Common Cerebral Histories

Presenting Exploding symptom Relevant system reviews Differential diagnoses Clues to differential
complaint Grouping Differentials
Headache Pain General Primary Tension headache •Bilateral tight band sensation
Site Fever, skin rashes/bruising •Recurrent
Onset •Occurs late in day
Character Neurological •Association with stress
Radiation •General: fits/falls/LOC, Cluster headache •Short painful attacks around one eye
Associated symptoms dizziness, vision/hearing, •Last between 30 mins – 3 hours
Timing memory loss, neck •Occur once/twice a day for 1-3months
Exacerbating/relieving factors stiffness/photophobia •May be lacrimation and flushing
Severity •Motor: weakness/wasting, Migraine •Unilateral pulsating headache in trigeminal
incontinence nerve distribution
Red flags •Sensory: pain, numbness, •Last between few hours – days
•Meningismus symptoms: tingling •may be aura (usually visual)
rash, fever, neck stiffness •Need to lie down in dark room
•Temporal arteritis symptoms: (photophobia)
visual problems, jaw Trigeminal •2 second paroxysms of stabbing pain in
claudication, scalp tenderness neuralgia untilateral trigeminal nerve distribution
•Glaucoma symptoms: visual •Face screws up with pain
problems, red eyes, halos Secondary - Meningitis •Photophobia
around lights intracranial •Neck stiffness
•Systemic symptoms e.g. fever, non-
blanching rash
Temporal arteritis •Unilateral throbbing pain
•Scalp tenderness and jaw claudication
•>55 years
•May be visual problems
Subarachnoid •Very sudden onset severe headache
haemorrhage •”like some on hit me with a brick over the
head”
•Meningismus
Raised intracranial •Worse in morning and with coughing and
pressure (e.g. bending
tumour, benign •Vomiting & reduced GCS
intracranial •May be neurological symptoms & seizures if
hypertension) tumour
Secondary - Glaucoma •Pain around one eye
extracranial •Swollen red eye
•Visual blurring and halos
Sinusitis •Facial pain exacerbated by leaning head
forward
•Rhinorrhoea
Other Intracranial venous thrombosis
differentials Intracranial haemorrhages (intracerebral, subarachnoid, subdural)
Infections (abscess, encephalitis, meningitis)
Malignant hypertension
Hypoxia/hypercapnia
Viraemia
Cervical spondylosis
Pre-eclampsia
Drugs ( e.g. nitrates, PPI, caffeine, analgesia overuse, hormones)

Vertigo Timing General Peripheral Benign positional •Attacks of sudden rotational vertigo
•When started Fever (vestibular) vertigo •Evoked by head turning
•Acute/ gradual onset •Last ̴ 30 seconds
•Duration ENT Vestibular neuritis •Often preceded by URTI
•Progression •Ear: hearing loss, tinnitus, (e.g. herpes virus) •Sudden rotational vertigo and vomiting
•Intermittent or continuous otalgia •Lasts several days but imbalance may persist
•Nose: rhinorrhoea, epistaxis •May re-occur several times per year
Background to attacks •Throat: saw throat, Viral labrinthitis •Often preceded by URTI
e.g. had before, frequency, odynophagia •Severe vertigo and hearing disturbance
impact on life •May be tinnitus, otalgia, N&V, fever
Cardiorespiratory Meniere’s disease •TRIAD: vertigo + tinnitus + hearing loss
Chest pain, palpitations, •Attacks last minutes-hours
SOB/wheeze, cough, sputum, leg Central Vertebrobasilar •Momentary vertigo attacks precipitated by
swelling insufficiency neck extension
•Elderly with cervical OA
Neurological Other Peripheral
•General: fits/falls/LOC, differentials Acoustic neuroma (vestibular schwannoma)
headache, dizziness, Chronic otitis media
vision/hearing, memory loss, Eusthachian tube dysfunction
neck stiffness/photophobia Ramsay-Hunt syndrome (vertigo, facial palsy, otalgia, zoster rash)
•Motor: weakness/wasting, Cholesteatoma
incontinence Central
•Sensory: pain, numbness, Vertebrobasilar stroke (e.g. PICA syndrome)
tingling Cerebellar haemorrhage
Neurological conditions (e.g. MS, epilepsy, brain tumour, migraine)
Head injury
Inner ear syphilis
Drugs
e.g. alcohol, salicylates, quinine, aminoglycosides, metronidazole, co-
trimoxazole, diuretics

© 2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision
Fit/Fall/ Attack General Cardiovascular Postural •Dizziness ± LOC on standing from lying
Syncope •Before: warning, Fever hypotension •Recently started/changed anti-hypertensive
circumstance Arrhythmia •Fall after transient arrhythmia
•During: duration, LOC, Cardiorespiratory •May have palpitations or feel very strange
movements Chest pain, palpitations, before collapse
(floppy/stiff/jerking), SOB/wheeze, cough, sputum, leg •Cardiac history or family history of sudden
incontinence/bite tongue, swelling death
complexion (GET •May have occurred during exercise or when
CORROBORATION) Neurological supine
•After: amnesia, muscle pain, •General: fits/falls/LOC, Aortic stenosis •Collapse on exertion
confusion/sleepiness, injuries headache, dizziness, •Breathlessness worse on exertion
from fall vision/hearing, memory loss, Neurological Seizure Partial
neck stiffness/photophobia •Simple partial: focal motor seizure, no LOC
Background to attacks •Motor: weakness/wasting, •Complex partial (e.g. temporal lobe
e.g. had before, frequency, incontinence epilepsy): strange actions with impaired
impact on life •Sensory: pain, numbness, awareness
tingling Generalised
•Tonic-clonic (grand mal): sudden LOC, limbs
stiff then jerk, may become incontinent, bite
tongue, feel awful with myalgia and
confusion afterwards
•Abscent (petit mal): unresponsively stare
into space for ̴ 5 seconds (in childhood)
•Atonic: all muscles relax and drop to floor
•Tonic: all muscles become rigid
•Myoclonic: involuntary flexion
Parkinson’s disease •QUADRAD = rigidity + tremor + bradykinesia
+ postural instability
TIA/stroke •Neurological symptoms e.g. limb/face
weakness, slurred speech, hemianopia
Vasovagal •Occurs in response to stimuli e.g.
emotion/pain/fear/prolonged standing
•Preceding nausea, pallor, sweat, closing
visual fields
•Then LOC for ̴ 2 mins
Other Mechanical
differentials Mechanical fall/postural instability
Cardiovascular
Structural e.g. HOCUM, ARVD
Situation syncopies (e.g. cough syncope, effort syncope, micturition
syncope)
Carotid sinus hypersensitivity (precipitated by head turning/ shaving)
Vertebrobasilar insufficiency (elderly with cervical OA)
Neurological
Neuropathy e.g. MS
Intracranial haemorrhages (extradural, subarachnoid, subdural)
Drop attack (sudden leg weakness without warning/LOC/confusion)
Drugs
e.g. alcohol, polypharmacy
Abdominal
Ectopic pregnancy
Ruptured AAA
Misc
Delirium (secondary to infection)
Any cause of vertigo above
Anaemia
Hypoglycaemia
Eyesight problems
Arthritis

© 2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision