History taking in Neurology patients

History taking consists of seven important components; 1) introduction of the patients; 2)

chief complains in chronological order; 3) History of present illness; 4) Past illness; 5) personal
history; 6) Family history and 7) treatment taken and response.

Neurological cases have few specialties and peculiarities that make the history taking the most
important tool for diagnosis. A patient having fever, headache and vomiting- diagnosis can be
meningitis but with headache, vomiting and fever this can be sub-arachnoid hemorrhage also so
the correct chronology is very important. Most common mistakes found in neurological case are
poor presentation of CHIEF COMPLAINS (CC). There is difference in chief complaint and
presenting symptom. All related symptoms should be arranged properly in sequential manner as
these appeared in cardinal manifestation. As it is commonly found that in common’s man
language one complaint might have several meanings e.g. patients complaining “chakkar” may
have, walking difficulty, vertigo, ataxia or seizures. Therefore instead of saying chakkar as CC, it
is better to say precisely the underlying neurological symptom. After your description of
presenting complain and the disease progression comes your negative history.

Negative history should be divided into 3 parts

1) negative history pertaining to localisation (to decide which part of neuraxis is involved)

2)negative history pertaining to etiology (to decide what is the etiology or to exclude the other
etiologies in the differential diagnosis)

3)negative history pertaining to complications (to rule out the complications associated with
suspected etiology

After putting chief complains and negative history in right order, you should review the
background illness (like Diabetes, Hypertension or hypothyroidism) if any in same patients.
Background illnesses are those illnesses that are non-curable diseases and continuously required
treatment and precautions.

Aim of the history taking is to make correct diagnosis. The word “Diagnosis” means “to know”
(gnosis) and “completely (Dia). The diagnosis is consisting of three major parts; 1) to know the
dysfunction caused by the disease. 2) Site of the disease (System involved, area involved and
structure involved), 3) Patho physiology or nature of disease (acquired/congenital/hereditary).
Example: A patient presenting with tingling sensation in all 4 limbs for last 4 months.

DYSFUNCTION – Associated motor weakness, bladder dysfunction, sexual dysfunction, loss of

sleep and loss of work are disabilities.
SITE OF LESION- Can be either at- peripheral nerve or Spinal cord. Further question about the
onset from upper limbs or lower limbs or from all 4 limbs at one time will decide the site.
Symptoms starting in upper limbs will be odd for peripheral nerve as site of involvement so
spinal cord will be first probable site.

PATHOPHYSIOLOGY – This can be compressive or non compressive. Positive root pains and
bladder symptoms will suggest the compressive nature while in patient of nutritional deficiency
and chronic disease this can be non-compressive.

NATURE OF LESION- Now if the spinal cord is the site of lesion then nature can be suggested by
associated symptoms like, Trauma prior to this- traumatic, fever- infective, old age with cervical
Spondylosis – degenerative nature will be evident.

CARDINAL SYMPTOMS IN NEUROLOGY: (These should always be asked in all patients and
mentioned even of absent)

 90% can be diagnosed by good history taken with good care attention.
 1. For Motor Pathway- Weakness (Hemiplegia, Paraplegia, Monoplegia or Quadriplegia),
Hypokinesia, Hyperkinesia, Convulsion, Ataxia, Wasting, Fasciculation, Loss of Balance,
2. For Sensory Pathway- Tingling, Burning, Paresthesias, Numbness And Ataxia

Other are related with dysfunction of special sensation- Visual Pathway, Taste
Pathway, Hearing, Tinnitis, and Smell disorder,

3. Pain Pathway- Headache, Backache, Radicular Pain, Neuralgic pain and

generalized or Half Body pain.
4. Dizziness and Vertigo or any other cranial nerve involvement.
5. Alteration in Consciousness- Seizure, Confusion, Stupor, Delerium and COMA
6. Mental and Cognitive Function- Hallucination, Dellusion, Memory Loss,
Dysphasia/Aphasia, Agnosia, Apraxia, Apathy, and Sleep disorder.
7. Autonomic Pathway- Syncope, Bladder Dysfunction, Perspiration disorder and
Causalgia.(very painful, sensitive skin)
Commonest of these are – Seizures, Headache, Hemiplegia, Paraplegia and COMA.

Common causes of cardinal manifestation of Neurological disorders

1. Headache - a). Intracranial – inflammatory or neoplastic intracranial lesions like tumor,
tuberculomas, hydrocephalus and meningitis, b) Extra cranial – ophthalmic, Dental and
ENT causes, c) Primary headaches – Vascular, tension type, d) Neuralgia
2. Seizures – a) Epilepsy, b) acute symptomatic like neurocysticercosis, tumor and acute
CNS insult due to any cause and c) remote symptomatic – Old CNS insult due any cause.
3. Hemiplegia/Hemiparesis – cerebrovascular disease, multiple sclerosis, ICSOL, Subdural
hematoma, cerebral contusion after trauma, ADEM and Encephalitis
4. Paraplegia/quadriplegia – ACUTE AND CHRONIC CASUES (Described elsewhere)
5. Walking difficulty – Ataxia, Parkinsons disease, myopathy, peripheral neuropathy,
paraparesis, Hemiplegia, musculoskeltal diseases and psychogenic.
6. Dysphagia/Dysphonia – PCA stroke, Myasthenia gravis, Bulbal palsy, Pseudobulbar palsy,
Polymyositis, Ocular pharyngeal muscular dystrophy, oesophageal/laryngeal carcinoma
7. Vertigo – Meniere’s disease, otosclerosis, benign paroxysmal positional vertigo,
vestibular neuronitis, labrynthitis, migraine, seizure and vertibro-basilar syndromes
8. Ataxia – Cerebellar ataxia, Spinocerebellar ataxia, Friedreich’s ataxia, SACD, Sensory
neuropathy, Vit E def, Drugs(antiepileptics), toxins(alcohol) and hypothyroidism.
9. Ptosis – 3rd Nerve palsy, Horner’s syndrome, Myasthenia gravis, congenital ptosis,
progressive external ophthalmoplegia, Oculopharngeal muscular dystrophy
10. Sudden unconsciousness – Brain stem stroke, Intracranial hemorrhage, seizure,
Hypoglycemia, Hypoxic ischaemic, toxic, postictal and hysterical.
11. Slowly progressive altered sensorium – septic metabolic encephalopathy, ICSOL,
Hydrocephalus, toxic, Meningoencephalitis and subdural hematoma.
12. Back pain – Muscular, Spondyloarthritis, Disc prolapse, Pelvic disease, osteoarthritis of
lumbar spine, Postural, pott’s spine, Fracture, trauma, multiple myeloma and
Metastasis.
13. Tremors – Parkinson’s disease, Cerebellar ataxia, Essential tremor, Thyrotoxicosis,
Neuropathic tremors, drug induced( Alcohol, Salbutamol, Lithium, Valproate) and
Anxiety.
14. Fainting or fall – Syncope, TIA, seizures and postural hypotension.
15. Neck Stiffness – Meningitis, Menigismus, Sub arachnoid hemorrhage, Osteoarthritis,
Extrapyramidal disorders and cerebellar tonsillar herniation.
16. Hand clawing – Hansen’s disease, Syringomyelia, C8-T1 radiculopathy, Motor-neuron
disease, median/ ulnar neuropathy, peripheral polyneuropathy and thoracic outlet
syndrome
17. Foot drop – Peroneal neuropathy, sciatic neuropathy, L5 Radiculopathy, and UMN
paralysis.
18. Wrist Drop – Radial Neuropathy, C7 Radiculopathy, lead toxicity, damage to posterior
cord of brachial plexes and UMN paralysis.
19. Tingling all 4 limbs – Peripheral neuropathy, Cervical Myelopathy, anxiety, Alkalosis,
Hypothyroidism.
20. Bladder retention or incontinence – Myelitis, Autonomic neuropathy, Hydrocephalus,
Encephalopathy, Frontal lesion, cauda equine syndrome and sacral plexus lesion.
21. Lhermitte’s sign: multiple sclerosis, spondylosis, B12 def, Radiation Myelopathy.
22. Neck Flexion/ extension weakness: myopathy, Myasthenia gravis, MND and myotonic
dystrophy.
23. Acute flaccid paralysis: GBS, Transverse myelitis, Periodic paralysis, Poliomyelitis,
Hypokalemia, Myasthenia gravis, Botulism and acute intermittent porphyria.
24. Thunderclap Headache: Subarachnoid Haemorrhage, Arterial Hypertension, Carotid and
vertebral artery dissection, meningoencephalitis and exertional headache.

Nature of disease: Decided by few important symptoms given below.

 Hereditary- family history positive for same disease.
 Congenial – By birth.
 Traumatic – correlated with recent trauma.
 Vascular – sudden, abrupt onset, while sleeping.
 Infective – Acute, fever is temporally associated with the dysfunction.
 Inflammatory – multi-systemic signs of inflammation.
 Demyelinating – Acute, recurrent, event related.
 Nutritional – social, dietary and environmental indices.
 Metabolic – features of underlying systemic metabolic disorder.
 Toxic – recent exposure, environment, occupation or addiction.
 Neoplastic – acute, progressive, old age, weight loss and related features
 Degenerative – old age, slowly progressive and site specific.
 Autoimmune
 Neurological examination

(Please refer to Huntchinson’s text book of clinical examination for detail)

1. Mental Status Examination

a) Level of Consciousness- Alert(Fully awake and alert), Lethargic(somnolence)-
Decreased alertness & awareness and drift to sleep when not stimulated & wanders
from topic to topic, Obtundation(difficult to arouse and confused), Stupor(only
respond to persistent vigorous stimulus, only mumbles and groans) and
Coma(unarousable).
b) Attention- Forward (7±2)and backward Digit span(6±2 ), Vigilance.
c) Speech testing/Language – Spontaneous speech(Fluency, articulation and
paraphasia), Verbal fluency(Animals per minute- 18±6), Comprehension, Repetition,
Naming, Reading and Writing.
d) Memory testing – Registration (Immediate memory)- Give three unrelated words, 3
minutes Recall(Recent memory), Remote memory.
e) Construction Ability- Copy, To command.
f) Higher cognitive function- Calculations, Proverbs interpretation(Don’t cry over
spilled milk), Similarities(Car and airplane)
g) Related Cognitive functions- Apraxia(Types-Ideomotor and Ideational)- Inability to
perform a learned, skilled task in presence of normal power, sensation,
coordination, comprehension and attention, Right-left Disorientation,
Agnosia(Unable to Recognize), Denial & neglect and frontal lobe dysfunction.

Quick method is possible by recording MMSE(Post graduate should know about

Different Lobar functions)

MMSE(Total score-30)- Orientation-10 points, Registration-3 points, Attention and

calculation (Serial subtraction of 7)-5 points, Recall- 3points, Language- Naming-2,
Repetition-1, 3 stage command-3, Reading-1, Write a sentence-1, Copy intersecting
pentagon-1.
2. Cranial nerve examination
a) 1st Nerve- Sense of smell, each nostril separately.
b) 2nd nerve – Visual acuity, Visual field, Color vision and Fundus.
c) 3rd ,4th and 6th – Pupil- PERRLA-pupil equal(mention size and shape), round, reacting
to light and accommodation, Eye position and Extra ocular muscle movements,
Pursuits & saccades, OKN test. Look for ptosis, Proptosis, Strabismus, Nystagmus,
Horner’s syndrome.
d) 5th – Facial sensations, Corneal reflex, Muscle of Mastication and Jaw Jerk. Look for
Jaw deviation and temporal wasting.
 e) 7th – Muscles of facial Expressions- frontalis, orbicularis oculi, Bell’s phenomenon,
nasolabial fold, Taste sensation of anterior 2/3rd of tongue, lacrimation and Ask for
hyperacusis. Look for eye closure, facial deviation, facial muscle wasting and mask
like facie. Can check for facial jerks.
f) 8th – Whisper, Tick of watch, Rinne’s test, Weber’s test(use 512 hz tunning fork), and
Caloric reflex test- Vestibular ocular reflex.
g) 9th & 10th – Pharyngeal sensation(9th nerve), Resting position of soft palate and
uvula, change in the position on speaking ahhh (Palatal movements by 10th
nerve)and Gag reflex.
h) 11th – shoulder shrugging and sternomastoid testing- weakness wasting and
fasciculations
i) 12th –Power and tongue protrusion. Look for Atrophy, weakness, fasciculations,
spasticity, tongue deviation and tremors
3. Motor system examination
a) First do Inspection- Attitude of limb, Deformities, Abnormal movements( tics,
tremor, Myoclonus, chorea, dystonia, seizures) & Fasciculations and Wasting.
Hypokinesia and bradykinesia.
b) Nutrition and Bulk- Mention about muscle wasting or any hypertrophy or
pseudohypertrophy, Take Girth measurements.
c) Tone- In extremities and Axial muscles. Normal, hypotonia, Spasticity, Cogwheel
rigidity, lead pipe rigidity & gagenhalten Rigidity. Look for flabby muscles and
muscle tenderness
d) Power- Extremities, Neck and trunk(sitting, Rolling in bed). Comment on power on
adduction/abduction/flexion/extension on different joints- in UMN/LMN weakness,
Proximal & axial (In primary muscle disease)and distal weakness- in Polyneuropathy,
Focal muscle weakness in mononeuropathy and Radiculopathy.
e) Reflexes- Superficial reflexes- Corneal, Abdominal, Cremastric, Anal and Plantar.
Deep tendon reflexes- BicepsC5, SupinatorC6, TricepsC7, FingerflexionC8T1,
KneeL234, Ankle jerkS1. Release Reflexes- Snout, Grasp, Palmomental and Glabellar
Tap.
f) Coordination(Check appendicular and truncal Ataxia)-Rebound phenomenon, finger
nose test, Finger nose finger test, heel knee shin test, Rapid Alternating
movements(Dysdiadochokinesia). Other cerebellar functions include tests for
Dysarthria(Scanning speech), Nystagmus(Gaze evoked nystagmus), Intention
tremors, hypotonia/pendular knee jerk(swing to and fro 3 or more times), gait(Do
tandem Walking) and stance.
4. Sensory system examination
a) Somatic sensation – Fine touch, Pain(pin prick), Temperature, Joint position and
Vibration
b) Cortical sensation – Tactile localization, Two-point discrimination ((1mm-tip of
tongue, 2mm-lips, 2to4mm-fingertips, 1cm- palm, 2to3cm- back of hand, 3to4cm-
dorsum of foot)), Stereognosis, Graphesthesia and Tactile Extinction.
 c) Rombergs Test(Mention with Gait)
5. Signs of meningial irritation – Neck stiffness, kernig’s sign and Brudzinski’s sign.
6. Skull and Spine examination – Head circumference in children, Tenderness, kyphosis,
scoliosis and gibbus. Look for low hair line, short neck, Spina bifida and Straight leg
raising test(For Lumbosacral Radiculopathy). Note- Low hair line: Below C5, Normal
neck- 13% +/- 4%.(Inion to C7/ht of individual multiply by 100 for getting the percent)
7. Stance and Gait –Posture, turning, arm swing, normal gait(Comment on steps and base),
and tandem walking. Check Romberg’s test, Postural reflexes. Note stance (how far
apart the feet are), posture, stability, how high the feet are raised off the floor,
trajectory of leg swing and whether there is circumduction (an arced trajectory in the
medial to lateral direction), leg stiffness and degree of knee bending, arm swing,
tendency to fall or swerve in any particular direction, rate and speed, difficulty initiating
or stopping gait, and any involuntary movements that are brought out by walking. Turns
should also be observed closely.
8. Peripheral nerve thickening- Ulnar nerve and common peroneal nerve.
9. Neurocutaneous Markers, Bed sores and Trophic changes.
Other System Examination:
CVS- Murmur, Cardiomegaly. Check for carotid brui, peripheral pulses and postural drop
of BP
RS- Single breath count, Chest expansion
Abdomen- Organomegaly
Neurological diagnosis should always be presented in 4 tiers:
1) Functional diagnosis: It means what the patient is actually suffering from. E.g. patient with
weakness on one side of the body functional diagnosis in hemiplegia.
2) Anatomical diagnosis: It means which part of neuraxis is involved. E.g. cortex, subcortical
structures, brainstem, spinal cord, peripheral nervous system.
3) Physiological diagnosis: it means which are the neurological structures involved in the
anatomical substrate. E.g pyramidal, extrapyramidal, spinothalamic, posterior columns etc.
4) Aetiological diagnosis : what is the aetiology according to the onset duration progress of the
disease.