Clinical medicine – Neurology
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NEUROLOGICAL SHEET
HISTORY
I. PERSONAL HISTORY: Ask about:
1. Name.
2. Age: 1st & 2nd decades  progressive muscular
dystrophy.
3rd & 4th decades  DS.
5th & 6th decades  Cerebrovascular Strokes.
3. Sex : ♂: Motor Neurone Disease =M.N.D
♀: Migraine
●Ask about O.C.Ps as they may cause
headache, depression or DVT.
4. Marital state: $  sterility, impotence or still-births.
5. Occupation: Drivers  Disc prolapse.
Printers
 Lead neuropathy.
6. Residence: Urban  Migraine. Rural  Nutritional diseases.
7. Special Habits: Alcohol  Peripheral Neuropathy = P.N.
8. Handedness: Rt-handed  Dominant hemisphere is the Lt
(>90% of population).
Dominant hemisphere = hemisphere which contains Broca's area
(44).
Also contains: Exner's area (45) & Angular gyrus area (39).
II. COMPLAINT: In patient's own words.
III. PRESENT HISTORY: Analysis of the complaint.
 Onset: Sudden (within sec. or min), Acute (within hrs) or
gradual (chronic = days, wks or mth).
 Course: Rapid (sudden or acute) + Regression  Vascular
(Thrombotic, Embolic or Hemorrhagic), Infective (Encephalitis
or B. abscess) OR Traumatic.
Slow + Progression  Degenerative = Demyelination
(DS) OR Neoplastic.
Intermittent  T.I.As, Strokes or DS.
 Duration.
 Sequence of event in chronological order.
E.g. The condition started since…..(duration) by acute or gradual
(onset) & regressive (course) of ……Tell the story of the disease
chronologically & in details.
*THEN YOU SHOULD ASK ABOUT THE FOLLOWING SYMPTOMS*
Clinical medicine – Neurology
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SYMPTOMS SUGGESTIVE OF ↑ICT:
1-Headache: pain above the level of eye brows till occipital &
suboccipital regions.
Analyze like any pain.
D.D.(causes):
1. Tension = Stress headache (the commonest) = psychogenic
- Takes long duration. - Bizarre description - ♀>♂
2. Vascular headache = Migraine (diagnosed from history)
- Young adult. – Aura (photopsia) or Scotoma. – Bil. Throbbing pain
- The pt. prefers darkness. – Associated with vomiting.
- Sleep may terminate the attack.
3. Local causes: -Errors of refraction - Sinusitis. – Toothache.
4. Meningitis & Encephalitis.
5. Post-traumatic.
6. At the beginning of cerebrovascular strokes & subarachnoid Hge.
7. ↑ICT: -awaking the pt. in early morning.
-associated with projectile vomiting (not proceeded by nausea,
on empty stomach) gradually, coming in stupor & disturbance in
consciousness.
8. Hypertension: not necessary to be associated with headache (no value in
follow up of hypertension); monitoring of BP should be done by
measuring BP.
2-Vomiting.
3-Blurring of vision (oedema of optic disc) ± Diplopia.
SYMPTOMS OF CRANIAL NERVE AFFECTION:
Cranial nerve #
Name
I
II
III, IV, VI
V
Olfactory
Optic
Ocular nerves
Trigeminal
VII
Facial
VIII
Cochleovestibular
IX,X,XI & XII
(Bulbar Nerves)
Glossopharyngeal,
Vagus, Accessory
& Hypoglossal
Symptoms of lesion
-Anosmia – Parosmia
-↓Acuity of vision - Field defects
-Diplopia (↑in which direction?)
-Motor  difficult mastication
-Sensory  abnormal facial sensations
-Accumulation of food behind cheek(affected side)
-Dripping of saliva (of affected side)
-Deviation of mouth (toward the healthy side)
-Inability to close the eye
-Cochlear part  ↓acuity of hearing + tinnitus
-Vestibular part  vertigo(pt. close his eye to
overcome)
-Dysphagia -Dysarthria -Dysphonia(hoarseness of voice)
-Nasal regurgitation
-Nasal tone of voice
SYMPTOMS OF MOTOR SYSTEM AFFECTION: (U.M.N.L, L.M.N.L, extra∆,
cerebellum):
1- Weakness or paralysis:  Destructive lesion
Clinical medicine – Neurology
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-Distribution: hemiplegia (almost always UMNL),
paraplegia, quadriplegia or monoplegia.
-Significance: UMNL or LMNL
-Ask about:
* Muscle tone (stiffness)
* Wasting
* More proximal or distal
* More in progravity or antigravity
muscles
2- Abnormal Movements:  Irritative lesion
-Convulsions: * Distribution * Significance (cortical
irritation of precentral gyrus)
-Fasciculation: *Def.: spontaneous contraction of
group of muscle fibers. It's visible & even palpable.
* Distribution * Significance (irritation of AHCs)
-Fibrillation: *Def. spontaneous contraction of a
single muscle fiber. It's hardly visible except in the tongue.
-Involuntary movements:
i. Tremors:
* Distribution
* Type: static or kinetic
* Rhythmic or not
* Significance: static (extra∆) or
kinetic (cerebellum)
* What ↑or↓ them
ii.
Unsteadiness: cerebellar lesion )‫(بيطوح‬
ّ
iii. Chorea, Athetosis & Dystonia:
* Ask about:
1-Rhythm
2-Part affected
3-Type
4-Speed
5-Shape
Chorea
Dys-rhythmic
Extremities
Involuntary
Rapid(jerky)
Semi-purposes
Athetosis
Dys-rhythmic
Extremities
Involuntary
Slow
Snake like
Dystonia
Dys-rhythmic
Trunk
Involuntary
Very slow
Torching of trunk
SYMPTOMS OF SENSORY SYSTEM AFFECTION:
1- Destructive lesion: * Partial Hyposthesia
* Complete
Anaesthesia
2- Irritative lesion: * Pain(site, reference, radiation, character,
↑&↓ factors) * Numbness
* D.D. of pain:
i.Peripheral nerve = neuritis (along nerve distr., ↑by
movement)
ii.Post. Root Ganglion =PRG (nerve distr., ↑by
straining)
iii.Thalamus (stretching of PRG, involving 1/2 body)
Clinical medicine – Neurology
iv.Hypersthesia(‫;)شكة ابرة يحسها كطعنة خنجر‬overreaction to
threshold stim.
v.Parasthesia (abnormal skin sensation)
* In all of the above ask about Distribution:
i. Glove & Stocking  P.N. (e.g. D.M.)
ii. Dermatome  PRG
iii. Sp. Cd. Lesion of 2 possibilities:
a. Extramedullary lesion (coming from outside inside) level
b. Intramedullary lesion (destroying from inside outside)jacket
iv. Hemiplegia Cortical, thalamus, capsular(common), B. stem or
spinal
SYMPTOMS OF AUTONOMIC (SPHINCTERIC) DISTURBANCES:
1- Control of micturition & defaecation.
2- Impotence: especially in cases of conus lesions, DS &
diabetic PN.
IV. PAST HISTORY: (To know the etiology of the lesion)
1- Trauma:
-Severe  paraplegia, quadriplegia, cauda lesion &
coma
-Mild subdural hmatoma in old alcoholics
-Trauma acts as * precipitating factor (as for DS & disc
prolapse) * direct factor (damaging of underlying neural tissue)
2- Fever:
-Indicating inflammatory conditions.
-Fever + site of lesion etiology
-In cases of encephalitis & meningitis.
3- Hypertension: (headache, tinnitus, epistaxis).
-↑ incidence of atherosclerosis  ↑ incidence of
cerebrovascular strokes.
- Hypertension encephalopathy.
-If the pt. is hypertensive(1ry)  present history.
4- D.M.: (polyuria, polydipsia, polyphagia & weight loss)
i. ↑atherosclerosis.
ii. Diabetic Coma (D. ketoacidosis, hypoglycemia,
hyperosmolar & lactic coma).
iii. D. radiculopathy iv-D. neuropathy = *Mononeuritis
*Polyneuropathy *Mononeuritis complex(>one trunk
in one limb)
iv. D. myelopathy
v. Cr.nr. palsy vii-Impotence
* If the pt. is Diabetic  present history.
5- T.B.: (hemoptysis, loss of weight & appetite, night fever &
sweats & anti-T.B. drug intake)
-Potts disease (paraplegia) -Cerebellar ataxia
-T.B. Meningitis -Tuberculoma -Drug complications
6- Syphilis: (chancre, recurrent still-births & abortion)
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-Sensory ataxia (tabes) -Mental deterioration with
convulsions (G.P.I.)
7- R.F., R.H.D. & Recurrent tonsillitis: (arthritis, epistaxis….)
-Emboli accident (hemiplegia)
-Rh. Chorea
8- Otitis media: (ear discharge)
-Facial palsy
-B. abscess
-Lateral sinus
thrombosis
9- Previous drug intake: in cases of :
-Cerebellar ataxia (barbs.) -Convulsions (ambilhar) Myopathy (chloroquine)
-P.N. (streptomycin, INH, sulphonamide) Parkinsonism (reserpine, phenothiazyde)
10- Previous similar attacks: in cases of: -DS
-TIAs
V. FAMILY HISTORY: (To know the etiology)
- Similar conditions in his family
his parents.
-Consanguinity between
AIM OF HISTORY: to define
-What is the nature of the lesion? -Where is the site of the lesion? What is the etiology of the lesion?
EXAMINATION