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Flashcards in Neuro History Taking Deck (21):
1

Give some examples of presentations which can localise neurological lesions.

Cerebral hemispheres = higher mental function, vision, motor weakness, loss of cortical sensation according to pattern

Brainstem = specific cranial nerves affected

Cerebellum = cerebellar signs

Spinal cord = loss of sensation and motor weakness according to level +/- bladder dysfunction, Brown-Séquard syndrome, syringomyelia

Nerve roots = specific dermatomes/myotomes affected

Nerve plexuses = complex motor and sensory disturbances

Peripheral nerves = glove and stocking distribution of sensory loss, individual nerve palsies

Neuromuscular junction = ptosis, diplopia, bulbar dysfunction (speech and swallowing), limb weakness, fatiguability, NO sensory loss

Muscle = proximal weakness, NO sensory loss

2

What are some important things to observe in a neurological examination?

Gait

Speech:
- articulation
- quality
- content

Involuntary movements:
- tremor
- tics
- choreas
- orofacial dyskinesias

+ third party information useful for assessing levels of consciousness and intellect

3

What are some important questions to ask in a neurological history?

Distribution of symptoms

Circumstances of event

Precipitating factors

Mode of onset (sudden = vascular until proven otherwise)

Progression (worsening = brain tumour, improving = stroke)

Systematic neurological enquiry:
- headache
- loss of consciousness
- fits
- problems with speech or swallowing
- bladder problems
- diplopia
- muscle weakness
- sensory loss
- clumsiness
- mental or cognitive difficulties

4

Give examples of terminology used by patients which need to be clarified.

"Gradual" (precise timeline)

"Blackout" (loss of consciousness v.s. loss of vision)

"Dizziness" (vertigo - sensation of spinning relative to their surroundings; presyncope - light-headedness or faint; unsteadiness in legs; anxiety)

"Weakness" (loss of strength or power; difficulty using limb; numbness; fatigue; general lack of energy; dyspraxia)

"Numbness" (lack of sensation; abnormal sensation e.g. pins and needles)

"Blurred vision (reduced visual acuity; diplopia; oscillopsia)

5

What is oscillopsia? What can it be caused by?

Moving visual field

Paraneoplastic syndrome

6

Give some differentials for temporary loss of consciousness.

Syncope:
- postural hypotension
- reflex (vasovagal or situational)
- cardiac

Seizure

Hypoglycaemia

Non-epileptic attack disorder

Other e.g. ascending aortic aneurysm, PE, aortic dissection

7

What are some discriminating features for temporary loss of consciousness?

Eye witness account (e.g. seizures)

Situation (e.g. situational vasovagal syncope)

Phases (pre-, intra-, and post-)

Stereotypy (epilepsy)

Serious injury

Prolonged post-ictal confusion (epilepsy)

Aura (partial seizure)

Precipitating events

Psychogenic seizures last longer than epileptic seizures (excluding status epilepticus)

Cardiac syncope:
- no prodrome
- 45yrs+
- history of abnormal ECG
- history of heart disease e.g. ventricular arrhythmia, congestive cardiac failure

8

Contrast the presentation of fits and faints.

WARNING:
- fits = 50%+ have some aura
- faints = felt faint/light headed, blurred/darkened vision

ONSET:
- fits = sudden, any position
- faints = only occurs sitting or standing, avoidable by change in posture

FEATURES:
- fits = eyes open, rigidity, falls backwards, convulses
- faints = eyes closed, limp, falls forwards, minor twitching only (if unable to fall flat),

RECOVERY:
- fits = confused, headache, sleepy, focal deficit (e.g. Todd's palsy)
- faints = pale, washed out, sweating, cold or clammy

OTHER:
- fits = tongue biting, loss of bladder control
- faints = loss of bladder control rare

9

Give some general differentials for headaches.

PRIMARY:
- tension type headache (TTH)
- migraine
- cluster headache
- other

SECONDARY:
- trauma
- raised ICP
- inflammation
- drugs
- neoplasia
- infection
- vascular
- metabolic
- toxins

10

How can the severity of a headache be assessed?

Ask patient what they do when they get the headache

e.g. sleep in a dark quiet room v.s. pacing, crying, punching the walls

11

Contrast the differentials for acute and chronic headaches.

ACUTE:
- meningitis, encephalitis, other infections (+ neck stiffness, rash, photophobia, fever)
- subarachnoid haemorrhage ("thunder clap"; very severe and rapid, no longer than a minute)
- post-coital
- migraine
- cluster headache
- acute angle closure glaucoma

+ focal neurology, N&V, recent onset or change in character

CHRONIC:
- temporal arteritis
- migraine
- analgesic abuse
- tension type headache
- Paget's disease
- raised ICP (present on waking, worse if lying down, exacerbated by valsalva/bending/cough, papilloedema

12

How can a morning headache be differentiated from a headache caused by raised intracranial pressure?

Raised intracranial pressure:
- present on waking
- improves when they sit up

Morning headache:
- not present on waking
- lasts longer

13

What is the presentation of a migraine?

Prodrome (hrs-days)

Aura immediately before the headache)

Pain

Postdrome

14

What is the presentation of cluster headaches?

Severe pain (some patients suicidal)

Short-lived (less than 1hr)

Unilateral, around eye

Episodic (daily for weeks)

+ nasal congestion, rhinorrhoea, ptosis, conjunctival infection

15

Contrast the presentation of migraines and tension headaches.

Pain:
- migraine = throbbing, pulsating
- tension headache = dull, pressure, tight band around the head

Photo/phonophobia:
- migraine = typical
- tension headache = rare

Location:
- migraine = deep stabbing pain in the temple or eye, usually unilateral, can change sides
- tension headache = generalised, usually bilateral, may be more intense; affects scalp, forehead, temples, and neck

Severity:
- migraine = moderate to severe
- tension headache = mild to moderate

Duration:
- migraine = 4-24hrs
- tension headache = can remain several days, fluctuates

Triggers:
- migraine = stress or relief of stress, sleeping too much/too little, foods, alcohol, odours, motion
- tension headache = stress

Aura/prodrome:
- migraine = scintillating scotoma (flickering lights), pins and needles, weakness, vertigo
- tension headache = none

Nausea and vomiting:
- migraine = common
- tension headache = rare

16

Give some examples of differentials for dizziness.

Vertigo:
- peripheral = benign paroxysmal positional vertigo, vestibular neuritis, Ménière's disease
- central = migraine, drugs, cerebellar disease/brainstem disorders

Loss of balance:
- Parkinson's disease
- peripheral neuropathies (loss of proprioception)

Presyncope

Anxiety

Other e.g. anaemia, hypoglycaemia

17

What is the general presentation of vertigo?

Occurs when moving the head

Temporal pattern of weakness

Hearing loss/tinnitus

Short duration

Fullness in ear

Nausea and vomiting

Headache

Precipitating events e.g. salt

Aura with no headache

18

What is the presentation of benign paroxysmal positional vertigo?

Abrupt onset

Short-lived (10-15s)

Precipitated by head movement
e.g. turning in bed, looking up, bending down

Onset delayed by a few seconds

Risk factors:
- vestibular neuronitis
- head injury
- age

19

What are some questions to help localise and formulate differentials for weakness?

Mode of onset

Distribution:
- proximal v.s. distal
- upper limbs affected early indicates central cord involvement (e.g. syringomyelia)
- resp. muscle weakness indicates problem with high cervical cord, NMJ, phrenic nerves, muscle, Guillain-Barré

Duration

Muscle appearance:
- wasting
- twitching
- increased bulk

Progression: short-term (e.g. fatiguability), intermittent, long-term, improvement

Other neurological involvement:
- sensory loss/tingling
- dysphagia
- bladder dysfunction
- dysarthria
- visual disturbance
- vertigo

Pain

Family history

Drug history/exposure to toxins

Systemic disease

note: bulbar weakness + ptosis indicates myasthenia gravis

note: fatiguable weakness = test by doing multiple tests of power in order to demonstrate reduced power over time

20

What are some of the questions to keep in mind when taking a neurological history?

Where is the lesion?

Is it a characteristic syndrome?

What is the pathological process?

21

Give some examples of causes of confusion.

- sepsis ---> delirium
- dehydration ---> delirium
- hypoglycaemia
- meningitis/encephalitis ---> RICP
- alcohol (& alcohol withdrawal)
- drugs
- Wernicke's encephalopathy
- hypoxia
- metabolic
- stroke
- head injury
- post-ictal seizure