CNS History Taking & Neurological Exam Guide OmpathStudy

CNS History Taking & Physical Examination 1. INTRODUCTION — NEUROLOGICAL TERMS Anatomical hierarchy (cortex → basal ganglia → cerebellum → brain stem → spinal cord → nerve root → plexus → cauda equina → nerve → neuromuscular junction → muscle) Suffix conventions -opathy = abnormality at the level of the nervous system named in the prefix -itis = inflammation at that level Term Meaning --- --- Encephalopathy Abnormality of the brain — focal/diffuse, metabolic/toxic Encephalitis Inflammation of the brain (focal or diffuse) Meningoencephalitis Inflammation of brain + meninges Meningitis Inflammation of the meninges Myelopathy Abnormality of spinal cord (e.g., radiation, compressive) Myelitis Inflammation of the spinal cord Radiculopathy Abnormality of a nerve root Plexopathy Abnormality of a nerve plexus (brachial/lumbar) Peripheral neuropathy Abnormality of peripheral nerves Polyradiculopathy Abnormality of many nerve roots Polyneuropathy Similar to peripheral neuropathy; contrasts with polyradiculopathy Mononeuropathy Abnormality of a single nerve Myopathy Abnormality of muscle Myositis Inflammatory disorder of muscle Functional (1) Non-structural abnormality of function, e.g. migraine; (2) psychiatrically-induced neurological abnormality, e.g. hysterical conversion --- 2. HISTORY Structure — most important part of the neurological evaluation 1. Age, sex, handedness, occupation 2. History of present complaint 3. Neurological screening questions 4. Past medical history 5. Drug history 6. Family history 7. Social history Key principle — for attacks of loss of consciousness or memory impairment, always take history from both patient and bystanders/witnesses if possible. Most common causes of reduced consciousness/awareness attacks: neurocardiogenic (vasovagal) syncope, epilepsy . Neurological symptoms (screening list) Cognitive symptoms (esp. memory impairment) · headache · loss of awareness/consciousness · altered perception (incl. déjà vu) · dizziness/vertigo · loss of balance · falls · loss of smell/taste/vision · positive visual symptoms (migraine aura components, hallucinations) · double vision · polyopia/palinopsia · oscillopsia · deafness · tinnitus · difficulty with speech/swallowing · weakness · abnormal muscle movements (cramp, fasciculations) · abnormal body movements (tremor, dystonia, myoclonus) · clumsiness · impaired limb control · altered/loss of sensation · pain · postural hypotension symptoms · sexual dysfunction · bladder/bowel impairment Presenting complaint — approach Let the patient tell their story with minimal interruption Clarify vague terms precisely: "dizziness" — vertigo (spinning) or lightheadedness? "Numbness" — weakness or loss of sensation? "Blurred vision" — double vision or dim/hazy vision? Time course → pathological process (key exam concept) Onset pattern Suggests --- --- Sudden/acute Vascular Subacute Inflammation, infection, or neoplasia Progressive Neoplasia or degenerative Stepwise/stuttering Vascular or inflammatory Relapsing–remitting Inflammatory Tempo of pathological processes (onset timescale by category) Seconds–minutes : vascular, epileptic Minutes–hours : migrainous Days–weeks : inflammatory, infective Weeks–months : neoplastic Months–years : degenerative, genetic Present since birth : congenital (Note: late vascular problems, e.g. chronic subdural haematoma, can present at the weeks mark — exception to typical vascular tempo) Worked example — 50-year-old man, complete right eye visual loss Time course Diagnosis --- --- Sudden, lasted 1 min Optic nerve compression (e.g. meningioma) Over 10 min, lasted 20 min Optic neuritis (inflammatory) Over 4 days, improved over 6 weeks Amaurosis fugax (vascular — impaired retinal blood flow) Progressed over 3 months Migrainous Worked example — 65-year-old woman, left face/arm/leg weakness Time course Diagnosis --- --- Since childhood Congenital Sudden, lasted 10 min TIA (vascular) Over 10 min, persists days Stroke (vascular) Over 4 weeks Likely tumour Over 4 months Consider subdural haematoma History of Present Illness (HPI) — components Precipitating/relieving factors Spontaneously reported symptoms carry more diagnostic weight than those elicited by direct questioning Previous treatments/investigations — benefit or adverse effects Current neurological state — what can the patient do now, relative to normal daily activities Hypothesis generation and testing while listening Screening for other neurological symptoms: headaches, fits, faints, blackouts, numbness/tingling/weakness, sphincter disturbance (urinary/faecal incontinence, retention, constipation), visual symptoms Always close with an open question: "Is there anything else you wanted to tell me about?" Diagnostic reasoning flow : Interpret symptoms → determine time course → generate hypothesis/differential → test hypothesis + ask about associated features/risk factors → neurological screening history → assess impact on life/work/family → conventional background history (