Neurological History Taking 2024 PDF

20 24 25 Neurological History taking Dr Emer O’Brien Clinical Lecturer Department of General Practice Presented by Dr. Abeer Khalaf Family Medicine Lecturer RCSI Bahrain ‘All the most acute, most powerful, and most deadly diseases, and those which are most difficult to be understood b...

20 24 25 Neurological History taking Dr Emer O’Brien Clinical Lecturer Department of General Practice Presented by Dr. Abeer Khalaf Family Medicine Lecturer RCSI Bahrain ‘All the most acute, most powerful, and most deadly diseases, and those which are most difficult to be understood by the inexperienced, fall upon the brain’ Hippocrates (circa 400 BC) MODULE LEARNING OUTCOMES Describe the development, structure and function of the healthy central nervous system Use effective strategies (e.g. communication, collaboration, interventions) as part of a multidisciplinary and interprofessional team to manage patients and populations with common or important central nervous system conditions Display high-quality communication with patients utilising a range of communication frameworks and approaches Identify the key elements of performing a Central Nervous System history Demonstrate the basic principles in conducting a structured history and physical examination of the central nervous system Demonstrate the application of professionalism, leadership and resilience (i.e. the constructs of Personal and Professional Identity) to manage self and engage with patients, colleagues and communities in the context of dealing with CNS conditions. Describe the normal molecular, cellular and biochemical functions in the healthy CNS system Explain the pathological and immunological processes underlying CNS diseases Outline the characteristics of the major groups of microorganisms that play important roles in the development of CNS diseases Describe the epidemiology, aetiology, pathogenesis, pathological appearances, clinical manifestations, complications and prognosis of common or important diseases Discuss the scientific basis, selection and interpretation of appropriate diagnostic investigations for CNS diseases Use an evidence-based approach to choose the appropriate medicines to manage common or important CNS diseases and describe the mechanism of action of those medicines and their adverse effects Describe the primary and secondary prevention of common or important CNS diseases at individual and population health levels with reference to healthcare systems and service LEARNING OUTCOMES Describe the Calgary Cambridge consultation model for communicating within the consultation Describe the formal structure of history taking as it applies to the neurological system Be aware of the patient’s ideas, concerns and expectations throughout the consultation Demonstrate how to take a neurological history Demonstrate how to take a specific headache and seizure history DURING EVERY INTERACTION Be respectful Be present Be professional Be kind Do not judge COMMUNICATION SKILLS Calgary Cambridge Consultation Model: Summary Initiating the session Gathering information Physical Examination Providing structure Building relationship (Explanation and planning) (Closing the session) HISTORY TAKING SEQUENCE Introduction and Consent Presenting Complaint Initiating the History of Presenting Complaint Session Past History - Medical History, Surgical History Medications Allergies Gathering Social History Information Family History Systems Review Summary Differential Diagnosis Management Plan PRESENTING COMPLAINT The main symptom the patient presents with Headache Neck/Back pain Fits/Faints/Funny turns Dizziness or Vertigo Disturbance of hearing, vision or smell Disturbance of gait Disturbed sensation Change or loss of power Disturbance of sphincter control (bladder or bowel) Involuntary movements or tremor Speech and swallow disturbance Altered cognition A patient may have more than one symptom. Important to ask which symptom(s) brought them to see you this time. HISTORY OF PRESENTING COMPLAINT Temporal course of illness important in taking neurological history as it gives clues to underlying aetiology Time course Acute (mins to hours) vascular or convulsive/seizure Subacute (hours to days ) inflammatory disorders or infection (meningitis, cerebral abscess) Chronic tumour (weeks to months) degenerative (mths to years) Distribution Localised versus Diffuse Level of involvement of the nervous system peripheral nervous system, spinal cord, posterior fossa, or cerebral hemispheres Remembering Previous neurological symptoms Previous neurological diagnosis HISTORY OF PRESENTING COMPLAINT Headache is a very common symptom → as with any pain important to determine SOCRATES But remember open questions ‘do you want to tell me more about this headache?’ OR ‘What is it like? Followed by more specific closed questions Did it come on suddenly? How severe was it? How severe is it? How long does it last? Do you get a warning (aura) before it starts? Flashing lights, zig zag lines? Is it associated with sensitivity to light? HISTORY OF PRESENTING COMPLAINT (closed questions continued) Do you feel drowsy or nauseated with the headache? Is the pain on one side over the temple and do you have blurred vision with it? Is the pain worse over your cheek bones? Do the attacks occur in clusters and cause watering of one eye? Is there a prolonged period of tightness around the head but with no other symptoms? Did you drink large amounts of alcohol last night?  HISTORY OF PRESENTING COMPLAINT Types of Headache Classical migraine unilateral headache preceded by flashing lights or zig zag lines and associated with photophobia Meningitis generalised headache associated with neck stiffness, fever and photophobia Subarachnoid haemorrhage dramatic instantaneous and severe Raised intracranial pressure generalised headache worse in morning associated with drowsiness and vomiting Tension type headache bilateral, occurs over the frontal, temporal or occipital area and described as sensation of tightness that lasts for hours and recurS often HISTORY OF PRESENTING COMPLAINT Red Flag symptoms of headache Early morning headache Seizures Vomiting Drowsiness Progressive neurological deficit Change in mental status Requires urgent referral HISTORY OF PRESENTING COMPLAINT Fits, Faints and Funny turns Patient may present with history of collapse with or without loss of consciousness Important to get a clear picture of what happened, what the patient felt and a collateral history of how the event looked from a witness Collapse seizure activity cardiac causes simple faint to differentiate between them…. HISTORY OF PRESENTING COMPLAINT Was event witnessed and is witness available? Was there genuine loss of consciousness? Where/when/how event happened? Length of LOC? Any trauma sustained? Any symptoms prior to event? Lightheadedness, headache, palpitations, nausea or any other prodrome? Symptoms during event? Witness description of patients colour, shaking/jerking, tongue biting or incontinence. Symptoms following the event? How long was recovery? Any amnesia/confusion/drowsiness? Any vomiting/speech difficulty or limb weakness? Any history of similar episodes? Previous diagnosis of epilepsy or previous head injury? HISTORY OF PRESENTING COMPLAINT Seizures Generalised tonic clonic seizures (grand mal) abrupt LOC which may be preceded by aura (warning symptom, unusual smell, taste, noise or visual disturbance) may have incontinence of urine and/or faeces and tongue may be bitten Partial seizure only one side of body involved if consciousness impaired = complex partial or unimpaired = simple seizures Recovery slow with post ictal phase of drowsiness and confusion Idiopathic absence seizures (petit mal) occur in children, frequent, brief loss of awareness, usually associated with staring. PAST HISTORY: PAST MEDICAL HISTORY (PMH)/PAST SURGICAL HISTORY (PSH) PAST HISTORY: PAST MEDICAL HISTORY (PMH)/PAST SURGICAL HISTORY (PSH) Open Questions How is your health generally? Do you have any known medical conditions? Are you attending a doctor, clinic regularly? Have you had any previous operations? Any investigations done in hospital? Any previous neurological problems? Closed Questions Do you have high blood pressure/high cholesterol/heart disease? previous stroke/transient ischemic attack/atrial fibrillation/ haematological disease? diabetes? epilepsy? bacterial endocarditis? MEDICATIONS MEDICATIONS Current medications Prescribed or over the counter (OTC) Herbal remedies (recreational drug use, only if appropriate to this consultation) List of medication what are they for? when prescribed? compliance? tolerated/side effects? ALLERGIES Any known allergies to medication latex Extent of allergy what happened when exposed? E.g. nausea/vomiting/ rash/swelling mild reaction versus anaphylaxis SOCIAL HISTORY SOCIAL HISTORY Home who do you live with, partner/parents? do you have any dependents/children? do you have good support from family and friends/neighbours? Occupation stressful, sedentary, how do you manage work/life balance Hobbies sport, how much exercise/week others SOCIAL HISTORY Smoking History do you smoke AND have you ever smoked? how many, for how long? one pack year = 20 cigarettes/day/1 year Alcohol History do you drink alcohol? would you drink everyday? how much, how often? 11 units/week female, 17 units/week male FAMILY HISTORY Parents/Siblings living or deceased chronic conditions Any known conditions that run in family? e.g. Huntington’s chorea Any conditions that can occur frequently in families? E.g. Alzheimer’s disease LEARNING OUTCOMES Describe the Calgary Cambridge consultation model for communicating within the consultation Describe the formal structure of history taking as it applies to the neurological system Be aware of the patient’s ideas, concerns and expectations throughout the consultation Demonstrate how to take a neurological history MODULE LEARNING OUTCOMES Describe the development, structure and function of the healthy central nervous system Use effective strategies (e.g. communication, collaboration, interventions) as part of a multidisciplinary and interprofessional team to manage patients and populations with common or important central nervous system conditions Display high-quality communication with patients utilising a range of communication frameworks and approaches Identify the key elements of performing a Central Nervous System history Demonstrate the basic principles in conducting a structured history and physical examination of the central nervous system Demonstrate the application of professionalism, leadership and resilience (i.e. the constructs of Personal and Professional Identity) to manage self and engage with patients, colleagues and communities in the context of dealing with CNS conditions. Describe the normal molecular, cellular and biochemical functions in the healthy CNS system Explain the pathological and immunological processes underlying CNS diseases Outline the characteristics of the major groups of microorganisms that play important roles in the development of CNS diseases Describe the epidemiology, aetiology, pathogenesis, pathological appearances, clinical manifestations, complications and prognosis of common or important diseases Discuss the scientific basis, selection and interpretation of appropriate diagnostic investigations for CNS diseases Use an evidence-based approach to choose the appropriate medicines to manage common or important CNS diseases and describe the mechanism of action of those medicines and their adverse effects Describe the primary and secondary prevention of common or important CNS diseases at individual and population health levels with reference to healthcare systems and service