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How to take Neurological History PowerPoint Presentation

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Description : DR.HIKMATULLAH SHERANI NEUROPHYSICIAN AT MH RWP PAKISTAN

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Published on : Feb 03, 2018 | Views : 4331 | Downloads : 20

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HOW TO TAKE NEUROLOGICAL HISTORY DR.HIKMATULLAH
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Remember The Introduction!
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PRE-REQUISITE Alertness of patient Informant Insight of patient regarding illness Doctor-patient relationship
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PROFORMA Patient particulars ( name, age , sex, occupation, area of residency, handedness) Presenting illness Past illness- medical/ surgical Personal history- toxin exposure, birth history Family history Treatment history
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GOAL OF HISTORY TAKING First priority is to identify the region of nervous system that is likely to be responsible for the symptoms Site of the lesion Nature of the lesion
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Quotable Sir William Osler  "If you listen carefully to the patient they will tell you the diagnosis“  "Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.“  “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”
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The neurological history should be a focused, goal directed exercise that answers the following questions: Where in the nervous system is the lesion? What is the pathological process (e.g. inflammatory, vascular, infectious)? Is this a purely neurological problem or a neurological manifestation of a systemic disease?
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Why Is the Neurological History Still Relevant? • Safest and most cost effective DIAGNOSTIC MODALITY available • The most direct method to cultivate trust and a sound doctor-patient relationship
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Helpful Hints To Avoid Polarizing The Interview “Brute force approach”  How much do you drink, Mr. Brown?  Do you know where you are, Mr. Brown?  Do you know why they brought you here? “Blame it on the other guy” approach  Is a cocktail or a beer something you enjoy regularly, Mr. Brown?  Did anyone have a chance to tell you the name of this place? Well, anyone can get mixed up in here.  Are they treating you well here? What are they doing for you?
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COMMON PRESENTATIONS IN NEUROLOGY Headache Visual disturbances Loss of consciousness Seizure Speech disorder Motor disorder Sensory disorder Cranial nerve disorder Alteration of state of mind Autonomic disorder Sphincter disorder
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HEADACHE Site Severity Onset ( sudden/ gradual ) Frequency Duration Character Time of occurrence ( e.g.morning ) Precipitating factors ( stooping / coughing ) Relieving factors Associated features ( vomiting, visual disturbances )
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First attack or presence of previous attacks - worst headache (SAH) - persistent ( secondary headache) Age of onset - childhood to young adulthood ( primary headache) - older than 50 yrs ( secondary headache) Activity at onset of headache - Valsalva maneuver ( SAH, CSF leak) - changes in posture (supine - ↑ICP , upright – low CSF pressure headache) - head trauma - exercise – can precipitate migraine
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Characteristics of headache - severe headache : SAH both primary & secondary HA may be mild to severe - timeframe : rapid onset – SAH, ICH gradual onset – migraine(mins to days) SDH, GCA(days to months)
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Associated symptoms : • Fever , diaphoresis , chills & rigor-meningitis,cerebral malaria • nausea & vomiting – migraine, ↑ICP, posterior fossa lesion • Photophobia & phonophobia – migraine or meningeal process • Neck stiffness – meningeal process • Changes in consciousness • Focal neurological symptoms
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LOSS OF CONSCIOUSNESS Head injury – recent / previous Sudden collapse – ICH , SAH Limb twitching ,incontinence – epilepsy/postictal Alcohol/ drug abuse Cardiovascular/ respiratory/ genitourinary disorder Acute/ gradual – mass lesion Metabolic – diabetes Psychiatric disorder - hysteria
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HISTORY OF SEIZURES • Obtain a description of the seizure/s: • From patient and witness (NB blackouts, faints, fits, loss of consciousness) • What happens at the onset of the fit? • What happens during the fit? • Does the patient fall or remain standing or sitting? • How does the fit end? • Confusion or other post-ictal symptoms?
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• Is there incontinence, any injury or tongue biting? • Frequency of seizures? • When do the seizures occur? • What medication is taken? • History of past/ current medication, compliance and response to medication
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• Change in seizure pattern • Family history of seizures • Head trauma or brain illness (especially in adult onset epilepsy) • Birth history (especially in early onset seizures)
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SYNCOPE • Fainting or LOC resulting from recoverable loss of adequate blood supply to the brain • Vasovagal syncope - provoked by emotionally charged event e.g. venipuncture • Cardiac syncope - sudden decline in cardiac output and hence cerebral perfusion e.g. severe aortic stenosis or heart bloc
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KILLER WORDS  DIZZINESS  SLURRED SPEECH  BLURRED VISION  NUMBNESS All of these symptoms are invisible BUT just like love, loyalty and patriotism, they all exist. The patient knows exactly what they are talking about (even if you may not)
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DIZZINESS  Spinning  Fast or Slow rotation  Fast-usually labyrinthine or vestibular  Slower-may be central  Often with a sense of “rocking boat”  Positional  Lightheaded or fainting  Orthostatic?  Hyperventilation?  Hypotension?  “Are you dizzy in your head or in your feet?”
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Three Most Common Causes Of Dizziness  Hemodynamic  Hyperventilation may =sighing  Positional Vertigo
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NUMBNESS  Often used interchangeably by the patient for weakness  Paresthesias = pins and needles  Dysthesias=unpleasant or unnatural sensation  Anesthesia=no feeling  Remember to get the zip code right (anatomical localization)  Diagrams of radicular and cutaneous innervation  Load on jump drive
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Sensory “Road Maps” For Patients
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BLURRED VISION  Most difficult aspect of the history  Ask instead:  Double vision?  See something that shouldn’t be there?  Typically of migraine such as scotoma  Is something missing in your vision?  Field cut  Remember that a field cut is usually sensed by the patient as being in one eye  Speed of onset  Stroke is sudden and dark  Migraine is wavelike in onset and resolution and usually bright
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FIRST AND LAST WORD ABOUT TPA  “When was the patient last seen in their normal state?”  Most important piece of history  Must be documented, especially if the decision is made NOT to give thrombolytic  Just to have TPA brought up increases the risk of litigation  Victory for the plaintiff in such cases is almost always for FAILURE to give TPA  Defendants (ER/neurology/hospital) still prevail the majority of the time
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CRANIAL NERVE DISORDER  Loss of smell, vision, taste  Difficulty in mastication , loss of sensation over face  Deviation of angle of mouth; facial asymmetry; epiphora  Deafness/ tinnitus – unilateral/ bilateral  Vertigo  Balance/ staggering – direction  Nasal intonation or regurgitation  Difficulty in deglutition  Change of voice  Wasting of tongue / dysarthria  Difficulty in neck movements
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Relationship of symptoms localization and causes Neurological diagnosis has three main components: 1. Pathological conditions causing the disease (causes) 2. Site of pathological changes within the nervous system (localization) 3. The above are reached through the interpretation of symptoms, together with previous history and current complaints. When the cause remains unknown, symptoms may form a part of the diagnosis. The interpretation of symptoms is our first task, therefore these three components have the following order in increasing significance: 1. symptoms, 2. localization, 3. causes
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1. The relationship between symptoms and localisation is the strongest in neurological disorders with focal lesions. It is a general rule that the lesion of identical structures causes identical symptoms. 2. The relationship between localisation and causes is not as strong, although knowing the site of lesion may in certain cases help in finding out its cause as well. 3. The relationship between symptoms and causes is rather loose, especially during the evolving phase of neurological diseases.
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Special aspects of history taking Patient’s age Clarification of complaints and symptoms Time course and evolution of complaints and symptoms Value of negative information Exclusion of irrelevant information Medications History from family members/persons close to the patient
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Patient’s age Similar complaints and symptoms may suggest different disorders in young and older patients. For example, nystagmus, ataxia and hemiparesis of acute onset in a 20-year-old patient are most likely caused by multiple sclerosis, whereas in an older patient, vertebrobasilar circulatory insufficiency is first suspected.
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Clarification of complaints and symptoms All patients who are conscious, able to speak and are not mentally retarded can provide precise information about their physical ailments. Patients provide core symptoms, and the circumstances surrounding their onset Important neurological symptoms include disorder of consciousness; paralysis; disorder of perception (visual, auditory, gustatory, tactile); disorder of gait and balance; disorder of production, comprehension and expression of speech; disorder of thinking, comprehension and behavior; pain (headache and neuropathic pain); episode of disorder of consciousness (epilepsy); autonomic dysfunction, etc. Patients and relatives without medical knowledge may describe these symptoms in many different ways. For example, the word fainting’ may indicate syncope or an epileptic seizure. confusion’ may mean delirium or sensory aphasia. It is often needed to ask repeatedly with different words about important elements of the history, until it is clearly understood what happened to the patient, or what was observed relating to the patient.
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Time course and evolution of complaints andsymptoms 1. In acute nervous system disorders, signs and symptoms develop within a few seconds, minutes or hours in apparently healthy patients (e.g. cerebrovascular disorders and epilepsies). 2. In non-acute nervous system disorders, signs and symptoms develop over a longer period of time. These include subacute’ and chronic’ disorders.
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Other aspects of history taking During the course of history taking, negative information is also very important. For example, when evaluating an episode of loss of consciousness, it is important to know whether the patient had convulsions, enuresis or tongue bite during the episode, or clouded consciousness following the episode. It is common that patients connect their complaints and symptoms to a previous event, such as lumbar puncture or other diagnostic or therapeutic interventions. It is usually impossible to dissuade patients from these convictions. It is therefore necessary to learn how to separate irrelevant information from valuable information. Neurological disorders are often of chronic in nature, requiring long-term treatment, even for many years. It is therefore important to know previous treatments, in addition to current medications. For example, if a patient treated for chronic pain had no adequate response to a drug given previously in an appropriate dose for an appropriate period of time, then it would be useless to experiment with the same drug.
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Certain patients with central nervous system diseases are unable to describe their symptoms due to a disorder of consciousness, speech or behavior. In these cases, information should be obtained from relatives or other relevant persons
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In Conclusion… There are no coincidences in neurology….EVER! Multiple events in a single patient occur for a reason. If you can figure out the relationships, you can make the diagnosis. Randy M Rosenberg, MD Neurologists only have to worry about two things…what the patient really has and what will kill the patient tonight. Arnold Bank, MD Every patient you see is a lesson in much more than the malady from which he suffers. The good physician treats the disease; the great physician treats the patient who has the disease William Osler MD
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