objectives
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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 • Patient’s 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 patient’s 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 Dramatic ACUTE INSIDUOUS Sudden Rapid Dr. Ahmed Gaber GRADUAL COARSE Regressive Stationary Intermittent Remittent/Exacerb Dr. Ahmed Gaber Progressive Consciousness • Alertness Vs Awareness • Continuous Vs episodic • Associated Phenomena Dr. Ahmed Gaber •Convulsions •Headache •Sleep disturbance •Focal deficit •Arrhythmias •Drug intake •Systemic illness •Fever 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 • • • • • • •Orientation (T, P, P) •Attention: (ill sustained, apathy, bradyphrenia) •Memory (anterograde, retrograde) •Thinking •Hallucination •Mood Attentive, Oriented Apathy (slow) Ill sustained attention Inattentive Confusion Disoriented Delerious (confused + irritable /hallucination) Dr. Ahmed Gaber EPISODIC STEREOTYPY NO STEREOTYPY EPILEPSY SYNCOPE MIGRAINE DELERIUM NOCT TIA NARCOLEPSY Dr. Ahmed Gaber CONTINUOUS AWARENESS LATERALIZING SIGNS DIFFUSE SIGNS Hemispheric ParietoOccipital Encephalitis ICT AROUSAL NO NON LATERALIZING LATERALIZING LATERALIZING SIGNS 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 Generalized Partial SYNDROMATIC ETIOLOGICAL Acute Symptomatic Isolated Cryptogenic Epilepsies Idiopathic Cryptogenic Dr. Ahmed Gaber Symptomatic Partial Epilepsy Simple Secondary Generalized 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 Spasms Dr. Ahmed Gaber 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 EXPRESIVE Language DYSPHASIA Articulation DYSARTHRIA 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 Local Parkinsonism Dr. Ahmed Gaber Unilateral Focal 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 Acute Loss of Color Vision Chronic Optic Neuritis Error of refraction (pain on eye mov) Optic neuritis Optic Neuritis Field Defect To one side Concentric Hemianopia Quadrantanopia Papil edema Dr. Ahmed Gaber Visual il usions Occipital Cx Viisual Hallucinations Il formed Wellformed Flashes, patterns animals, persons Black and white coloured may be hemifield both fields 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 Double vision + Single Eye Closure Corrected Non Corrected Binocular Diplopia Monocular Diplopia Horizontal Images Oblique Images On Looking Down words Trochlear nerve Divergent Squint Convergent squint No Squint Occulomotor n Medial rectus (3 rd) Abducent n Median Long Bundle Dr. Ahmed Gaber Local Eye Cause Occipital cortex Lesion 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 WeaK Orbicularis Occuli Intact Orbicularis Oculi Myogenic, MNJ Neurogenic Diurnal Variation No diurnal Variation Myasthenia Gravis Myopathy Lid Oedema Nuclear third lesion Dr. Ahmed Gaber Unilateral Correctable Non correctable Horner Syndrome Occulomotor Never Complete ptosis May be complete ptosis TRIGEMINAL Mastication/Biting/ Mouth Deviation Wasting/ Fasciculations Facial Sensations Superficial Deep Dr. Ahmed Gaber Neuralgia INTERPRETATION Motor Weak biting Bilateral atrophy Bilateral LMNL Mouth deviation Unilateral atrophy Unilateral LMNL Systemic Focal MND Extraxial FSH Intraaxial Myotonic Dyst Dr. Ahmed Gaber SENSORY IRRITATION DESTRUCTION Burning, electric See exam Division Whole n V3 TG Neuralgia TG Neuralgia Migrainous Neuralgia R Structural Pathology Not V3 Structural Pathology Dr. Ahmed Gaber 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 Corrected by emotions Epsilateral to Limb Wk Intact Glabellar Exagerated 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 Irritation PN Tinnitus Vestibular Destruction Deafness CX Hallucination VERTIGO Epileptic 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 Pseudo bulbar Severe Less No Emotional Lability Nasal Regurge NO Atrophy, fascic NO No Brisk Jaw Dr. Ahmed Gaber 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 Laterality UL/LL P/D F/E Abd/Add Dr. Ahmed Gaber State Fasciculations TONE Hypotonia UMNL Hypertonia LMNL Cerebellar Caudate/chorea Massive UMNL Shock Stage Spasticity Parietal Lobe hypotonia Dr. Ahmed Gaber Rigidity Weakness Quadreparesis/ Paraparesis Hemiparesis 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 Monoparesis Weakness Quadreparesis/ Paraparesis Hemiparesis P>D Monoparesis 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 Roots LMNL PN AHCs Dr. Ahmed Gaber Roots UMNL Cortical 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 Dr. Ahmed Gaber •Gait deviation •Intention tremor •Speech change BALANCE DISORDER VESTIBULAR EXTRAPYRAMIDAL Vertigo Propulsion Retropulsion Postural ref COORDINATION 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 Depression Dr. Ahmed Gaber DYSKINESIA Distribution Axial/Acral Precipitation Rest/ Spontaneous Action UL/LL Startle D/P Kinetic Segmental Intetion kinetic Focal Postural Generalized Task/Position specific Hemi Isometric Overflow Time/Day Rate/Rhythm Dr. Ahmed Gaber Stereotypy Stimulus sensitive DYSKINESIA Stereotyped Non Stereotyped Shock Like Single, clusters Proximal, Rapid, Pseudopurposive Myoclonus Chorea Regular/Rhythmic Distal, Slow, Snake like Tremor Athetosis Irregular Maintained, Spasm, Posturing Tics Dr. Ahmed Gaber Dystonia SENSORY SYSTEM PAIN •CC •Site •Radiation •+/•When •Autonomic SENSORY SYSTEM What?? SUPERFICIAL DEEP Burning Heat/Cold Dysthesia Tingling Numbness Narrow Band Broad Tight band Swelling Soft ground Rhombergism Dr. Ahmed Gaber SENSORY SYSTEM Where?? Dermatome= Root PN Radicular Pain Hemihypothesia =Cranial Level=SP Cd Dr. Ahmed Gaber 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 ICT Severity ++++ +++ Autonomic ++++ +++ Neck Pain +++ +++ 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 • Anton’s 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? Focal What? Systemic Multifocal Disseminated Dr. Ahmed Gaber OCD+where MOTOR Focal N. injury Systemic 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 C D FOCAL SYSTEMIC G P E C <3y SOL (Malig, inflammatory) Degenerative G P L C >3y SOL (Benign, Granuloma) Metabolic, Toxic, Nutritional D Non Short prog Traumatic, Vascular, Migraine, Epileptic ----- Vascular, inflammatory, Demyelinating Toxic, Acute Metabolic Rp Non Short prog Dr. Ahmed Gaber Thank you Dr. Ahmed Gaber
