For undergradute students and master students

1. HISTORY TAKING
When did the story begin ?
By Mohamed A. Tarek

2. -Personal History
-Complaint
-History of present illness
-Past History
-Family History
-Case Formulation
-Diagnosis
AGENDA

3. PERSONAL
HISTORY
-Name
-Age
-Sex
-Residence
-Marital status
-Occupation
-Handedness
-Special Habits of medical importance
eg: Smoking, alcohol
-Menstrual History

4. Example :
M.A.M , a 40 yrs old male patient , from el maragha ,Sohag
.He works as an engineer , married for 12 years now and
has 2 off spring , the youngest is 3 years old and the oldest
is 5 years old . He is a heavy smoker (20 CPD for 14 years).
He is Rt handed.
N.B:
Smoking index = CPD X total duration in years
Mild if <100
Moderate if 101-300

5. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

6. COMPLAINT
-In patient own words
-Onset , Course , Duration
(OCD)
-The most recent complaint is
the only mentioned

7. EXAMPLE:
Rt sided weakness of acute onest ,
Regressive course of 10 days duration.

8. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

9. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

10. SYMPTOMS
OF MOTOR
SYSTEM
Motor Weakness
UMNL LMNL
Involuntary Movement
Fits Tremors Extra-
pyramidal
Motor Incoordination
Cerebellar Deep Sensory

11. UMNL
LMNL

14. MOTOR SYSTEM
MOTOR WEAKNESS:
1- OCD>>>Onset :sudden ‫دقائق‬
–
‫ساعات‬
Acute ‫أسبوعين‬
subacute ‫أسبوعين‬
–
‫شهرين‬
Chronic >‫شهرين‬
Course : regressive – Progressive - Stationary
Duration

15. MOTOR SYSTEM
MOTOR WEAKNESS:
2-Distribution :
Rt vs lt
Symmertcal or Asymmetrical
UL vs LL
Distal vs proximal
Flexors vs extensors
3-Tone
4-Fasciculations (twitches)
5-Wasting
6-Ambulance : without support - with minimal support – with
maximum
support - wheel chair bound – bed ridden

16. EXAMPLE :
The condition started 10 days ago when the patient developed
weakness of acute onset , regressive course of Rt UL & LL . Distal
more than proximal . The patient felt his limb flai. There was no
wasting or muscle twitches . The ptient is ambulant with maximal
support . there were no manifestations affecting the other side

17. MOTOR SYSTEM :
INVOLUNTARY MOVEMENTS:
Fits :
Attacks of involuntary movement, could occur during sleep
1. Description
a) Prodroma
b) Aura
c) Ictus
d) Post Ictal state
2. Duration
3. Frequency

18. MOTOR SYSTEM
INVOLUNTARY MOVEMENTS:
Tremors
1-OCD
2-Distribution
3-Description
a) Static → Parkonism
b) Kinetic → Ataxia
c) Postural
Fine → Anxiety, Thyrotoxicosis, senile, familial (essential)
Course (Flapping) → Organ Failure
4- Effect of stress: ↑
5- Effect of movement: ↓
6- Effect of sleep: x
7-interfering with activities of daily living.

20. MOTOR SYSTEM
COORDINATION
Motor Incoordination : Tremors & Gait
Swaying from side to side during walking
Side Difference: no/more to the Rt/Lt side
Q: ‫ممكن‬ ‫تمشي‬ ‫لما‬ ‫؟‬ ‫توازن‬ ‫بعدم‬ ‫تحس‬ ‫ممكن‬ ‫هل‬ ‫؟‬ ‫ايه‬ ‫مشيتك‬ ‫اخبار‬
‫تحدف‬
‫؟‬ ‫ناحية‬ ‫علي‬
Effect on dim light:
a) No change: Cerebellar
b) Increase: Mixed cerebellar & deep sensory
c) Only in dim light: Deep sensory
3. Association
a) Staccato speech, nystagmus: Cerebellar
b) Basin sign, Stamping gait: Deep Sensory

21. EXAMPLE :
The patient complains of Abnormal involuntary
movements affecting Rt UL and LL that occur on action
and 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

22. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

23. SENSORY :
SUPERFICIAL :
Numbness – Abnormal sensation .
Q ‫حاسس‬
‫؟‬ ‫خدالن‬ ‫او‬ ‫نمل‬ ‫فيه‬ ‫انه‬
:
Diminution of sensation
Q: ‫حاسس‬
‫السخن‬ ‫بين‬ ‫الفرق‬
‫والساقع‬
‫مش‬ ‫جسمك‬ ‫في‬ ‫معين‬ ‫جزء‬ ‫فيه‬ ‫هل‬ ‫؟‬
‫حاسس‬
‫؟‬ ‫بيه‬

24. SENSORY
DEEP:
Walking on sand or sponge
Q: ‫ازاي‬
‫حاسس‬
‫وال‬ ‫صلبه‬ ‫تحتك؟‬ ‫من‬ ‫األرض‬
‫كانك‬
‫اسفنج؟‬ ‫او‬ ‫رمل‬ ‫علي‬ ‫ماشي‬
Basin sign : imbalance on closing eyes
Q: ‫تخش‬ ‫او‬ ‫عينيك‬ ‫تغم‬ ‫لما‬
‫اوضة‬
‫ضلمة‬
‫تحس‬
‫بايه‬
‫؟‬
‫لما‬
‫بتقف‬
‫تحس‬، ‫عينيك‬ ‫وتغمض‬ ‫الصبح‬ ‫وشك‬ ‫تغسل‬
‫بايه‬
‫؟‬
٬

25. Define pain and parasthesia in terms
of the following :
-Type and character
-Location and distribution
-Radiation
-Severity
-Persistent or in attacks
-PPT factors: stress – touch- sleep
deprivation- neck movements
-Relieving factors eg : sleep , stress
management

28. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial
nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

29. CRANIAL NERVES
1-OLFACTORY
Q
:
‫عندك‬ ‫الشم‬ ‫حاسة‬
‫اتغيرت‬
‫؟‬ ‫الشم‬ ‫حاسة‬ ‫في‬ ‫مشاكل‬ ‫أي‬ ‫فيه‬ ‫؟‬
Q
:
‫؟‬ ‫الناحيتين‬ ‫وال‬ ‫واحدة‬ ‫ناحية‬ ‫في‬ ‫هل‬

30. CRANIAL NERVES
2-OPTIC NERVE
-Visual acuity :
Q: ‫عينك‬ ‫؟‬ ‫ضعف‬ ‫نظرك‬ ‫او‬ ‫؟‬ ‫النظر‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫فيه‬ ‫هل‬
‫ضلمت‬
‫فيه‬ ‫؟‬
‫او‬ ‫ستارة‬
‫غيامة‬
‫؟‬ ‫عينك‬ ‫قصاد‬
-Field defects :
Q: ‫مش‬ ‫الصورة‬ ‫من‬ ‫جزء‬ ‫فيه‬ ‫هل‬
‫شايفه‬
‫دراعك‬ ‫تمشي‬ ‫ممكن‬ ‫؟‬ ‫كويس‬
‫مش‬ ‫عشان‬ ‫الحيطان‬ ‫في‬ ‫يخبط‬
‫شايفها‬
‫؟‬
If there is diminution of vision :
Ask about : OCD - Painful or not - any local eye
manifestations – any limitation of ocular motility

31. CRANIAL NERVES
OCULOMOTOR (3) , TROCHLEAR (4)
,ABDUCENS (6)
-Diplopia :
Q: ‫الحاجة‬ ‫بتشوف‬
‫اتنين‬
‫؟‬
-Drooping of the upper eyelid:
Q: ‫حاسس‬
‫؟‬ ‫سقط‬ ‫عينك‬ ‫جفن‬ ‫ان‬
-Limitation of eye movement or any obvious deviation
Q: ‫حاسس‬
‫مش‬ ‫عينك‬ ‫حركة‬ ‫او‬ ‫حجرت‬ ‫عينك‬ ‫ان‬
‫مظبوطة‬
‫؟‬

32. CRANIAL NERVES:
TRIGEMINAL NERVE (5)
-Motor part:
Q: ‫بتمضغ‬
‫؟‬ ‫المضغ‬ ‫في‬ ‫مشاكل‬ ‫أي‬ ‫عندك‬ ‫؟‬ ‫كويس‬
-Sensory part :
Q: ‫؟‬ ‫الوجه‬ ‫في‬ ‫اإلحساس‬ ‫في‬ ‫مشاكل‬ ‫أي‬ ‫عندك‬
‫السخن‬ ‫بين‬ ‫الفرق‬ ‫تحس‬ ‫وشك‬ ‫تغسل‬ ‫لما‬
‫والساقع‬
‫؟‬
‫وشك‬ ‫في‬ ‫الكهرباء‬ ‫زي‬ ‫بلسعه‬ ‫تحس‬ ‫ممكن‬ ‫هل‬
‫تيجي‬
‫؟‬ ‫بسرعه‬ ‫وتروح‬

33. CRANIAL NERVES:
FACIAL NERVE (7)
-Motor part :
Q ‫وانت‬ ‫كويس‬ ‫عينك‬ ‫تغمض‬ ‫بتعرف‬
‫نايم‬
‫؟‬ ‫مفتوحة‬ ‫تفضل‬ ‫وال‬
-
‫بقك‬
‫بيتعوج‬
‫؟‬ ‫كده‬ ‫قبل‬ ‫ناحية‬ ‫علي‬
‫االكل‬
‫بيتجمع‬
‫خدك‬ ‫تحت‬
‫ومتعرفش‬
‫؟‬ ‫بقك‬ ‫جنب‬ ‫من‬ ‫تنزل‬ ‫المية‬ ‫او‬ ‫؟‬ ‫تحركه‬
-Sensory
Q:‫؟‬ ‫االكل‬ ‫بطعم‬ ‫اإلحساس‬ ‫في‬ ‫مشاكل‬ ‫أي‬ ‫عندك‬ ‫؟‬ ‫اتغير‬ ‫االكل‬ ‫طعم‬

36. CRANIAL NERVES :
VESTIBULOCOCHLEAR (8)
-Hearing :
Q: ‫؟‬ ‫السمع‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬
‫او‬ ‫قل‬ ‫السمع‬
‫بتحس‬
‫؟‬ ‫ودنك‬ ‫في‬ ‫وش‬ ‫او‬ ‫بصفاره‬
-vertigo:
Q: ‫بتحس‬
‫؟‬ ‫بيك‬ ‫بتلف‬ ‫الحيطان‬ ‫او‬ ‫بيك‬ ‫بتقلب‬ ‫الدنيا‬ ‫ان‬ ‫تحس‬ ‫او‬ ‫بدوار‬

37. CRANIAL NERVES :
GLOSSOPHARYNGEAL (9) & VAGUS
(10)
-Dysphagia and chocking:
Q; ‫البلع‬ ‫في‬ ‫مشاكل‬ ‫اي‬ ‫عندك‬ ‫فيه‬
..
‫فيه‬ ‫وال‬ ‫كويس‬ ‫بتبلع‬
‫صعوبه‬
‫؟‬
‫؟‬ ‫االكل‬ ‫وال‬ ‫اكتر‬ ‫المية‬
‫ممكن‬
‫بصورة‬ ‫تشنق‬
‫متكرره‬
‫لما‬
‫تاكل‬
‫؟‬ ‫تشرب‬ ‫او‬
-Nasal regurgitation :
Q: ‫؟‬ ‫مناخيرك‬ ‫من‬ ‫ويخرج‬ ‫تشنق‬ ‫يخليك‬ ‫الشرب‬ ‫او‬ ‫االكل‬
-Nasal tonation and hoarsensess of voice :
Q: ‫حاسس‬
‫؟‬ ‫اتغير‬ ‫صوتك‬ ‫ان‬
‫حاسس‬
‫فيه‬ ‫ان‬
‫خنفة‬
‫؟‬ ‫صوتك‬ ‫في‬
-Dysarthria :
Q: ‫؟‬ ‫الكالم‬ ‫في‬ ‫مشاكل‬ ‫أي‬ ‫عندك‬
‫حاسس‬
‫او‬ ‫تقل‬ ‫الكالم‬ ‫ان‬
‫بيخرج‬
‫بصعوبه‬
‫؟‬

38. N.B:
Dysphagia: neurogenic is for fluids > solids UMNL
& LMNL
Dysarthria
Nasal tonation
Nasal regurgitation LMNL
Chocking attacks
Hoarseness of voice UMNL

39. CRANIAL NERVES :
SPINAL ACCESSORY NERVE (11)
Q: ‫حاسس‬
‫أي‬ ‫فيه‬ ‫؟‬ ‫ساقطة‬ ‫كتافك‬ ‫ان‬
‫؟‬ ‫رقبتك‬ ‫حركة‬ ‫في‬ ‫مشكلة‬

40. CRANIAL NERVES:
HYPOGLOSSAL NERVE (12)
Q: ‫؟‬ ‫كويس‬ ‫لسانك‬ ‫بتحرك‬
‫؟‬ ‫كويس‬ ‫بقك‬ ‫في‬ ‫االكل‬ ‫تقلب‬

41. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

42. SPEECH & LANGUAGE
-change in speech >>>become slurred ،, Volume of speech, tone
Q: ‫؟‬ ‫الكالم‬ ‫في‬ ‫لته‬ ‫فيه‬ ‫كان‬ ‫او‬ ‫عليك‬ ‫تقل‬ ‫لسانك‬ ‫هل‬
-Fluency
-word finding difficulty
-understand spoken speech
-difficulty in naming objects.
-difficulty in reading
-difficulty in writing
N.B: donot forget OCD 

43. IMPORTANT SPEECH PROBLEMS:
Dysarthria: Difficulty in articulation of speech but the patient can
understand spoken words.
Motor Aphasia: inability to speak but the patient can
understand spoken words.
Sensory Aphasia: inability to understand spoken words.
Mixed Aphasia (Global) : inability to speak with inability to
understand spoken words.

44. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

45. SPHINCTERIC
URINARY:
-Precipitancy :Bilateral partial gradual pyramidal tract affection
Q: ‫؟‬ ‫يسبقك‬ ‫ممكن‬ ‫البول‬ ‫؟‬ ‫ايه‬ ‫البول‬ ‫في‬ ‫التحكم‬ ‫اخبار‬
‫بتقدر‬
‫؟‬ ‫منك‬ ‫يفلت‬ ‫ممكن‬ ‫وال‬ ‫كويس‬ ‫نفسك‬ ‫تمسك‬
‫؟‬ ‫وخالص‬ ‫كده‬ ‫مره‬ ‫حصل‬ ‫وال‬ ‫؟‬ ‫متكرر‬ ‫ده‬ ‫الموضوع‬
-Retention :Bilateral acute complete pyramidal tract affection.
Q: ‫؟‬ ‫قسطرة‬ ‫تركب‬ ‫واحتجت‬ ‫كده‬ ‫قبل‬ ‫عنك‬ ‫اتحاش‬ ‫البول‬
-Hesitancy: deep sensory or posterior column affection
Q: ‫؟‬ ‫فتره‬ ‫بعد‬ ‫قليلة‬ ‫بكمية‬ ‫وينزل‬، ‫ينزل‬ ‫عشان‬ ‫البول‬ ‫علي‬ ‫وتتحايل‬ ‫مزنوق‬ ‫بتبقي‬
-Urgency : UTI or local urinary cause
Q: ‫لكن‬ ‫كتير‬ ‫الحمام‬ ‫وتخش‬ ‫مزنوق‬ ‫بتبقي‬
‫بتتحكم‬
‫كويس‬ ‫البول‬ ‫في‬
‫وميسبقكش‬
‫؟‬
-Incontinence:
Q: ‫بتحس‬
‫وال‬ ‫البول‬ ‫بزنقة‬
‫بينزل‬
‫تحس‬ ‫ما‬ ‫غير‬ ‫من‬ ‫طول‬ ‫علي‬ ‫عليك‬
‫ومتقدرش‬
‫؟‬ ‫فيه‬ ‫تتحكم‬

46. SPHINCTERIC
ANAL:
- Constipation
-Fecal incontinence

47. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-
Cognition
7-Symptoms of
increased ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

48. COGNITION
-Take history from the relative in addition to the patient
-conscious level.
-Attention
-orientation
-Memory
-Calculation
-Apraxia: inability to do previously learnt actions.
-Behaviour
-Agnosia : inability to recognize faces , objects..etc
-Mood disturbances

49. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-
Symptoms
of increased
ICP.
8-Others :Sleep
disturbances - -
Autonomic Dysfunction.
This Photo by Unknown Author is licensed under CC BY

50. SYMPTOMS OF ICP:
Headache:
– Character: Bursting,
– Location: Allover
– Timing: more severe in early morning
– What aggravate: ↑ by leaning forward & coughing – What relief it: ↓
partially by vomiting & analgesics
Vomiting:
– Character: Projectile (propulsive not preceded by nausea), – Timing:
common in the morning
– Relation to meals : no
Blurring of vision: (due to papilloedema): the details of image is not
apparent even from a near distance.
Convulsions: Focal or generalized
Alteration of consciousness: drowsy, stupor or coma.

51. HISTORY OF
PRESENT ILLNESS
1-Motor
2-Sensory
3-Cranial nerves
4-Speech
5-Sphincteric
6-Cognition
7-Symptoms of increased ICP.
8-Others
:Sleep
disturbances
- -Autonomic
Dysfunction.
This Photo by Unknown Author is licensed under CC BY

52. OTHERS :
- Sleep disyurbances
-Autonomic symptoms:
-Orthostatic hypotension
- sweating abnormality
- Genital eg: ED
-Urinary symptoms eg: storage , voiding ,
retention symptoms

53. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

54. Past History
-Similar attacks .
-Previous illnesses .
-Trauma or accident
-operations.
-blood transfusion
-Previous medication.
-In children, a brief history
of motor & mental

55. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

56. Family
History
-Similar conditions among the
patient’s relatives.
-Vascular risk factor (in suspected
vascular AE)
-Consanguinity among the
patient’s parents.

57. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

58. CASE
FORMULATI
ON
Short summary of:
• Relevant points in personal
history : Age , sex , special
habits.
.Relevant family and past
history.
.OCD
.Patient’s symptoms
formulated in scientific terms .

59. AGENDA
Personal History
Complaint
History of present illness
Past History
Family History
Case Formulation
Diagnosis

60. DIAGNOSIS: ( PROVISIONAL )
1- Clinical diagnosis
• According to motor deficite e.g.
– Rt Sided hemiplgia, Rt UMNL VII & XII.
– Spinal Paraplegia, Painless Retention of Urine.
– Mixed Cerebellar & Deep sensory ataxia.

61. CONT. DIAGNOSIS:
2- Anatomical diagnosis
• Whether it is focal, systemic or disseminated or multifocal.
– Focal:
All symptoms could be explained by one area in the nervous system (Not respecting neurological
systems).
– Systemic:
Bilateral & symmetric distribution of the whole system or systems (Selective affection of 1 or more
neurological systems that could be explained by well known systemic disease). EX :
PD
– Disseminated:
Bilateral & asymmetric (Dissemination in time & space). EX; MS

62. CONT: DIAGNOSIS
• Where is the Lesion? Eg:
– Lt Internal capsule.
– Bilateral Cerebellar tracts, Posterior column.
– Rt Optic Nerve, Lt Cerebelar Tract, Rt Δ Tract.

63. CONT: DIAGNOSIS:
What is the lesion ? VITAMIN C & D 
Vascular>>>>sudden onset , regressive or stationary course.
Infectious/Inflammatory>>> rapid onset and regressive course
Traumatic>>> sudden onset ,regressive or stationary course.
Autoimmune
Metabolic/Toxic
Idiopathhic
Neoplastic>>>gradual onset and progressive course
Congenital>> onset since birth and stationary course
Degenerative / Hereditary >>> gradual onset and progressive

64. Email :
m.a.tarek91@gmail.com
Slide share : Mohamed Ahmed
Tarek