Neurological history taking

1. Neurological history taking
Dr Mohamed Rizk Khodair
Lecturer of neurology
October 6 university
Mohamedrizk.med@edu.edu.eg

2. Aim
The neurologic history and screening examination when performed in a systematic manner provides the clinician with
the necessary data to make management decisions.

3. Agenda
• Introduction
• Personal history
• Complaints and its duration
• History of present illness
• Past history
• Family history

4. Introduction:
• The history is the most important part of the neurological assessment.
• The student should aim to be a good listener showing interest and sympathy as the patient’s story unfolds.
• It is important to get the patient’s trust and confidence.
• First introduce yourself to the patient, explain who you are and ask permission to take a history and to
carry out an examination.
• Make patient at ease : introduce yourself, exchange social pleasantries , secure privacy .
• Be friendly , attentive , courteous ( don’t haste or stereotype)
• Analyze and inquire about significant symptoms , minimize irrelevancies
• Modify your approach according to pts personality , age , education , culture and sex.
• Some clinical findings are apparent to the examiner during history taking; these include general state of
health and obvious neurological deficits and disabilities.
• If there is alteration in the level of consciousness or the patient is unable to give a history, then it may be
necessary to obtain a history and witnessed account from a relative or friend before proceeding directly to
neurological examination
• Some clinical findings are apparent to the examiner during history taking; these include general state of health
and obvious neurological deficits and disabilities.
• in some neurological disorders , it is the only key to diagnosis ( epilepsy and migraine)

5. What is the
Lesion?
Where is
the Lesion?

6. What is the Lesion?
V Vascular
I Infectious
T Trauma
A Autoimmune
M Metabolic & Toxic
I Iatrogenic & Inflammatory
N Neoplastic
C Congenital/Familial
D Degenerative
E Epileptic
F Functional

7. Where Is the Lesion?
A. Central nervous system:
Cranial:
1. Cerebral: (Right # left, Which lobe? Cortical
#subcortical)
2. Cerebellar:
3. Brain stem:
Spinal: (Intramedullary # Extra medullary)
B. Peripheral nervous system:
Roots
Nerves
NMJ
Muscles

8. Components
1. Personal history
2. Complaint
3. Present history
4. Past history
5. Family history

9. KEY POINTS IN A NEUROLOGICAL HISTORY
Personal history
Name, age, sex, occupation, handedness, marital status and no. of siblings, residence, special habits, and history of the
use of contraceptive pills, menstrual history ( age , regulatory , duration , flow , pain ).
 Age: certain diseases are commonly related to age as:
-Demyelinating diseases in early and middle adulthood.
-Degenerative diseases and cerebrovascular diseases in late adulthood and elderly.
 Sex: some diseases are common for each sex as:
- Myasthenia gravis and migraine are common in females.
- Myotonia atrophica and cerebrovascular stroke are common in males.
 Marital status & number of siblings.
 Occupation: Some diseases related to certain occupation as:
- Parkinsonism in manganese miners.
- Some occupations are avoided in epileptic patients.

10.  Occupation: Some diseases related to certain occupation as:
- Parkinsonism in manganese miners.
- Some occupations are avoided in epileptic patients.
 Residence: some diseases are common in certain areas as:
-Demyelinating diseases are common in Northern countries.
-Meningitis is common in tropical areas.
 Special Habits:
- Smoking: smoking index= number of cigarettes/days × years of smoking
- Alcohol and Drug addiction
- Cerebrovascular diseases are common in smokers and in those who are drug adductors.
 Contraceptive methods:
- Benign increased intracranial tension and venous stroke are common in females receiving oral contraceptive pills.
 Handedness:
Right or left-handed to determine the dominant hemisphere.

11. Personal History & Chief Complaint
Male patient Mr. Mohamed is 26 years old worker , married , has 3 offspring
the youngest one is 3 years old ; he is smoker with no other special habit of
medical important , right-handed Caucasian gentleman presented to the OPC
complains of heavness of right side 2 months ago,

12. Complaint and its duration
 Asking the patient to state what the problems are and the reason for Hospital
admission or referral.
 This could begin with open questions such as “what is the main problem" or “tell me
about it from the start”.
 Determine the order of the presenting complaints, These should ideally not
number more than three or four and be in order of importance. if more than one event?!
Most recent
 Write in the patient's words.

13. Examples
• Weakness or heaviness in limbs
• Difficulty walking
• Pins and needles or numbness in arms, legs or body
• Change in mood, memory, concentration or sleep
• Pain, headache, face or limbs·
• Loss of consciousness or dizzy spells
• Loss of vision or double vision
• loss of hearing or balance
• Difficulty speaking or swallowing
• Difficulty with passing urine, bowels and sexual function

14. HISTORY OF PRESENTING ILLNESS
A) Ask the patient to describe (of each main complaint)
Ask the patient to describe (of each main complaint)
• Onset duration between 1st symptom till complete
clinical picture (sudden, acute, rapid, subacute,
gradual):
1- Sudden  over seconds or minutes (as stroke,
trauma)
2- Acute  over hours (as vascular, inflammatory)
3- Subacute or rapid --- over days to weeks (as
inflammatory, demyelinating)
4- Gradual  over months to years (as neoplastic,
degenerative)
• Progress (course) behavior of the disease
1. Regressive  (towards improvement)(as trauma,
vascular, inflammatory, demyelinating)
2- Stationary  (as inflammatory, trauma, vascular)
3- Remittent (as demyelinating, vascular)
4- Progressive  (as neoplasm, degenerative)
5- intermittent ( epilepsy and migraine)
• Duration,
• Site & Side

15. B) Analysis of symptoms
1. Symptoms suggestive of motor system affection
2. Symptoms suggestive of increased intracranial tension
3. Symptoms suggestive of cranial nerve affection
4. Symptoms suggestive of sensory system affection
5. Symptoms suggestive of sphincteric disturbances
6. Symptoms of Higher brain functions disturbance.
7. Meningeal and stretch symptoms.
8. Symptoms suggesting of Epilepsy, headache, others.
9. Other systems manifestation.

16. Motor system
• OCD
• Distribution : Uni/bilateral
symmetrical/ asymmetrical
distal/proximal
flexor/extensor
simultaneous/ sequential
• Discrimination : UMN/LMN (early wasting , fasciculation, flail/stiff)
• Degree of severity (ambulation) :
I. Ambulant without support
II. Ambulant with minimum support
III. Ambulant with maximum support
IV. Wheelchair
V. Bedridden
Weakness Involuntary movements Incoordination
Weakness
analysis
Onset Course Duration Character Distribution

17. Identify presence of weakness or paralysis ‫بضعف‬ ‫حاسس‬
(
‫ثقل‬
)
‫؟‬ ‫الحركة‬ ‫في‬
Distribution :
‫شمال‬ ‫وال‬ ‫يمين‬ ‫واحدة‬ ‫ناحية‬ ‫في‬
,
‫االثنين‬ ‫وال‬ ‫ساق‬ ‫وال‬ ‫ذراع‬
‫الثانية‬ ‫من‬ ‫اكتر‬ ‫ناحية‬ ‫فيه‬ ‫وال‬ ‫الدرجة‬ ‫نفس‬
‫فتح‬ ‫في‬ ‫صعوبه‬ ‫في‬
,
‫بالمفتاح‬ ‫الباب‬ ‫فتح‬ ‫او‬ ‫مياة‬ ‫زجاجة‬ ‫قفل‬
‫تقيله‬ ‫حاجة‬ ‫شيل‬ ‫او‬ ‫الشعر‬ ‫تسريح‬ ‫في‬ ‫صعوبه‬ ‫فيه‬
‫تسند‬ ‫ما‬ ‫غير‬ ‫من‬ ‫الكرسي‬ ‫على‬ ‫من‬ ‫تقوم‬ ‫لما‬ ‫اكتر‬ ‫الضعف‬
,
‫السلم‬ ‫تطلع‬
‫رجلك‬ ‫من‬ ‫يفلت‬ ‫الشبشب‬
Discrimination:
‫بتشوفها‬ ‫او‬ ‫بيها‬ ‫بتحس‬ ‫العضالت‬ ‫في‬ ‫رفه‬ ‫فيه‬ ‫وهل‬ ‫خسيت‬ ‫عضالتك‬ ‫ان‬ ‫الحظت‬
‫متخشب‬ ‫وال‬ ‫سايب‬ ‫جسمك‬ ‫ان‬ ‫حاسس‬
‫االتنين‬ ‫وال‬ ‫واحدة‬ ‫ناحية‬
Degree of severity :
‫يساعدك‬ ‫حد‬ ‫محتاج‬ ‫وال‬ ‫لوحدك‬ ‫تمشي‬ ‫تقدر‬

18. Coordination
• UL : intention tremors : increase on reaching target (key to locker , spoon to mouth ) , difficult
buttoning
• LL : clumsiness , staggering , wide base gait
• Dysarthria : staccato
Cerebellar Ataxia (Cerebellum) Sensory Ataxia (Deep Sensation)
Upper limb Lower limb Upper limb Lower limb
Upper limb is affected
lately → tremors
during eating.
‫المعلقة‬ ‫تاكل‬ ‫تيجي‬ ‫لما‬
‫بترتعش؟‬
Lower limb is
early affected
→ staggering
gait.
‫بتمشي؟‬ ‫وانت‬ ‫بتطوح‬
‫البدلة؟‬ ‫زرار‬ ‫تقفل‬ ‫بتعرف‬
‫الف‬ ‫سوسته‬ ‫تقفلي‬ ‫بتعرفي‬
‫ستان؟‬
Falling when eyes
are closed,
‫بتغسل‬ ‫وانت‬ ‫عينيك‬ ‫غمضت‬ ‫لو‬
‫وشك‬
,
‫بتقع؟‬

19. Abnormal movement :
• slow or fast
• regular or irregular
• postural / twisting / pseudopuposeful stereotype or not
• hypertonia or hypotonia
• increase or decrease by
• uni or bilateral
• association
Involuntary
movements
analysis
Onset Course Duration Character Distribution

20. Weakness (paresis) or paralysis

21. The physical exam findings correlating with location of lesion
UMN dysfunction LMN dysfunction NMJ dysfunction Muscle dysfunction
• Increased muscle
tone
(spasticity/rigidity)
• Increased muscle
stretch reflex
(hyperreflexia)
• Extensor plantar
reflex (positive
Babinski’s sign)
• Decreased muscle
tone (flaccidity)
• Decreased muscle
stretch reflex
(hyporeflexia)
• Flexor plantar
reflex (absent
Babinski’s sign)
• Fluctuating
weakness
• Worsening
weakness with
repeated activity
(fatiguability)
• +/− Decreased
muscle tone
• Proximal muscles
are most
commonly
involved
• +/− Decreased
muscle tone

22. UMN VS LMN
Upper Motor Neuron Lower Motor Neuron
Mild-moderate weakness Severe weakness
Spastic tone Flaccid tone
Minimal disuse atrophy Marked muscular atrophy
Hyperreflexia Reduced or absent reflexes
Pathological Babinski sign No Babinski sign
Clonus may be present No clonus
No fasciculations Fasciculations

23. Example
The condition started 2ws ago when the patient experienced acute onset , regressive course of
weakness of RT UL and LL , such weakness was Distal >Proximal , the patient felt his limbs neither
flail or stiff , there were no fasciculation , no wasting , no manifestation as regard the other limbs, and
at the onset the patient was ambulant with maximum support and now he is ambulant without
support

24. Sensory
• OCD
• Distribution : Uni/bilateral
symmetrical/ asymmetrical
simultaneous/ sequential
extent (glove and stock / dermatomal sensory/ hemi)
• Discrimination :
• Superficial : +ve : paresthesia , hyperesthesia , allodynia , pricking , burning and electrical
-ve :hypo/ anesthesia
• Deep : +ve Romberg ,walk on sponge
• Cortical sensation

25. ‫االحساس‬ ‫في‬ ‫تغيير‬ ‫الحظت‬
hypoesthesia
‫قل‬ ‫احساس‬
‫والبارد‬ ‫بالسخن‬ ‫بتحس‬
Hyperesthesia
‫بااللم‬ ‫زائد‬ ‫احساس‬ ‫فيه‬
Paresthesia :
‫؟‬ ‫سبب‬ ‫اي‬ ‫غير‬ ‫من‬ ‫كهرباء‬ ‫او‬ ‫حرقان‬ ‫او‬ ‫بشكشة‬ ‫احساس‬
‫شمال‬ ‫وال‬ ‫يمين‬ ‫واحدة‬ ‫ناحية‬ ‫في‬
,
‫االثنين‬ ‫وال‬ ‫ساق‬ ‫وال‬ ‫ذراع‬
‫الثانية‬ ‫من‬ ‫اكتر‬ ‫ناحية‬ ‫فيه‬ ‫وال‬ ‫الدرجة‬ ‫نفس‬
‫لفين‬ ‫وصل‬ ‫ده‬ ‫التاثر‬
,
‫؟‬ ‫محزمك‬ ‫الجسماو‬ ‫نصف‬ ‫واخد‬
Deep :
‫تقع‬ ‫ممكن‬
,
‫؟‬ ‫الصبح‬ ‫وشك‬ ‫تغسل‬ ‫لما‬ ‫او‬ ‫عينيكو‬ ‫تقفل‬ ‫ما‬ ‫اول‬ ‫تتطوح‬
‫اسفنج‬ ‫او‬ ‫رمل‬ ‫على‬ ‫ماشي‬ ‫كانك‬ ‫وال‬ ‫صلبة‬ ‫رجلك‬ ‫تحت‬ ‫االرض‬
‫؟‬ ‫رقبتك‬ ‫تتني‬ ‫لما‬ ‫فجاءة‬ ‫بكهرباء‬ ‫بتحس‬
!
Cortical sensation :
‫جيباك‬ ‫في‬ ‫وهو‬ ‫المفتاح‬ ‫تعرف‬

26. example
The condition was also associated with diminution of sensation ( tingling and numbness ) involving
right side of the body
The patient loses his balance on closure his eyes or on entering a dark room
The patient is feeling the ground underneath as if sponge

28. Cranial nerves
• Olfactory : decrease or altered smell, olfactory hallucination
• Optic : -ve : decrease vision , scotomas +ve : flashes , unformed or formed
hallucination
• Occulomotor , trochlear , abducent : ptosis , diplopia , oscillopsia
• Trigeminal : altered sensation / pain in face , weak mastication
• Facial : decrease facial muscle eye closure
• Vestibulocochlear : decrease hearing , tinnitus , vertigo , unsteadiness
• Glossophrangeal , vagus , accessory nerve , hypoglossal : dysphagia , dysarthia ,
dysphonia

29. Olfactory nerve
‫؟‬ ‫عندك‬ ‫قلة‬ ‫الشم‬ ‫حاسة‬
‫؟‬ ‫ايه‬ ‫قد‬ ‫لفترة‬ ‫؟‬ ‫شممها‬ ‫غيرك‬ ‫ماحدش‬ ‫؟‬ ‫وحشة‬ ‫روائح‬ ‫بتشم‬

30. Optic nerve
Visual acuity
‫ضعف؟‬ ‫او‬ ‫قل‬ ‫نظرك‬ ‫حسيت‬
Field of vision
‫؟‬ ‫ماشي‬ ‫وانت‬ ‫حاجات‬ ‫في‬ ‫تخبط‬ ‫ممكن‬
Retinal affection
‫خطوط‬ ‫تشوف‬ ‫ممكن‬
,
‫؟‬ ‫االشياء‬ ‫حجم‬ ‫في‬ ‫تغيير‬ ‫انوار‬
Colored vision
‫؟‬ ‫اختلفت‬ ‫للوان‬ ‫رويتك‬ ‫ان‬ ‫الحظت‬

31. Diminution of vision
• OCD
• Distribution : Uni/bilateral
symmetrical/ asymmetrical
simultaneous/ sequential
• Severity
• Painful or not
• Limitation of ocular motility ( double vision )
• Ptosis
• Local eye manifestations : photophobia , lacrimation , exophthalmos

32. 3rd , 4th and 6th cranial nerves
Diplopia :
‫رؤية‬ ‫في‬ ‫ازدواجية‬ ‫فيه‬
,
‫؟‬ ‫اتنين‬ ‫الحاجة‬ ‫بتشوف‬
binocular
‫واحدة‬ ‫عين‬ ‫تغمض‬ ‫لما‬
,
‫اتنين؟‬ ‫الحاجة‬ ‫بتشوف‬ ‫برضه‬
Which muscle affected ( upside down or lateral and medial )
‫؟‬ ‫بعض‬ ‫فوق‬ ‫وال‬ ‫بعض‬ ‫جنب‬ ‫الصورتين‬
‫معين‬ ‫وضع‬ ‫في‬ ‫تتحسن‬ ‫او‬ ‫؟‬ ‫معينة‬ ‫ناحية‬ ‫في‬ ‫تبص‬ ‫لما‬ ‫بتزيد‬ ‫الرؤية‬ ‫ازدواجية‬

33. Diplopia
• OCD
• Monocular or binocular
• Corrected with closure of one eye or not
• 2 images ( next to each other , above each other )
• False(outer image) or true image ( fixating eye )
• Painful or not
• Diminution of vision
• Ptosis
• Local eye manifestations

34. Oculumotor .. Cont
Pupillary affection:
‫الشمس‬ ‫في‬ ‫بتزغلل‬ ‫عينيك‬
Oscillopsia: nystagmus
‫قدامك‬ ‫بتهتز‬ ‫الصورة‬ ‫تحس‬ ‫ممكن‬
Ptosis:
‫ال‬ ‫وال‬ ‫سقط‬ ‫جفنك‬ ‫الحظت‬

35. Ptosis
• OCD
• Distribution : Uni/bilateral
symmetrical/ asymmetrical
simultaneous/ sequential
partial or complete
• Severity
• Painful or not
• Limitation of ocular motility ( double vision )
• Diminution of vision.
• Local eye manifestations : photophobia , lacrimation , exophthalmos

36. Trigeminal nerve :
‫فرقة‬ ‫ناحية‬ ‫في‬ ‫؟‬ ‫منمل‬ ‫وشك‬ ‫ان‬ ‫حاسس‬
‫التانية‬ ‫عن‬
‫؟‬ ‫كويس‬ ‫االكل‬ ‫بتمضغ‬ ‫انك‬ ‫حاسس‬
!
‫؟‬ ‫منمل‬ ‫انه‬ ‫حاسس‬ ‫كمان‬ ‫لسانك‬

37. Facial nerve
‫كويس‬ ‫عينيك‬ ‫تقفل‬ ‫بتعرف‬
‫؟‬ ‫االخر‬ ‫النص‬ ‫زي‬ ‫بيتحرك‬ ‫مش‬ ‫وشك‬ ‫نصف‬ ‫ان‬ ‫الحظت‬

38. Vestibulocochlear
‫؟‬ ‫قل‬ ‫سمعك‬ ‫ان‬ ‫حسيت‬
‫وش‬ ‫فيه‬ ‫حسيت‬
,
‫االذنين‬ ‫إحدى‬ ‫في‬ ‫زن‬
‫بالدوار‬ ‫احساس‬ ‫فيه‬ ‫هل‬
(
‫حواليك‬ ‫اللي‬ ‫او‬ ‫انت‬
)
‫؟‬
‫؟‬ ‫االتزان‬ ‫بعدم‬ ‫احساس‬ ‫فيه‬ ‫هل‬

39. 9th , 10th , 11th , 12th cranial nerves
Dysarthria ( nasal tone ) :
‫خنفان؟‬ ‫فيه‬ ‫؟‬ ‫اتغير‬ ‫صوتك‬ ‫ان‬ ‫حسيت‬
Dysphagia to liquids :
‫سائل؟‬ ‫اي‬ ‫او‬ ‫المياه‬ ‫بتشرب‬ ‫لما‬ ‫بتشرق‬
Nasal regurgitation :
‫ترجع‬ ‫ممكن‬ ‫المياة‬
(
‫ترد‬
)
‫؟‬ ‫منخيرك‬ ‫من‬
Tongue :
‫؟‬ ‫خس‬ ‫او‬ ‫ناحيه‬ ‫علي‬ ‫اتوجع‬ ‫لسانك‬ ‫هل‬
!

40. Sphincter & autonomic dysfunction
• UMNL : acute : retention … gradual : precipitancy ‫ال‬ ‫وال‬ ‫بيسبقك‬
Complete … incomplete bilateral pyramidal tract affection
• Posterior column : hesitancy difficult beginning the flow of urine
• Autonomic manifestations :
Altered taste, vomiting , CVS (postural hypotension , palpations ,skin ( trophic changes ), GIT (
delayed emptying, diarrhea, constipation), genitalia ( erectile dysfunction )

41. Symptoms of ↑ ICP
• Headache
• Blurring or double vision
• Deterioration in level of consciousness

42. Symptoms of Higher brain functions disturbance
Speech: ‫اتغير‬ ‫كالمه‬ ‫هل‬
-
‫واضح‬ ‫مش‬
-
‫مضغوم‬
-
‫مكسر‬ ‫او‬
Memory:
Short memory
Long memory
‫فين‬ ‫اوشيلها‬ ‫فين‬ ‫االشياء‬ ‫حاطط‬ ‫ينسى‬
‫اتغذى‬ ‫او‬ ‫فطر‬ ‫او‬ ‫اكل‬ ‫انه‬ ‫ينسى‬
‫الحمام‬ ‫مكان‬ ‫ينسى‬
‫يتوه‬ ‫ممكن‬ ‫خرج‬ ‫ولو‬ ‫البيت‬ ‫مكان‬ ‫ينسى‬
‫اوالده‬ ‫فى‬ ‫يلخبط‬ ‫او‬ ‫الناس‬ ‫اسماء‬ ‫او‬ ‫االيام‬ ‫ينسى‬
Work skills:
Home skills:
‫لوحده‬ ‫يستحم‬
‫لوحده‬ ‫ياكل‬ ‫يعرف‬
‫لوحده‬ ‫الحمام‬ ‫يدخل‬
‫لوحده‬ ‫يلبس‬ ‫ويعرف‬ ‫لوحده‬ ‫هدومه‬ ‫يغير‬

43. HISTORY SUGGESTIVE OF ENCEPHALITIS
DCL
Convulsions
Disturbed sleep rhythm
Oculogyric crisis
Behavioral or mental changes
Focal manifestations as cranial nerve palsy and long tract
lesions.

44. Neck pain or stiffness
Toxemic manifestations as fever, malaise
Manifestations of ICT
DCL
Focal manifestations as cranial nerve palsy and long tract lesions.
HISTORY SUGGESTIVE OF MENINGITIS

45. Special situations
Headache / pain:
• OCD , character , site , radiation
• Increase , decrease , associated
• Severity (interrupt sleep, interfere with daily activity )
• Relation ( sleep , stress , mental , physical or psychological)
Epilepsy or syncope:
• Started:
• Last attack:
• Rate (frequency) Now & on medications
• Type & Similarity of attacks:
• Sequences:
• PDF:
• Previous & Current medications & doses

46. Current Medications & Allergy
Current Medications:
Dose.
Frequency.

47. Review of other systems
GIT: Heart burn, indigestion
Skin & orifices: rashes or tick bites, bleeding
Skeletal: arthralgias or myalgias
cardiopulmonary: chest pain, palpitations, or leg swelling
Metabolic: Fever & body weight

48. Past History
• Diseases ( chronic illness , allergies , admission to hospital )
• Operations ( type and time , anesthesia , blood transfusion )
• Drugs of neurological importance ( chronic drug intake : TB )
• Trauma of neurological importance ( site , associated symptoms )
• Fever of neurological importance .

49. Family history
• Consanguinity
• Similar condition or risk factors in the family
please establish ( pedigree chart )
• Other neuropsychiatric disorder
• Family history of medical illness : DM ,HTN ,
Cardiac .

50. Case formulation
A male patient aged 60 ys old, known to be diabetic and hypertensive and he is compliant on
treatment. One week ago, he had acute left sided hemiplegia that was associated with dysarthria, left
UMN facial N lesion. This weakness was affecting D>P, UL>LL. There was no DCL, mental changes,
fits or sensory affection.

51. Reaching provisional diagnosis
The history is the most important part of neurological evaluation that guides to establish :
• Anatomical diagnosis: focal , systemic , disseminated
• Etiological diagnosis: hereditary , symptomatic , idiopathic

52. Determine Where & What Is The Lesion:
A. Where is the lesion?
- Means the relation between different symptoms and affected structures.
- Determined by positive and negative symptoms.
Types;
1) Focal: affected structures are related anatomically.
2) Multifocal: symptoms are explained by more than one focus e.g., multiple arteriovenous malformations (AVMs),
multiple space occupying lesions.
3) Disseminated: symptoms are disseminated in place (multifocal, with selectivity) and time MS.
- For focal, multifocal or disseminated lesions determine localization e.g., right hemiparesis,
hemihypersthesia, plus cortical expressive aphasia lesion in left cortical-subcortical frontoparietal
region.
4) Systemic disease: affected structures are related physiologically or functionally:
Parkinsonism disease → (extrapyramidal system)
Myasthenia gravis (MG) → (myoneural junction).
- Determine the affected system(s) (could be single or multiple) as extrapyramidal system or peripheral
nerves.

53. B. What is the lesion?
- Means the underlying etiology and pathology.
- Types: vascular, inflammatory, degenerative, congenital, traumatic, metabolic,
neoplastic, or drug induced.
- Determined from onset, course, and duration, e.g.,
-Sudden onset, regressive or stationary course vascular (stroke), or traumatic.
-Gradual onset, progressive course degenerative, neoplastic, or metabolic.

55. Thank you
Mohamedrizk.med@o6u.edu.eg