The art of neurological history taking and sheet formulation

1. History taking
Ahmed Dahshan MD, FEBN
Neurology lecturer
Department of neurology
Cairo university
Neurology department clinical summer course 2021

2. General rules for history taking

3. History in neurology sheet consists of:
•Personal history.
•Complaint.
•Family history.
•Past history.
•Present history.

4. Personal history
• Name. ‫ثالثي‬ ‫االسم‬
• Age (in years).
• Was born in …... and now living in …... since ….
• Occupation: ‫؟‬
‫المرض‬ ‫عشان‬ ‫هل‬ ‫؟‬ ‫ليه‬ ‫سابه‬ ‫نسال‬ ‫الزم‬ ‫شغله‬ ‫ساب‬ ‫ولو‬
• Marital status and if he has any children and age of the youngest.
• Handedness (left cerebral hemisphere is the dominant hemisphere in all Rt.
Handed individuals and 70 % of Lt. handed individuals).
• Special habits of medical importance: smoking, drinking alcohol, …. (also, asking
about ex-habits is important) + amount + duration.
• If the patient is female, ask about the following:
▪ Menstrual history.
▪ Age of menarche and menopause.
▪ Contraceptive history
▪ Obstetric history: completed labors and abortions (at which point of pregnancy
and the cause of abortion).

5. A. M. D., a male patient, 37 years old, was born and living now in
Cairo. He works as an engineer, married for 13 years now with 3 off-
springs, the youngest is 3 years old. He smokes cigarettes, 20 cigarettes/
day for 14 years now. He is Rt. Handed.

6. Complaint
• In the patient own words.
• Onset, course and duration (OCD) is a must.
• The most recent complaint is only mentioned (what brought the patient
to the hospital).
The patient is complaining of acute onset, regressive course Rt. sided
weakness of 10 days duration.

7. Family history
• Consanguinity: if +ve, to which degree.
• Similar conditions or other neurological conditions in the family.
• Pedigree: Only if
- A genetic syndrome is suspected.
- Inherited disorder as ataxia, myopathy, ….
- It should be for at least 3 generations.

9. +ve consanguinity (cousins), no similar condition or any other
neurological conditions in the family.

10. Past history
• Chronic diseases: HTN, DM, cardiac, renal, ….
• Chronic regular drug intake.
• Operations: and the course.
• Trauma or accidents.
• Blood transfusion and any complications.
• Allergies: foods, medications, ….

11. • The patient is diabetic for 5 years now, on oral hypoglycemics. He had
history of appendicectomy 3 years ago with clear perioperative history
and full recovery. He had no history of any significant trauma or blood
transfusion. There is no history of known allergy for any foods or
medications.

12. Present history
• Motor.
• Sensory.
• Cranial nerves.
• Sphincter.
• Coordination.
• Others: cognition, headache/pain, AIMs, ….
‫عالباقي‬ ‫نسال‬ ‫وبعدين‬ ‫ونحللها‬ ‫المريض‬ ‫بشكوى‬ ‫بنبتدي‬
.

13. Motor (weakness)
• OCD: Sudden (minutes), Acute (hours – days), subacute (weak – month), Chronic (> 2
months) onset.
Regressive, progressive or stationary course.
course ‫ال‬ ‫مبنقولش‬ ‫اسبوع‬ ‫من‬ ‫أقل‬ ‫الشكوى‬ ‫لو‬
• Distribution: Rt. Vs Lt., UL Vs LL, Distal Vs Proximal, Flexors Vs extensors.
• Tone: the patient felt his limb flail, stiff or neither flail nor stiff.
• Fasciculations (twitches).
• Wasting.
• Ambulance:
• Without support.
• With minimal support (unilateral support) ‫د‬ ‫واح‬ ‫شخص‬ ‫يسنده‬
•With maximum support (bilateral support) ‫شخصين‬ ‫يسنده‬
• Wheel chair bound ‫للسرير‬ ‫الكرسي‬ ‫من‬ ‫نفسه‬ ‫ينقل‬ ‫يقدر‬
•Bed ridden ‫عالسرير‬ ‫من‬ ‫نفسه‬ ‫ينقل‬ ‫ميقدرش‬
• Other limb.

14. The condition started 10 days ago with acute onset, regressive course of
weakness of Rt. U and L limbs. Such weakness was distal more than
proximal. The patient felt his limbs flail. There was no wasting or
muscle twitches. The patient is ambulant with maximal support. There
were no manifestations affecting the other side.

15. Sensory
• Superficial:
- Numbness – Abnormal sensation ‫؟‬
‫نمل‬ ‫فيه‬ ‫انه‬ ‫حاسس‬
- Diminution of sensation ‫جسمك‬ ‫في‬ ‫معين‬ ‫جزء‬ ‫فيه‬ ‫هل‬ ‫؟‬ ‫والساقع‬ ‫السخن‬ ‫بين‬ ‫الفرق‬ ‫حاسس‬
‫؟‬ ‫بيه‬ ‫مشحاسس‬
• Deep:
- Walking on sand or sponge ‫رمل‬ ‫على‬ ‫ماشي‬ ‫كأنك‬ ‫وال‬ ‫صلبة‬ ‫؟‬ ‫تحتك‬ ‫من‬ ‫االرض‬ ‫حاسس‬ ‫ازاي‬
‫؟‬ ‫اسفنج‬ ‫او‬
- Basin sign: imbalance on closing eyes ‫بايه‬ ‫تحس‬ ،‫ضلمة‬ ‫اوضة‬ ‫تخش‬ ‫او‬ ‫عينيك‬ ‫تغمض‬ ‫لما‬
‫؟‬ ‫بايه‬ ‫تحس‬ ، ‫عنيك‬ ‫وتغمض‬ ‫الصبح‬ ‫وشك‬ ‫تغسل‬ ‫بتقف‬ ‫لما‬ ‫؟‬
- L’hermite sign: electric like sensation on pending the neck ‫بتحس‬ ‫لقدام‬ ‫رقبتك‬ ‫بتتني‬ ‫لما‬
‫؟‬ ‫رقبتك‬ ‫حركة‬ ‫مع‬ ‫ظهرك‬ ‫في‬ ‫بيها‬ ‫بتحس‬ ‫زنة‬ ‫او‬ ‫كهربا‬ ‫فيه‬ ‫هل‬ ‫؟‬ ‫بايه‬

16. The condition was associated with diminution sensation involving the
Rt. Side of the body (in the same distribution of weakness). The patient
didn’t feel as if walking on sponge or lose his balance on closing eyes or
entering a dark room.

17. Cranial nerves
• Olfactory nerve ‫؟‬
‫الشم‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫فيه‬ ‫؟‬ ‫عندك‬ ‫اتغيرت‬ ‫الشم‬ ‫حاسة‬
• Optic nerve:
-Visual acuity ‫ستارة‬ ‫فيه‬ ‫؟‬ ‫ضلمت‬ ‫عينك‬ ‫؟‬ ‫ضعف‬ ‫نظرك‬ ‫؟‬ ‫النظر‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫فيه‬
‫؟‬ ‫عينيك‬ ‫قصاد‬ ‫اوغيامه‬
- Field defects ‫في‬ ‫يخبط‬ ‫دراعك‬ ‫تمشي‬ ‫ممكن‬ ‫؟‬ ‫كويس‬ ‫شايفه‬ ‫مش‬ ‫الصورة‬ ‫من‬ ‫جزء‬ ‫فيه‬
‫؟‬ ‫شايفها‬ ‫مش‬ ‫عشان‬ ‫الحيطان‬
If there is any affection → analysis: OCD, painful or not, any limitation
of ocular motility and any local eye manifestations.

18. • Oculomotor, trochlear, abducens nerves:
- Diplopia: ‫؟‬
‫اتنين‬ ‫الحاجة‬ ‫بتشوف‬
OCD.
Monocular or binocular diplopia: binocular diplopia is the significant one regarding neurology sheet.
Relation between the 2 images: beside each other or above each other.
Any associated local eye manifestations.
Aggravating and relieving factors.
Any Diurnal variation.
- Drooping of the upper eye lid: ‫؟‬ ‫ليك‬ ‫صورةقديمة‬ ‫توريني‬ ‫ممكن‬ ‫؟‬ ‫سقط‬ ‫عينك‬ ‫جفن‬ ‫ان‬ ‫حاسس‬
- Limitation of eye movement or any obvious deviation: ‫عينك‬ ‫ان‬ ‫حاسس‬
‫مظبوطة‬ ‫مش‬ ‫عينك‬ ‫حركة‬ ‫او‬ ‫حجرت‬
• Trigeminal nerve:
- Motor part: ‫؟‬
‫المضغ‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬ ‫؟‬ ‫كويس‬ ‫األكل‬ ‫بتمضغ‬
- Sensory part: ‫؟‬
‫الوجه‬ ‫في‬ ‫االحساس‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬
‫والساقع؟‬ ‫السخن‬ ‫بين‬ ‫الفرق‬ ‫تحس‬ ‫وشك‬ ‫تغسل‬ ‫لما‬
‫؟‬ ‫بسرعة‬ ‫تروح‬ ‫تيجي‬ ‫وشك‬ ‫في‬ ‫الكهرباء‬ ‫زي‬ ‫بلسه‬ ‫تحس‬ ‫ممكن‬ ‫هل‬

19. • Facial nerve:
- Motor part: ‫؟‬
‫مفتوحة‬ ‫تفضل‬ ‫وال‬ ‫نايم‬ ‫وانت‬ ‫كويس‬ ‫عينك‬ ‫تغمض‬ ‫بتعرف‬
‫؟‬ ‫كده‬ ‫قبل‬ ‫ناحية‬ ‫على‬ ‫بيتعوج‬ ‫بقك‬
‫؟‬ ‫بقك‬ ‫جنب‬ ‫من‬ ‫تنزل‬ ‫الميه‬ ‫او‬ ‫؟‬ ‫تحركة‬ ‫ومتعرفش‬ ‫خدك‬ ‫تحت‬ ‫بيتجمع‬ ‫االكل‬
- Sensory part: ‫؟‬
‫األكل‬ ‫بطعم‬ ‫االحساس‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬ ‫؟‬ ‫اتغير‬ ‫األكل‬ ‫طعم‬
• Vestibulocochlear nerve:
- Hearing: ‫؟‬
‫ودنك‬ ‫في‬ ‫وش‬ ‫او‬ ‫بصفارة‬ ‫بتحس‬ ‫او‬ ‫قل‬ ‫السمع‬ ‫؟‬ ‫السمع‬ ‫في‬ ‫مشاكب‬ ‫اي‬ ‫عندك‬
- Vertigo: ‫؟‬
‫حواليك‬ ‫بتلف‬ ‫الحيطان‬ ‫او‬ ‫بيك‬ ‫بتقلب‬ ‫الدنيا‬ ‫ان‬ ‫تحس‬ ‫او‬ ‫بدوار‬ ‫بتحس‬
• Glossopharyngeal and vagus nerves:
- Dysphagia and chocking: ‫صعوبة‬ ‫فيه‬ ‫وال‬ ‫كويس‬ ‫بتبلع‬ ‫؟‬ ‫البلع‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬ ‫فيه‬
‫؟‬ ‫تشرب‬ ‫او‬ ‫تاكل‬ ‫لما‬ ‫متكررة‬ ‫شرقة‬ ‫تشرق‬ ‫ممكن‬ ‫؟‬ ‫االكل‬ ‫وال‬ ‫اكتر‬ ‫الميه‬ ‫؟‬
- Nasal regurgitation: ‫؟‬
‫مراخيرك‬ ‫من‬ ‫ويخرج‬ ‫يشرقك‬ ‫الشرب‬ ‫او‬ ‫االكل‬
- Nasal tonation and hoarseness of voice: ‫ان‬ ‫حاسس‬ ‫؟‬ ‫اتغير‬ ‫صوتك‬ ‫ان‬ ‫حاسس‬
‫؟‬ ‫صوتك‬ ‫في‬ ‫خنفة‬ ‫فيه‬
- Dysarthria: difficulty in articulation in spite of good communication:
‫؟‬ ‫بصعوبة‬ ‫بيخرج‬ ‫او‬ ‫تقل‬ ‫الكالم‬ ‫ان‬ ‫حاسس‬ ‫؟‬ ‫الكالم‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬
• Accessory nerve ‫؟‬
‫رقبتك‬ ‫حركة‬ ‫في‬ ‫مشكلة‬ ‫اي‬ ‫فيه‬ ‫؟‬ ‫ساقطه‬ ‫كتافك‬ ‫ان‬ ‫حاسس‬
• Hypoglossal nerve ‫؟‬
‫كويس‬ ‫بقك‬ ‫في‬ ‫االكل‬ ‫تقلب‬ ‫؟‬ ‫كويس‬ ‫لسانك‬ ‫بتحرك‬

20. Coordination
• Intention kinetic tremors (AIM):
- OCD.
- Distribution: which part, distal or proximal.
- Description: static or kinetic?
- Rhythmic or dysrhythmic?
- Aggravated by and decreased by? - Relation to: action or rest, stress,
fatigue, sleep, …
- Interfering with ADL.
• Gait: ‫ناحية‬ ‫على‬ ‫تحدف‬ ‫ممكن‬ ‫تمشي‬ ‫لما‬ ‫؟‬ ‫توازن‬ ‫بعدم‬ ‫تحس‬ ‫ممكن‬ ‫هل‬ ‫؟‬ ‫ايه‬ ‫مشيتك‬ ‫اخبار‬

21. • The patient complains of AIM affecting the Rt. UL and LL that occur
on action in the form of rhythmic shaking distally which increase on
approaching the target. He also experiences unsteadiness of gait with
deviation to the Rt. on walking which is of the same onset and course
as weakness. All these interfere with his ADL.

22. Sphincter
• Precipitancy: bilateral partial gradual pyramidal tract affection.
‫منك؟‬ ‫يفلت‬ ‫والممكن‬ ‫كويس‬ ‫نفسك‬ ‫تمسك‬ ‫بتقدر‬ ‫؟‬ ‫يسبقك‬ ‫ممكن‬ ‫البول‬ ‫؟‬ ‫ايه‬ ‫البول‬ ‫في‬ ‫التحكم‬ ‫اخبار‬
‫؟‬ ‫كله‬ ‫بينزل‬ ‫وال‬ ‫نقط‬ ‫؟‬ ‫ايه‬ ‫قد‬ ‫بتنول‬ ‫اللي‬ ‫الكمية‬
‫؟‬ ‫وخالص‬ ‫كده‬ ‫مرة‬ ‫حصل‬ ‫وال‬ ‫متكرر‬ ‫ده‬ ‫الموضوع‬
• Retention: bilateral acute complete pyramidal tract affection.
‫؟‬ ‫قسطرة‬ ‫تركب‬ ‫واحتجت‬ ‫تنزله‬ ‫عارف‬ ‫ومكنتش‬ ‫كده‬ ‫قبل‬ ‫فيك‬ ‫اتحاش‬ ‫البول‬
• Hesitancy: deep sensory or posterior column affection.
‫؟‬ ‫فترة‬ ‫بعد‬ ‫قليلة‬ ‫بكمية‬ ‫وينزل‬ ،‫ينزل‬ ‫عشان‬ ‫البول‬ ‫على‬ ‫وتتحايل‬ ‫مزنوق‬ ‫بتبقى‬
• Urgency: UTI or local urinary cause.
‫؟‬ ‫وميسبقكش‬ ‫كويس‬ ‫البول‬ ‫في‬ ‫بتتكم‬ ‫لكن‬ ‫كتير‬ ‫الحمام‬ ‫وتخش‬ ‫مزنوق‬ ‫بتبقى‬
• Incontinence: no control of urination
‫؟‬ ‫فيه‬ ‫تتحكم‬ ‫ومتقدرش‬ ‫احساس‬ ‫غير‬ ‫من‬ ‫علطول‬ ‫عليك‬ ‫بينزل‬ ‫وال‬ ‫البول‬ ‫بزنقة‬ ‫بتحس‬
• Impotence: ‫؟‬
‫القذف‬ ‫او‬ ‫االنتصاب‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندنا‬ ‫هل‬ ‫؟‬ ‫ايه‬ ‫الزوجية‬ ‫العالقة‬ ‫اخبار‬

23. Others (in certain sheets)
• Pain/headache:
- OCD.
- Site and radiation.
- Character (± preceded by).
- Aggravating factors and relieving factors.
- Relation to: Posture, Coughing and sneezing, Diurnal variation.
- Association with: Vomiting/ blurring of vision, Photophobia/phonophobia.
- Response to analgesics.
- Interference with activity of daily living.
• Increase ICP:
- Headache.
- Projectile vomiting.
- Blurring of vision.
• Muscle cramps: muscle sheet.
• Sleep disturbances: initiation or maintenance, day time sleepiness, …
• Cognition.

25. Where is the lesion?
Focal
- Asymmetry.
- Level.
- Sphincteric affection.
Systemic
- Gradual progressive.
- Bilateral, symmetric.
- No level.
- No Sphincteric affection.
Disseminated
- In time.
- In space.

26. Focal …. Where?

27. What is the lesion?
Inherited, congenital or genetic etiology:
➢ Usually +ve family history.
➢ Mitochondrial: GIT troubles, myoclonus, night blindness, mental changes.
❖ Traumatic: usually history of trauma.
❖ Vascular: presence of risk factors as DM, HTN, dyslipidemia, cardiac, …
❖ Autoimmune:
➢ Vasculitis: skin rash, joint pains, renal troubles.
➢ Behcet disease: recurrent orogenital ulcers, DVT, eye troubles, post coital
bleeding.
➢ Antiphospholipid syndrome: recurrent abortions, migraine.
➢ Demyelinating disorder: dissemination in time and space (recurrent
neurological deficits).
❖ Neoplastic: bleeding tendency, bony pains, body swellings.

28. ❖ Infectious:
➢ TB: night fever, night sweating, loss of weight, loss of appetite.
➢ HIV: history of blood transfusion, travelling abroad, extramarital relations or IV drug abuse.
➢ Brucellosis: history of contact with animals or drinking unpasteurized milk.
➢ Leprosy: history of skin lesions, epistaxis.
➢ Encephalitis: fever, DCL, seizures, neck stiffness.
➢ Sarcoidosis: history of chest troubles.
❖ Metabolic:
➢ Hepatic failure.
➢ Renal failure.
➢ Porphyria: abdominal pains, seizures, psychiatric troubles.
➢ Endocrinal abnormalities:
▪ Thyrotoxicosis: heat intolerance, loss of weight (in spite of good appetite), anxiety, palpitations.
▪ Hypothyroidism: cold intolerance, weight gain, constipation, harsh voice.
▪ Cushing: truncal obesity, stria, menstrual irregularities.
Idiopathic.

29. • Scan: all the possible causes of the anatomical diagnosis.
• Filter: according to the patient history.
• Arrange: set priorities.
• Stamps: for negations.

30. Thank you
Drdahshanneuro@kasralainy.edu.eg
01016657072
drahmed.dahshan
Giza square – El Nasr Building – Floor 11