The importance of the case history in reaching a neurological diagnosis

1. The importance of the case history in reaching a neurological diagnosis Dr Massud Wasel MD DO ND BSc (Hons) PGCAP Fellow of Higher Education Academy

2. Case history (components of the adult health history) • Identifying Data- age, gender,occupation,marital status Source of the history-patient,family,friend,letter of referral or medical record • Reliability Varies according to the patient’s memory,trust and mood

3. Chief Complaint(s) The one or more symptoms or concerns causing the patient to seek care • Present Illness Amplifies the chief complaint, describes how each symptom developed Includes patient’s thoughts and feelings about the illness Includes medications, allergies, habits, smoking, alcohol

4. Past History Childhood illness Adult illness (medical, surgical, obstetric/gynaecologic and psychiatric Includes health maintenance (immunizations, screening tests, lifestyle issues)

5. Family History Age and health, cause of death, siblings, parents and grandparents Document presence or absence of specific illnesses like CVD,HBP and etc… • Personal and social History(family of origin, personal interests and lifestyle • Review of System

6. Review of System • General • Skin • Head, Eyes, Ears, Nose, Throat • Neck • Breast • Respiratory • Cardiovascular & peripheral vascular • GIT • Genital • Musculoskeletal • Psychiatric • Neurologic • Hematologic • Endocrine

7. Whilst listening, think about what might be causing the patient’s problems • Explore facts related to your hypothesis (Like handwriting in case of Parkinson’s)

8. Screen for other neurological symptoms, whether the patient has had any headaches, fits, faints, blackouts, numbness, tingling or weakness,

9. Any sphincter disturbance or visual symptoms (double vision, blurred vision or loss of sight The Health History Common or Concerning Symptoms Headaches ,dizziness, generalized, proximal, or distal weakness, numbness, Abnormal or lost sensation Loss of consciousness, syncope, Seizures Tremors or involuntary movement

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11. History-taking • Important in indicating both the probable site and the possible nature of the lesion • The secret of good history-taking is to be a good listener • You must be constantly aware that the majority of patients are extremely frightened • Different behaviour-ranges (tongue-tied-anxiety) • Apologetic for wasting your time

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14. History-Taking • Essential to avoid the presumption that because the patient is in the neurological clinic they must have a disease and it must be neurological. • Patient must be relaxed • When the patient is relaxed and talking freely,discussion of the actual symptoms can begin

15. Referral letter may be of help in guiding the questioning, but it is always important to ask the patient to relate the entire history again • Cross-checking the history with a relative or friend can be important • If the patient wishes to have a friend or relative in the consultation with them,this should be welcomed

16. Epileptic patient • Weakness of the arm coming on overnight,over week or several months is so important • Clerk with a radial nerve palsy To exclude stroke To diagnose ‘Saturday night radial nerve palsy’

17. In neurological medicine • To make the initial diagnosis • Establish a friendly and confident relationship at the first interview • Patients do not expect to be hectored or lectured when they have come for help, and the consultation should not be allowed to degenerate into a confrontation

18. Amazing how often patients describe their feeling and symptoms in almost identical phrases • If the patient has difficulty describing the quality of his/her symptoms; offer a selection of adjectives to see if they can select an appropriate description like P&N rather than ‘paraesthesia’

19. Some times they bring ‘a few notes’ to assist the interview • Or bundle of papers in a large briefcase

20. Several further direct questions including: • Previous medical history • Previous occupational history • Family history (inherited disease)

21. Past medical history • Any surgical procedures-esp. malignancy • Some times relatives know but not the patient • Deep X-ray therapy for seminoma causes myelopathy syndrome which mimics motor neuron disease

22. General conditions such as • Arterial disease have neurological implications • DM and collagen vascular diseases can be associated with a multitude of complications • Steroids and immunosuppressant • Neurosyphilis • AIDS

23. Any drugs in the past may be significant • Tadive dyskinesia may occur 20 years after the use of a major tranquillizer for an acute psychotic breakdown • Elderly patients with apparent idiopathic Parkinson’s disease may be found to be still taking prochlorperazine after 20 years, to prevent any recurrence of ‘dizziness’

24. Occupational • Asbestos • Nasopharyngeal carcinoma (wood dust) • Alcohol and tobacco consumption • Recreational drugs

25. Family history • Cause of death in family • Natural causes • Inherited disease • Dunchenne muscular dystrophy • Friedreich ataxia • Huntington chorea

26. The history serves to indicate those parts of the examination that should be performed with special care, skill and finesse • Physical examination for headaches • Examinations for leg pain • Or patient with both complaints

27. duration severity frequency Character (aching, throbbing) Headache Onset Sudden, gradual Associated features Vomiting, visual disturbance Timing Precipitating factors site Relieving factors

28. Impairment One/both eyes Total/partial visual loss Whole/partial field loss duration frequency Diplopia- gaze direction Where maximal Visual disorder Onset Sudden, gradual Hallucinations False sensations Without stimulus Formed-real images Unformed-shapes and colours Precipitating factors Illusions-stimulus that is misperceived

29. Nervous system examination • General examination :important may find systemic disease with neurological complications • Degenerative diseases like atherosclerosis causes stroke • Rheumatoid arthritis causes neuropathies,Csp cord compression • Hypothyroidism causes myopathy

30. Diabetes causes neuropathy • Neoplasia (breast, lungs) causes cerebral metastases

31. Techniques of examination (important areas of examination) • Appearance and behaviour • Speech and language • Mood • Thoughts and perceptions • Cognition, including memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability

32. Speech • Hearing ---------------------Deafness • Understanding--------------Aphasia • Thought and word finding--Aphasia • Voice production------------Dysphonia • Articulation------------------Dysarthria

33. Speech Throughout the interview note the characteristics of the patient’s speech, including the following: • Quantity • Rate • Loudness • Articulation • fluency

34. Mental state and Behavior • Self-neglect • Depressed • Anxious • Behave appropriately • Mood change • Patient’s concern about his/her symptoms

35. Delusions • Hallucinations • Attention and orientation • Memory • Calculation

36. Examination • Gait Romberg’s test • Cranial nerves • Motor system-tone, reflexes,myotoms • Sensation Vibration sense Joint position sense Light touch Pin Prick Temperature Joint position sense Two-point discrimination

37. Coordination (finger-nose test, repeated movement, Heel-shin test)

38. Nervous system examination 1 • General: • Anxious • Depressed • Handedness • Abnormal gait

39. Nervous system examination 2 • Neck: • Stiffness • Carotid bruits

40. Nervous system examination 3 • Face; • Lack of facial expression • Asymmetry

41. Nervous system examination 4 • Speech and language: • Dysarthria • Dysphasia

42. Nervous system examination 5 • Higher cerebral function • Orientation • Memory • Attention/concentration • Judgement and reasoning

43. Nervous system examination 6 • Cranial nerves: • II- vision,papilloedema • III,IV,VI-abnormal eye movement • VII-facial weakness • VIII-hearing loss • IX,X,XI-dysphagia,dysphonia • XII-tongue wasting

44. Nervous system examination 7 • Motor function • Muscle wasting • Involuntary movements • Tendon reflexes • Plantar reflexes • Reduced power • Altered tone,clonus

45. Nervous system examination 8 • Co-ordination • Cerebellar signs • Dyspraxia • Rombergism

46. Nervous system examination 9 • Sensory function • Pinprick, two-point discrimination • Joint position, vibration • Temperature

47. Investigations of the central and peripheral N.S • Skull x-ray

48. Radionuclide imaging • Radionuclide bone scans in a 28-year-old woman with a palpable swelling over the calvarium (same patient as in Images 3-4 in Multimedia) show a solitary lesion within the skull and a photon-deficient mass surrounded by a rim of intense activity. Biopsy results confirmed the diagnosis of eosinophilic granuloma.

49. EEG • Intracranial pressure monitoring • Evoked potentials-visual,auditory and somatosensory • Lumbar puncture • CSF • EMG/nerve conduction studies • Neuro-otological test

50. Clinical presentationdiagnostic approach • Headache • Meningism • Raised intracranial pressure • Coma and impaired consciousness level • Transient loss of consciousness(reduction in cerebral arterial O2 supply-cardiac,vasovagal attack,VBI,basilar migrain,hypoglycemia,epilepsy,drug abuse,alcohol,barbiturates)