

Dr. Ahmed Gaber

HPI
Consciousness, HCF, Epilepsy Speech Cranial Nerves Motor system Sensory system and pain Sphincters Cranium, spine Stretch Increase ICT, Headache Hypothalamic + Autonomic Other systems
Dr. Ahmed Gaber

SPHINCTERS
Bladder: Urgency, precipitancy, incontinence Hesitency, retention, over flow Desire Local (pain, mechanical obstruction, stress incontinence) Saddle hypothesia Sexual: Potency Premature ejaculation Rectal: As bladder
Dr. Ahmed Gaber

Cranium & Spine/Stretch

Pain Tenderness

Dr. Ahmed Gaber

HEADACHE
CC Site Radiation Autonomic Features Persistence Relation to posture/sleep Periodicity
Dr. Ahmed Gaber

MIGRAINE Severity Autonomic Neck Pain ++++ ++++ +++

ICT +++ +++ +++ +++ ++ +++ +++ +++

Relation to posture +++ Throbbing +++

Awaken from sleep Persistant Consiousness +/Dr. Ahmed Gaber

HYPOTHALAMIC
Polyurea, polydepsia, polyphagia Obesity Sleep disturbances Libido loss, impotence Temp change Emotional change Autonomic

Dr. Ahmed Gaber

HPI
Consciousness, HCF, Epilepsy Speech Cranial Nerves Motor system Sensory system and pain Sphincters Cranium, spine Stretch Increase ICT, Headache Hypothalamic + Autonomic Other systems
Dr. Ahmed Gaber

Prefrontal: Conation: Apathy, abulia Attention: Akinetic mute, waxy flexibility, Perseveration (thinking, acts) Thinking:Abstraction, judgement, OCD Personality change Orbitofrontal: Jukular, disinhibited, sexual RT Parietal: Neglect (motor, sensory, Anoso, atopatoto) Geographical disorientation Visuospatial disorientation Dressing (constructional) Lt Parietal: Finger agnosia Left right disorientation Dyscalculi Dysgraphia (dyslexia)

HCF
Temporal: Nominal aphasia Vertigo Hallucination (formed, visual and auditory) Occipital: Field Illusions,Hallucinations Visual neglect, Color agnosia, color blindness Antons Synd (cortical blindness + unaware) Balint syn (neglect, Optic ataxia, psychologic optic paresis)

Dr. Ahmed Gaber

HCF (cont.)
SPEECH: Dysarthria Dysphasia (receptive, expressive, repitition) Dysphonia, Aphonia Dysgraphia Dyslexia Dyscalculia APRAXIA: Ideational, ideomotor, motor Dressing, construction, gait, callosal
Dr. Ahmed Gaber

FORMULATION
Summary in physiological terms

Dr. Ahmed Gaber

DIAGNOSIS

Where?

What?

Focal

Systemic

OCD+where

Multifocal

Disseminated

Dr. Ahmed Gaber

MOTOR

Focal

Systemic

N. injury

UMN

LMN

Spinal cord

Pyramidal

Muscle/MNJ

Brain stem

Extrapyramidal

PN/Radiculopathy

Capsular

Cerebellar

MND

Subcortical

Cortical

Dr. Ahmed Gaber

APPROACH TO WHAT IS THE LESION

O
G P

D
E C <3y

FOCAL
SOL (Malig, inflammatory)

SYSTEMIC
Degenerative

G
D

L C >3y

SOL (Benign, Granuloma)

Traumatic, Vascular, Migraine, Epileptic Vascular, inflammatory, Demyelinating

Metabolic, Toxic, Nutritional

----Toxic, Acute Metabolic

Non Short prog

Rp Non Short prog

Dr. Ahmed Gaber

Thank you

Dr. Ahmed Gaber