Neurological History Taking

What are the three fundamentals of neurological history taking?

Listening is more important than talking

The patient is more important than you

But...listening is not enough you must ask the right questions and be curious

How can you optimise communication in neurological history taking?

Quiet environment, minimise distractions

Is the hearing aid working?

Are you speaking clearly & articulately?

Can the patient see you & your mouth? (masks)

Do you need paper / pen?

(carer?)

How can you optimise communication in a phone or video consultation

• Can you see me/hear me

• Who else is in the room...is that OK?

• Think about appearance & background

- Plain wall best / think about back lighting

• Confirm pt ID

• Document phone / video & reason e.g. covid triage

- Ask and document red flags

• If repeat consultation may need face to face

What are some important observations to make in neurological history taking?

Observations: state of health, mode of dress, age, eye contact, mood, tics, are they clean and tidy/ taking care of themselves?

Content of conversation: level of education, intelligence, mood.

Articulation of speech (dysarthria), dysphasia, slurring their words, does their thought pattern go off on tangents?

Why is it important to ask a patient about their dominant hand?

If they have a unilateral disability and it's on their dominant side they are going to be much more disabled and vice versa.

Almost all right handed people are left hemisphere dominant for language so can be important in diagnosing neurological conditions

The skills for neurological history taking lie in...

Clarifying

Being curious

Sifting & sorting

Analysing the information

Recognising the value of negatives

Observing how things are said, not just listening to what is said

Succinctly documenting the story

What is the presenting complaint

The symptom that has brought the patient to the doctor

How should you record the presenting complaint

Ideally record it in the patient's own words e.g. "dizzy"

But clarify and expand on it. Patients don't always use terminology to mean what you think it means!

What is a common cause of dizziness

Benign positional vertigo

Give an example of a typical history of benign positional vertigo

The dizziness started suddenly when I was in bed and rolled over...

Feels like I am on a roundabout...lasts a couple minutes then settles

OK if I keep my head still but if I look up suddenly it can start again

What are some follow up questions for the presenting complaint?

• Duration of symptoms

• Speed of onset

• Location

• Variation

• Intensity

Give examples of some common neurological presentations

• Altered cognitive ability

• Fits, faints & funny turns

• Headache

• Dizziness

• Weakness or movement disorders

• Numbness or sensory disorders

• Visual impairments

What is a common diagnosis for a PC of increasing difficulty doing up buttons

Parkinsons - issues with fine motor movement

What follow up questions can you ask if someone presenting with difficulty doing up buttons

Have you noticed any changes in your writing?

Any differences in the way you walk?

Some Parkinson's patients also notice a difference in their sense of smell

What origin can fits, faints and funny turns have

Cardiovascular, neurological or possibly endocrine

It's orientation week at the Principal's reception your parents are listening to wise words being spoken. There are no seats and wine is being served. One of the mothers falls to the floor. Is this collapse likely to be of cardiovascular origin, endocrine origin or neurological origin?

Cardiovascular - typical vasovagal faint

In which condition may a history be diagnostic?

Epilepsy

Why can a history be diagnostic for epilepsy

Sodium, glucose, magnesium, urea, neuroimaging and electroencephalogram may all be normal

What is epilepsy?

Abnormal, excessive paroxysmal discharge of

cerebral neurons

What percentage of the population is affected by epilepsy

Approx 1%

What can cause a seizure in a normal healthy person?

Abnormal electrolytes and blood glucose can cause fits in anyone - these can be caused by poor sleep. They cause a decrease in the seizure threshold

What are the best ways to go about diagnosing fits, faints and funny turns?

Good history from patient

A description from witness

If recurrent think of asking to record the event (smartphone)

What questions can you ask about fits?

What was happening immediately before?

What factors might have lowered the seizure

threshold?

What position was the patient in?

Any prodromal symptoms?

What happened during the episode?

After? - did they wake up in an ambulance, on the floor?

What was the last thing they remember?

What questions should you ask about a headache?

• Site - "show me where"

• Radiation - "does it go anywhere else?

• Sort - "what kind of pain"

• Severity

• Timing

• Aggravating & relieving factors

• Associated features (especially nausea)

What questions should you ask about the time course and evolution of symptoms of a headache?

• Sudden e.g. "thunder clap" headache

• Recurrent (but well between episodes)

• Deterioration over hours

• Relapsing / remitting

• Deterioration over weeks/months

What does a headache that deteriorates over hours suggest?

An infection

What does a relapsing/remitting headache suggest?

MS

What does a headache that deteriorates over weeks/months suggest?

Parkinsons

What questions should you ask about weakness?

What does the patient mean... chronic "aesthenia" "fatigue" or specific muscle weakness.

What activities are they finding difficult?

Is the problem in the muscle or in the nerve supply to the muscle?

What does weakness of sudden onset suggest?

Stroke until proven otherwise

What is the ice pack test?

Compression over ptosis with ice pack - test for myasthenia gravis. Positive if the ptosis improves

Focal weakness suggests

Neurological origin

Give examples of proximal muscle weakness

rising from sitting

drying hair

Give examples of distal muscle weakness

standing on tip toes

fine finger movements

What questions should you ask about walking, in terms of weakness?

• Has the distance they can manage changed?

• Why? What makes them stop?

• What about hills?

• One leg or both legs?

• Any sensory symptoms?

What does too little movement suggest

Parkinson's disease...slowing of movement, stiffness

What is the most common cause of too much movement

Huntingtons chorea

What is choreoathetosis?

Decreased tone...rapid, writhing changes in movement (consider over treatment of PD)

What is paraesthesia?

Abnormal tingling or prickling sensation (caused by damage to peripheral nerves) - "feels like a tight bandage wrapped around my leg"

What is allodynia?

Severe pain sensation evoked with a stimulus that doesn't normally induce pain e.g. brushing against someones skin can cause them intense pain

Complete sensory loss is likely to be of what origin?

Functional origin

A patient complains of "Wake up in the middle of the night with ache and numbness in my thumb and first two fingers" Which nerve is affected?

Median nerve

What chronic illnesses may result in neurological impairment?

Diabetes, sarcoid, TB

What are activities of daily living (ADLs)?

ADL's are the activities required to maintain a daily life existence. They are eating, dressing, transferring, toiling, walking or moving around and bathing

What should you think about when taking a history from a younger patient?

Milestone i.e. Was there any evidence of developmental delay?

What can birth asphyxia/a difficult birth cause?

Cerebral palsy

What are some normal ages for milestones

1 to walk & 2 to talk but can be earlier or later - bum shuffling is very normal

What does regression in a child suggest e.g. started walking or talking but has regressed

ALWAYS abnormal and must be investigated

When do children normally smile first?

6-8 weeks

What questions should you ask about prescribed drugs?

What treatment(s) are they on?

Are they compliant?

Is it optimal?

Allergies?

Could it be the cause of the problem?

Is there any interaction between the drugs?

Is the patient thinking of becoming pregnant?

What are anti-convulsants contra-indicated in?

Pregnancy

What can analgesic overuse cause?

Headaches

What questions should you ask about non-prescribed drugs?

What other drugs are you taking?

How often, how much, how long?

Tell me about your pattern of drinking alcohol

What symptoms do you have if you don't take drugs / drink?

What should you ask about in your systems enquiry?

Psychological...depressed?

Autonomic nervous system...bowel, bladder function, sexual dysfunction, light headedness?

Recent infection?

Why is it important to take a family history for a neurological history

Genetic component to many neurological disorders.

You must ask & document

What should you ask about in a social history?

Who is at home?

Home circumstances

Are home circumstances contributing to medically unexplained symptoms?

Occupational history e.g. bed and bathroom all on one level?

Give examples of cranial nerve screening questions

Change in your sense of smell?

Vision?

Double vision?

Dry eyes?

Dry mouth?

Change in taste?

Hearing?

Dizziness?

Change in voice?

Articulation?

What impact does COVID-19 have on the olfactory nerve

Changes sense of smell - can have lasting damage

How should you document a neurological history?

Not a verbatim record of what the patient has told you

Filtered and critically analysed record

Often important to record negatives

Conclude with a summary, differential diagnosis & action plan

How should you come up with a differential diagnosis in neurology?

The neurological system is logical so think logically!

Age, gender, pattern of onset

Risk factors

Relative incidence...common things are common

Assess probability

What percentage of symptoms are medically unexplained

30%

Why might some people consider further investigations following a history

- To complete a checklist?

- To increase your certainty of diagnosis?

- To exclude important things?

- To reassure you?

- To reassure the patient?

- The results should guide / change management

Give examples of assessment tools for cognitive assessment

• 4As test (rapid, initial screen for delirium)

• Mini Mental State Examination (MMSE)

• Montreal Cognitive Assessment (MOCA)

• Addenbrookes Cognitive examination (ACE III)

What is delirium?

• Mental confusion that can happen if someone becomes medically unwell. Can also be called "acute confusional state"

How common is delirium?

Common 1:10 hospital patients

What is the Montreal Cognitive Assessment (MoCA)?

• No copyright!

• Better at identifying mild levels of impairment

• Less bias ethnicity / age/ education

What is the Addenbrookes Cognitive examination (ACE III)

• About 20 minutes to do

• Scored out of 100

• 5 cognitive domains:

- Attention

- Memory

- Verbal fluency

- Language

- Visuospatial abilities

What is confabulation?

Fabricates events to fill in memory gaps

• Great authority, great certainty

• Often autobiographical in nature

• No intent to deceive

What conditions often present with confabulation?

• Korsakoff's syndrome

• Alzheimer's dementia