The Neurological History

A thorough neurologic history allows the clinician to define the patient's problem and, along with the result of physical
examination, assists in making a diagnosis.

Solid knowledge of the basic principles of the various disease processes is essential for obtaining a good history.

The history of the presenting illness or chief complaint should include the following information:

 Symptom onset: Acute onset symptoms (minutes to hours) suggest vascular or convulsive problems and may be
preceded by an aura. Subacute onset (hours to days) occurs with inflammatory pathology such as that associated with
meningitis, Guillian-Barre syndrome. Chronic onset (weeks to months) may indicate malignant aetiology; and onset
in the order of months to years is associated with degenerative disease.
 Duration
 Course of the condition (eg, static, progressive, or relapsing and remitting)
 Associated symptoms, such as pain, headache, nausea, vomiting, weakness, and seizures
 Symptoms may be localized or diffuse and a logical assessment of the nervous system level of pathology can be made
on this basis. Is the pathology occurring at the level of the cerebral hemispheres, posterior fossa, spinal cord,
peripheral nervous system?

Important miscellaneous factors of the history include the following:

 Results of previous attempts to diagnose the condition

 Any previous therapeutic intervention and the response to those treatments

A complete history often defines the clinical problem and allows the examiner to proceed with a complete but focused
neurologic examination

Presenting symptoms
1) Headache

Obtain details on all 10 characteristics of pain (outlined below).

The typical symptoms of the commonest causes of headaches are outlined. These are the commonest features, but every patient
is different.

Tension Migraine Cluster SAH

Unilateral/ Local,then
Site Generalised near eyes Over one eye generalised

Radiations neck(occasional) variable forehead/cheek Neck

Character ache sharp or ache ache thunderclap
Severity subjective subjective subjective worst ever
Onset gradual gradual gradual sudden
Periodicity variable variable recurring bouts
Duration hours hours intermittent persistent
Aggravating stress/posture light pollen/allergens
Relieving rest/analgesia rest/analgesia decongestant

Nausea/aura Lacrimation
Associations vomiting rhinorrhoea neck stiffness

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Other causes of headache

Meninges

 meningitis

Intra- cranial

 Trauma
 Tumour / abscess / congenital malformation

(Any space-occupying lesion, which can cause raised intra-cranial pressure)

Systemic

 Asociated with infection, connective tissue disease, etc

Vascular

 Acute cerebral artery/vein thrombosis

 Temporal arteritis
 Carotid aneurysm

Sinuses, middle or inner ear

2) Faints

Syncope is defined as a transient loss of consciousness with an inability to maintain postural tone that is followed by
spontaneous recovery. The term syncope excludes seizures, coma, shock, or other states of altered consciousness. Dizziness
(faintness) is the symptom which precedes syncope.

Causes of syncope
 Cardiac syncope:

Vascular disease, cardiomyopathy, arrhythmia, or valvular dysfunction

 Noncardiac syncope:

Vasovagal syncope is the most common type in young adults but can occur at any age. It usually occurs in a
standing position and is precipitated by fear, emotional stress, or pain (eg, after a needlestick). Autonomic
symptoms are predominant. Classically, nausea, diaphoresis, blurred or faded vision, epigastric discomfort, and
light-headedness precede syncope by a few minutes. Syncope is thought to result in decreased peripheral vascular
resistance. It is not life threatening and occurs sporadically.

Dehydration and decreased intravascular volume contribute to orthostasis. Orthostatic syncope describes a
causative relationship between orthostatic hypotension and syncope.

Situational syncope is essentially a reproducible vasovagal syncope with a known precipitant. Micturition,
defaecation, and carotid sinus syncope are types of situational syncope. These stimuli result in autonomic
reflexes, ultimately leading to transient cerebral hypotension.

Neurologic syncope may have prodromal symptoms such as vertigo, dysarthria, dysphagia, diplopia, and ataxia.
Syncope results from preexisting bilateral vertebrobasilar insufficiency with some superimposed acute process.
Consider a transient ischemic attack as an alternative diagnosis.

A detailed account of the event must be obtained from the patient. The account must include the circumstances surrounding the
episode: the precipitant factors, the patient's activity involved in prior to the event and the patient's position when it occurred.

 Physicians should specifically inquire to identify symptoms, such as chest pain, dyspnoea, palpitations, severe
headache, focal neurologic deficits, diplopia, ataxia, or dysarthria prior to the syncopal event.

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  Patients should be asked to estimate the duration of their loss of consciousness. Syncope is associated with patient
estimates ranging from seconds up to 1 minute in most cases. To discriminate from seizures, patients should also be
asked if they remember being confused about their surroundings after the event or whether they have oral trauma
[tongue biting] or incontinence.
 A detailed account of the event must also be obtained from any available witnesses. Witnesses can aid the clinician in
differentiating among syncope, altered mental status, and seizure.

3) Fits

Seizure: a sudden change in behaviour that is the consequence of brain dysfunction.

Epileptic seizures: sudden change in behaviour due to abnormal electrical activity in the brain (cerebral cortex). Electrical
activity can be measured using an EEG.

Non – epileptic seizures: sudden change in behaviour, without abnormal electrical activity in the brain.

Characteristics of seizure

 Altered/loss of consciousness
 Involuntary movements – jerking

 Incontinence

 Tongue-biting

 Preceded by an aura (abnormal visual/auditory/olfactory sensation)

 Weakness following fit (Todd’s paralysis)

Types of Epileptic Seizures

 Simple – no loss of consciousness

 Complex – loss of consciousness

 Generalised – abnormal activity widespread in brain

 Partial – abnormal activity in focal part of brain

Causes of Epileptic Seizures (damage to CNS)

 Brain injury( trauma/haemorrhage)

 Stroke

 Intracranial infection

 Congenital malformation

 Tumour

Causes of Non –Epileptic Seizures (These are generalized seizures)

 Metabolic – hypo/hyperglycaemia, hypothyroidism, hypercalcaemia, hyponatraemia.

 Hypoxia – infection, blood loss, cardiac dysfunction

 Renal failure/ Liver failure

 Drugs/medications – alcohol, sedatives

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4) Dizziness/vertigo

Vertigo is an illusion of movement, caused by disease of the inner ear, the eighth cranial nerve, or the central connections of
the eighth cranial nerve.

In true vertigo, there is a sensation of rotation

Associations: Nausea, vomiting, unsteadiness, pallor, weakness.

Causes of Vertigo

 Inner Ear Causes

Otitis interna
Acute labyrinthitis

 CN 8 Causes

Acoustic neuroma (tumour of CN 8)

 Central Connection Causes ( disease in the pons, origin of CN 8)

Tumour
Vascular disease
Multiple Sclerosis (demyelination)

5) Deafness

Impaired hearing can be due to damage/ obstruction of the ear canal, or due to damage to the nerve supplying the ear. (CN 8,
vestibulocochlear nerve)

Ear Canal Causes

 Middle ear infection ( otitis media)

 Wax (cerumen)

Nerve Causes

 Noise exposure
 Trauma (skull fracture)
 Drugs (alcohol)
 Congenital infections (rubella)

6) Visual disturbances

 Diplopia – double vision

Weakness of intra-ocular muscles or damage to nerves/blood supply of intra-ocular muscles

 Amblyopia – blurred vision

 Photophobia – light intolerance (migraine/ meningitis)

 Visual field loss – These patterns are discussed in the clinical tutorials

 Visual loss

a) Acute visual loss– damage to the eye/ nerve supply/blood supply/brain

 Stroke
 Haemorrhage
 Multiple Sclerosis
 Retinal vascular occlusion

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 b) Chronic progressive visual loss– damage to the eye/nerve supply/blood supply/brain

 Cataracts (ageing/DM/glaucoma/steroids)
 Diabetes Mellitus (damages blood supply and nerves and causes cataracts)
 Ageing (macular degeneration)

7) Gait

Many neurological conditions can impair walking. Gait can be abnormal due to disease of

 brain/ spinal cord (CNS)

 nerves to the leg muscles (PNS)
 leg muscles
 joints
 systemic disease

Types of impaired gait

 Cerebellar disease – unsteady, reeling

 Stroke – hemiplegic gait , dragging of one side
 Parkinson’s disease- small steps, shuffling, slow

8) Disturbed sensation

With regards to temperature sensation, patients can be asked whether they have any problems detecting water temperature.
Failure to notice cuts, wounds after injury due to lack of sensation. For fine touch discrimination, patients can be asked
whether they have problems pulling the correct coin or other objects out of their pockets. Position sense can be explored by
asking whether patients have problems knowing where their feet are on the car accelerator and brake pedals.

One should also inquire about pins and needles which can result from nerve entrapement or peripheral neuropathy

Causes of Sensory Neuropathy include

 Diabetes Mellitus
 Chronic renal failure
 Vitamin B12 deficiency
 Hereditary syndromes

9) Weakness

Weakness may be local – one arm or leg, or may be generalised.

Enquire as to whether it is constant or intermittent.

Causes

 Central Nervous System

Following CVA
Cerebral tumour
Spinal cord injury

 Peripheral nervous system

DM
Toxins

 Anterior horn cell

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 Motor Neuron Disease

 Neuromuscular junction

Myasthenia gravis

 Muscle

Alcohol
Medications (steroids)
Connective tissue diseases (SLE)
Endocrine (thyroid disease, Cushing’s, acromegaly)

10) Tremor and Involuntary movements

Distinguish between resting (visible at rest), postural (present throughout movement) and intention (increases toward target).

Causes of Tremor include

 Parkinson’s disease
 Cerebellar disease
 Hyperthyroidism
 Anxiety
 Medications (inhalers, e.g. Ventolin)

11) Speech

Dysarthria – difficulty with articulation

Causes of dysarthria

 Cerebellar disease ( slurred speech)

 Local oral disease – mouth ulcers, cleft palate

Dysphasia – difficulty with communication

Caused by disease of the dominant cortical hemisphere

 Receptive dysphasia: where the patient cannot understand the spoken or written word. Speech is fluent but
disorganised. Ask patient to follow commands, unable to do so.

 Expressive dysphasia: the patient understands but cannot answer appropriately. Ask to name objects, repeat
words.

 Nominal dysphasia: patient cannot name objects. Point to your pen, watch and ask patient to name them.

Other Higher Centre Functions include:

 Frontal lobe– personality

 Temporal lobe– memory, speech
 Parietal lobe– performing tasks, speech
 Occipital lobe– vision

Past Medical and Surgical history

Start with the OPEN ENDED enquiry first. “Have you ever been admitted to hospital for any reason?” is a good way to start.
Follow this with “Do you have any medical conditions or health problems of any kind?” and “Have you ever had any
operations no matter how minor before?”

In this part of the history it is helpful to ask the open ended question in a number of ways because what you and the patient
consider a past medical history does not always coincide.

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Then you can focus on specifics. If the answer is “yes” to any of these, ask what the treatment has been, any changes in
treatment and how successful any treatment has been.

 History of trauma / injury

 History of meningitis / encephalitis
 History of epilepsy / convulsions
 History of Diabetes – If no, ask whether blood sugars have actually been checked
 History of high cholesterol – Also ask if this has been checked specifically.
 History of hypertension – Again, ask if it has been checked recently
 History of heart disease or peripheral vascular disease
 History of Atrial fibrillation or any other arrhythmia
 History of rheumatic fever or endocarditis

Medications/Allergies

 “Are you on any medications?”

 “How about over the counter medications”
 “Any herbal remedies?”

Enquire about allergies and whether any medication has made the patient unwell before. Ask what the patient means by
“allergy”?

Relevant specifics:

 Anticoagulants and / or anti platelet agents

 Anti convulsants
 Antihypertensive agents
 Treatment for high cholesterol
 Oral contraceptive pill

Social History

 Home circumstances: Including who is with the patient at home and the general health of that person, home
modifications and home layout.
 Occupation
 Smoking (how much and how long?).
 Alcohol intake (Long term alcohol use is associated with dementia, neuropathy, cerebellar degeneration,
encephalopathy)

Family History

 Again, OPEN ENDED enquiry first. “Are there any medical conditions that run in the family?”
 Then more specific if suitable (i.e. not in an 85 year old patient): “Are your parents still alive?” “How is their health?”
or “What was the cause of their passing?”
 The same for siblings
 Then “Any relatives with a neurological condition?”
 Family history of heart disease, stroke, hypertension, diabetes, high cholesterol, epilepsy

Systems review

 Start with “ Is there anything else you would like to add” or “Do you have any other symptoms to report ”
 Then ask about general wellbeing, weight and appetite.
 Then 4-5 questions about each body system in quick point form.