1 HPC: headache Past Medical History Precipitating factors: - - PDF document

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Neurology teaching

History taking and common presenting neurological symptoms

Agata Plonczak

Thursday Feb 21st 2013

Neurological History: symptoms

• Headache
• Fits, faints and funny turns
• Disturbance of higher mental function
• Visual, hearing disturbance
• Speech difficulties
• Dizzness
• Swallowing difficulty
• Weakness, numbness, paraesthesia
• Problems with sphincter control (bowel/bladder)

HPC: syncope

• Syncope vs pre-syncope
• Pre/peri/post-syncope history is essential and

should be supplemented by a collateral history

• Routine investigations should always include:
• ECG,
• capillary blood glucose,
• lying and standing blood pressures

HPC: syncope

• Was the onset gradual or sudden?
• How long was the LOC?
• Any recall of the events
• What was the patient doing at the time?
• Any warning symptms/aura?
• Any associated cardiac symptoms? (ie chest pain,

palpitations, nausea, sweating? Any relationsip with the use of medication (ie antihypertensives and GTN spray)

HPC: syncope

• When the patient came round were there any other

symptoms?

• Was there any tongue biting or urinary or faecal

incontinence?

• Was there any motor activity during the

unconscious episodes?

• How long did it take for the patient to feel back to

normal?

• Facial appearance: cyanosed or pale?

HPC: headache

• Character: dull, severe, sharp
• Severity
• Site
• Duration and onset: sudden vs insiduous
• Frequency
• Radiation
• Aggravating factors: early morning or after periods
• f lying down, straining at stool, laughing, coughing
• Relieving factors: analgesia

2

HPC: headache

• Precipitating factors: stress, OCP, specific foods,

alcohol

• Associated factors: nausea and vomiting,

photophobia, neck stiffness, fever, rashes, pharyngitis, cough, sputum, myalgia, arthralgia, seizures, decreased level of consciousness, coma

Past Medical History

• Any previous neurological disorder?
• Any systemic diseases, particularly cardiovascular

conditions (stroke is a very common cause of neurological deficit)

Drug History

• Consider both treatment of neurological disorders

and medication that may be causing symptoms

Family History

• Any family history of neurological disease?
• There may be important hereditary neurological

conditions such as Huntington’s chorea

• Draw a family tree if appropriate

Social history

• What are the patient’s disabilities?
• Any mobility aids?
• Where does the patients live? Do they receive any

help? What support is available to them?

• Smoking, alcohol, drug misuse?

Causes of collapse

A. Acute myocardial infarction B. Cerebrovascular accident C. Dissecting aortic aneurysm D. Drug allergy E. First-dose hypotension F. Left ventricular failure G. Ruptured Abdominal aortic aneurysm H. Stable angina I. Stokes-Adams attack J. Supraventricular tachycardia K. Vasovagal syncope L. Ventricular rupture M. Wolf-Parkinson-White syndrome 1. A 45 year old woman collapses during a church service in summer. Her hisband states that she turned pale and collapsed shortly after standing

• up. She did not jerk or lose urinary
• continence. She denies chest pain,

shortness of breath and palpitations. She recovered after 30 secs and now feels back to her usual self. All

• bservations –including blood tests,

ECG and lying and standing BP are normal

3 Causes of collapse

A. Acute myocardial infarction B. Cerebrovascular accident C. Dissecting aortic aneurysm D. Drug allergy E. First-dose hypotension F. Left ventricular failure G. Ruptured Abdominal aortic aneurysm H. Stable angina I. Stokes-Adams attack J. Supraventricular tachycardia K. Vasovagal syncope L. Ventricular rupture M. Wolf-Parkinson-White syndrome 1. A 25 year old woman collapses suddenly while visiting her grandmother in hospital. There appears to be no pulse. The crash team is called and manage to resuscitate her after identifying ventricular fibrillation on the cardiac

• monitor. The attending anaesthetist

records a repeat ECG and notes that the QRS complexes are broad with slurred upstroke of R wave

Causes of collapse

A. Acute myocardial infarction B. Cerebrovascular accident C. Dissecting aortic aneurysm D. Drug allergy E. First-dose hypotension F. Left ventricular failure G. Ruptured Abdominal aortic aneurysm H. Stable angina I. Stokes-Adams attack J. Supraventricular tachycardia K. Vasovagal syncope L. Ventricular rupture M. Wolf-Parkinson-White syndrome 1. A 75 year old woman is brought to the A&E department after collapsing. On examination, her heart rate is 80 bpm and irregular with a BP of 150/90

• mmHg. She has difficulty moving her

arm and leg .

Causes of collapse

A. Acute myocardial infarction B. Cerebrovascular accident C. Dissecting aortic aneurysm D. Drug allergy E. First-dose hypotension F. Left ventricular failure G. Ruptured Abdominal aortic aneurysm H. Stable angina I. Stokes-Adams attack J. Supraventricular tachycardia K. Vasovagal syncope L. Ventricular rupture M. Wolf-Parkinson-White syndrome 1. A 67 year old man presents to the emergency department follwing a

• collapse. He has a history of ishaemic

heart disease with hypertension diagnosed only last week. He remembers feeling dizzy when he got

• ut of his chair to go to the toilet before
• fainting. He regained consciousness

almost immediately and had fully recovered within 5 minutes.

Causes of collapse

A. Acute myocardial infarction B. Cerebrovascular accident C. Dissecting aortic aneurysm D. Drug allergy E. First-dose hypotension F. Left ventricular failure G. Ruptured Abdominal aortic aneurysm H. Stable angina I. Stokes-Adams attack J. Supraventricular tachycardia K. Vasovagal syncope L. Ventricular rupture M. Wolf-Parkinson-White syndrome 1. A 57 year old man is found collapsed at work. On arrival at the emergency department, he is complaining of mild epigastric discomfort that started at

• rest. He appears pale and sweaty and

has vomited once. He is on insulin for type 1 diabetes mellitus.

2- Seizures

A. Anoxic seizure B. Complex partial seizure C. Febrile convulsions D. Nacrolepsy E. Partial motor seizure F. Partial sensory seizure G. Pseudo-seizure H. Status epilepticus I. Tonic-clonic seizure J. Tonic seizure K. Versive seizure 1. A 14 year old boy is playing football at school when he suddenly falls to the

• floor. Soon after, his friends notice him

jerking around and unresponsive. During the episode, he is incontinent of urine and starts bleeding from his

• mouth. When the boy finally regains

consciousness he is confised and sleepy.

2- Seizures

A. Anoxic seizure B. Complex partial seizure C. Febrile convulsions D. Nacrolepsy E. Partial motor seizure F. Partial sensory seizure G. Pseudo-seizure H. Status epilepticus I. Tonic-clonic seizure J. Tonic seizure K. Versive seizure 1. A 36 year old woman is found on the street having a fit by passers-by. They stand close until she finished fitting, and then try to rouse her. Before she regains consciousness, she starts having another seizure. By the time the ambulance arrives 10 minutes later, she is still fitting.

4 2- Seizures

A. Anoxic seizure B. Complex partial seizure C. Febrile convulsions D. Nacrolepsy E. Partial motor seizure F. Partial sensory seizure G. Pseudo-seizure H. Status epilepticus I. Tonic-clonic seizure J. Tonic seizure K. Versive seizure 1. A 19 year old man attends the univeristy GP with sleep problems. He finds that he falls asleep multiple times during the day, including during small group seminars. On two occassions, he also experienced sudden collapses –both when he was laughing. His friends say that he was not incontinent

• f urine during these episodes, nor did

he bite his tongue.

2- Seizures

A. Anoxic seizure B. Complex partial seizure C. Febrile convulsions D. Nacrolepsy E. Partial motor seizure F. Partial sensory seizure G. Pseudo-seizure H. Status epilepticus I. Tonic-clonic seizure J. Tonic seizure K. Versive seizure 1. A 21 year old woman is sitting in the pub with friends. At one point, her friends notice that she is staring blankly into space, licking her lips. She remains sitting in her chair and at no point does she begin fitting. After a few minutes she returns to normal. She denies being aware of what happened.

2- Seizures

A. Anoxic seizure B. Complex partial seizure C. Febrile convulsions D. Nacrolepsy E. Partial motor seizure F. Partial sensory seizure G. Pseudo-seizure H. Status epilepticus I. Tonic-clonic seizure J. Tonic seizure K. Versive seizure 1. A 3 year old girl is brought to the emergency department after having a

• fit. She has no history of epilepsy and

is on no medication. The seisure lasted 5 minutes. She is very hot to touch and you notice an inflamed left ear drum. Her father says she has been pulling her ear all day.

3- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 32 year old man presents to the emergency department with a sudden

• nset severe occipital headache. It

started 1 hour ago and is accompanied by vomiting. He has a history of polycystic kidney disease. On examination he has a stiff neck.

3- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 45 year old man presents to his GP with a 3-week history of severe

• headaches. The headaches have
• ccurred at the same time each day –

around 2 am and last around 30 mins. Headaches are accompanied by lacrimation and redness of the right eye.

3- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 62 year old woman presents with intermittent scalp pain. She says the pain is specifically on the left side at the front and is worse when she is touching the area. She has no medical

• history. She is very tender over the

affected area. Examination is

• therwise unremarkable.

5 3- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. An 18 year old woman presents with a 6-month history of intermittent

• headaches. She describes these as

throbbing and on the left side. The headaches are accompanied by vomiting and she occasionally sees flashing lights in her visual field.

3- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 24 year old woman presents to GP with a 4 month history of headaches. These are intermittent and are frequently accompanied by blurring of

• vision. She is otherwise well.

Fundoscopy shows bilateral papilloedema.

4- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 52 year old woman presents to GP with a 2 month history of worsening

• headaches. The headaches are worse

in the morning, and are exacerbated by coughing and laughing. More recently she has been complaining of nausea and blurred vision

4- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 64 year old woman presents to A&E with malaise and left-sided headache that has been getting worse over the last 24 hours. She also complains of some pains in her shoulders. On examination she is tender over the left side of her head. Fundoscopy is normal.

4- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 34 year old man presents with a 6 month history of dull, generalised

• headache. He says it feels as if

someone is pressing on his head. He denies nausea, visual disturbance, or focal neurological signs.

4- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 17 year old girl presents with a 1 week history of headache and pain in her face that is worse of coughing. She is worried about failing her advanced A-level modules, as she already had 2 weeks off school with a cold. On examination she is tender over her left

• cheek. Fundoscopy is unremarkable.

6 4- Headache

A. Cluster headache B. Coitus-induced headache C. Gient cell arteritis D. Ice-cream headache E. Idiopathic intracranial hypertension F. Meningitis G. Migraine H. Saggital sinus thrombosis I. Sinusitis J. Space-occupying lesion K. Subarachnoid haemorrhage L. Tension headache M. Trigeminal neuralgia 1. A 32 year old woman presents to A&E with a sudden onset frontal headache and vomiting. Fundoscopy shows bilateral papilloedema, but examination is otherwise

• unremarkable. She has no significant

PMH and takes the OCP. While in the depaertment she has a seizure. .