Professor/Gharib Fawi mohamed

Professor - Professor of neurology and chairman of the department of neurology and psychological medicine

Faculty of medicine

Address: Sohag .gomhoria street

history talking

2018-10-04 12:29:25 |

History taking

Overview

Taking the patient's history is traditionally the first step in virtually every clinical encounter. A thorough neurologic history allows the clinician to define the patient's problem and, along with the result of physical examination, assists in formulating an etiologic and/or pathologic diagnosis in most cases.

Solid knowledge of the basic principles of the various disease processes is essential for obtaining a good history. As Goethe stated, "The eyes see what the mind knows." To this end, the reader is referred to the literature about the natural history of diseases. The purpose of this article is to highlight the process of the examination rather than to provide details about the clinical and pathologic features of specific diseases.

A complete history often defines the clinical problem and allows the examiner to proceed with a complete but focused neurologic examination.

History taking is fundamental to neurological diagnosis. For instance, epilepsy or migraine is diagnosed solely on the basis of the history, with the examination merely ensuring there is no evidence of associated underlying structural disorders of the brain. The history is usually much more informative than examination, which generally is either reassuringly normal or merely confirms features anticipated from the history. However, sometimes examination is crucially helpful. For instance, in localizing the cause of muscle weakness, specific physical signs will reveal whether the lesion affects the upper motor neuron, the lower motor neuron, or the muscle. An unanticipated physical sign, such as an extensor plantar response, signifying pyramidal-tract damage, or papilloedema, signifying raised intracranial pressure, will alter one's diagnostic view fundamentally if the history has pointed to diagnoses such as psychologically determined weakness or benign tension headache.

With experience one recognizes that patients often describe the symptoms of certain disorders in a very distinctive way. Intuitive recognition of a characteristic history plays a large part in diagnosis. There is no particular list of questions to ask. It is best to invite the patient to describe their symptoms in the order in which they occurred, with approximate dates. Important detail can be clarified by specific questioning during or after the patient's account. It is helpful to determine whether the patient's symptoms are so ‘disabling’ as to prevent crucial everyday activities or work, or whether they merely constitute a ‘nuisance’. This will guide the decision as to whether a symptom such as headache needs treatment.

Negative symptoms

Definition

Negative symptoms are those in which normal neurological functions are lost, and are the most common symptoms of damage to the nervous system.

Examples

* hemiparesis due to cerebral-hemisphere infarction,

* memory loss due to Alzheimer's disease,

* muscle weakness due to motor neuron degeneration,

* the loss of micturtion control due to a cauda equina tumour.

Positive symptoms

Definition

Positive symptoms are novel phenomena which often suggest specific diagnoses.

Examples

* A ‘pill-rolling’ tremor of the fingers and thumb at rest is characteristic of Parkinson's disease.

* Flashing lights (photopsia) or zigzag lines (fortification spectra) preceding a headache are diagnostic of classical migraine.

* Repetitive twitching of the fingers or the corner of the mouth occurs in focal motor seizures.

* A hallucination of an odd smell, often like burning rubber, is typical of an epileptic discharge in the temporal lobe.

* Tingling in the toes and fingers is typical of acquired, rather than inherited, peripheral neuropathy.

Neuroanatomical localization

Sometimes enquiry about other specific symptoms is necessary to localize the disease process anatomically.

* For example, a patient with suspected motor neuron disease should be asked whether there are sensory or sphincter symptoms which might point to the alternative diagnoses of generalized peripheral neuropathy or to spinal cord compression.

* A patient with sensory symptoms in the legs should be asked whether their hands are also affected; this would be a pointer to a polyneuropathy or cervical myelopathy rather than a focal lesion of the cauda equina or thoracic spinal cord.

* Determine whether a patient with dysphasia also has impaired spatial abilities, such as a dressing apraxia or getting lost in familiar places; this would point to a generalized dementing process involving both cerebral hemispheres rather than a focal lesion of the left hemisphere causing isolated dysphasia.

* Question a patient with gait unsteadiness about vertigo or double vision, which would imply damage to the brainstem rather than to the cerebellum or somatosensory pathways.

Personal history

-Name: For identification and to be familiar with the patient

-Age: Some diseases have certain age predilection;

Congenital diseases >>>> since birth.

Hereditary diseases >>>> infancy and early childhood, however sometimes later.

Demyelinating diseases >>>> early adulthood.

Vascular diseases >>>>>> elderly.

-Sex: many neurological diseases have certain sex incidence;

MG >>>> more common in females.

Myotonia Atrophica >>> more common in males.

-Occupation: it can be a key for the diagnosis of certain diseases e.g.

Driver, porter

.spondylosis

.paraplegia

.cauda equina

Lead neuropathy more in common in patients dealing with lead.

In certain diseases some occupations in forbidden e.g. driving in epilepsy

-Residence: Some diseases are common in certain areas. e.g.

DS >>> in northern countries.

Endemic disease >>> e.g. TB (so paraplegic patients coming from these areas Pott's should be put in mind)

-Habits:

Smoking

Alcohol

-Handedness: All centers of brain are bilaterally represented except speech centers which

are present in the dominant hemisphere

Rt. handed (over 90% of population)

Left dominant hemisphere

Left handed

90%

Left dominant hemisphere

10%

Right dominant hemisphere (or)

Bilaterally presented

Complaint:

The chief complaint (or the several main complaints) is the usual starting point of the diagnostic process. It is the most distressing symptom which enforce pt to medical advice or admitted to hospital

Points that should be noted:

(1) Should be mentioned with its duration.

(2) As short as possible.

(3) One complaint is sufficient.

(4) No medical terms "in pt. own words"

for example:

Rt. Hemiplegia >> inability to move right UL and LL.

Paraplegia >> inability to move both LIL.

Parkinsonism >> involuntary movement or shaking movement.

Myopathy >> difficulty in standing from sitting position.

Ataxia >> unsteadiness during walking or standing.

History of Present Illness (HPI).

(1) As long as possible.

(2) Medical terms.

(3) Arrangement

1- Analysis of the complaint.

2-positive data mentioned chronologically. (+ve or –ve Symptoms)

3-negative data (+ve or –ve Symptoms) (mention related then non related).

4-other system affection

5-general symptoms and general diseases

Analysis of the complaint:

Fixed

Variable

* Onset, course, duration

* Timing (diurnal or seasonal variation )

* Precipitating and relieving factors

* Associated symptoms (symptoms of the same system)

* History of drug

* According to C/O

(1) Onset: It is the time from the beginning (appearance of the first symptom) of the disease till the clinical pictures is completed.

*Sudden (abrupt or instantaneous)*	Seconds to Minutes	· Trauma · Epilepsy (sudden loss of consciousness) · Embolic cerebral infarction · Instantaneous headache of SAH
*Acute:*	Hours	· Thrombotic cerebral infarction · Acute inflammatory process or demyelinating disorders
*Subacute*	Days to Weeks	· Demyelinating diseases · Inflammatory diseases
*Gradual*	Months to Years	· Degenerative diseases · Neoplastic diseases

Write the onset as follows:

The onset was acute so the picture was completed in hours, minutes …etc

(2)Course

*Progressive*	Symptoms increase in severity or new Symptoms appear
*Regressive*	Symptoms decrease in severity or some symptoms disappear
*Stationary*	No change	e.g. congenital post-inflammatory post-infective
*Intermittent*	The course in attacks and the patient is free in between attacks.	e.g. TIAs Epilepsy Migraine
*Remittent*	The course in attacks and the patient is not free (does not reach baseline) in-between attacks.	e.g. D.S.

(3) Duration.

(4) Details of the patient complaint.

Analysis of other neurological symptoms; to cover the following points:

Symptoms of mental state and speech disorders.
Symptoms of increase ICT.
Symptoms of cerebellar features.
Symptoms of cranial nerves affection.
Symptoms of motor system affection.
Symptoms of sensory system affection.
Symptoms of sphincteric disturbances.
Other neurological symptoms (gait, sleep, dizziness) .
Symptoms of other systems affection.

Symptoms of cranial nerves affection.

(I) Olfactory nerve.

Irritation:

Parosmia.

Olfactory hallucination

Destruction:

Hyposmia هل حاسة الشم قلت او ضعفت ولا لأ؟

Anosmia

(II) Optic nerve.

-Diminution of vision نظرك ضعف و لا طبيعى؟

-Field defects. و انت ماشى فى مكان زحمة بتاخد بالك من اللى حواليك و لا ممكن تخبط فيهم؟

-Colour blindness. بتعرف تمييز الالوان؟

(III) Oculomotor (IV) Trochlear (VI) Abducens.

-Ptosis. هل حدث سقوط فى جفنك؟

-Squint. هل لاحظت او اى حد غيرك لاحظ حول فى عينك؟

-Diplopia. بتشوف الحاجة اتنين ولا طبيعى؟

(V) Trigeminal nerve.

(1) Motor Function:

Difficult mastication. فى صعوبة فى المضغ و لا طبيعى؟

Jaw deviation.

(2) Sensory:

a- Irritation; pain, parathesia (tingling and numbness).

هل فى الم او شكشكة او تنميل فى اى مكان فى وشك؟

b-Hypo or anaesthesia. هل الاحساس فى وشك قل؟

(VII) Facial nerve:

- Inability to close the eyes.

لما بتغسل وشك بتزر على عينيك كويس ولا الصابون ممكن يدخل فيهم؟

- Epiphora. عينيك بتدمع زيادة ولا طبيعى؟

- Deviation of the angle of the mouth to normal side.

هل الفم اتعوج على ناحية واى ناحية؟

- Accumulation of food behind the affected side of the cheek

الاكل بيتحوش فى بقك و لا لأ و فى اى ناحية؟

VIII) Vestibulo-cochlear

cochlear division

Irritation:

(1) Tinnitus هل فى وش او زنة فى ودنك؟

(2) Auditory hallucination.

Destruction:

(1)Deafness هل سمعك ضعف؟

(2) Vestibular division:

Irritation & Destruction >> Vertigo بتحس ان الحجرة بتلف بيك ؟

(IX) Glossopharyngeal (X) Vagus (X) cranial part of accessory

Palatal

Nasal tone هل صوتك اخنف؟

Nasal regurgitation of fluids لما بتشرب المية بترد من مناخيرك؟

Laryngeal

Dysarthria هل فيه صعوبة فى الكلام عندك؟

Hoarsness of voice هل صوتك اتبح؟

Pharyngeal

Dysphagia هل فيه صعوبة فى البلع عندك؟

Chocking بتشرق ولا لأ؟

(XI)Spinal part of accessory:

(1) Unilateral

(a) Sternomastoid: weakness of head rotation to opposite side

هل فيه صعوبة فى حركة راسك يمين و شمال؟

(b) Trapezius: shoulder depression هل كتفك سقط ؟

or weakness of shoulder elevation هل فيه صعوبة لما بتحاول ترفع كتفك لفوق؟

(2) Bilateral

(a) Sternomastoid: back words falling of head

(b) Trapezius: forward falling of head

(XII) Hypoglossal

Dysarthria هل فيه صعوبة فى الكلام؟

Deviation of the tongue to the diseased side on protrusion

هل لسانك اتعوج على ناحية و اى ناحية؟

Or inability to protrude the tongue

N.B. How to write cranial nerves in HPI

If only one or 2 cranial nerves are affected we can say:

Apart from inability to close the right eye perfectly, deviation of the mouth to the left side and accumulation of food behind the right cheek, there are no other symptoms of cranial nerves affection

*If many cranial nerves are affected describe each.

Symptoms of motor system affection

*+ve symptoms*	Weakness
*-ve symptoms*	Involuntary movements

(I) Weakness:

-How to analyze weakness?

Fixed

Variable

* Onset, course, duration

(etiological diagnosis. (see before)

* Precipitating and relieving factors

* Associated symptoms

* Distribution

(anatomical diagnosis will diff. UMNL & LMNL)

* Character

(anatomical diagnosis will diff. UMNL & LMNL)

# Distribution:

(1)UL or LL or both (if both which is more affection) الضعف اللى عندك فى ايدك و لا رجلك

و لا الاتنين مع بعض؟ فى مين اكتر؟ و فى مين الاول؟

(2)Unilateral or bilateral (If bilateral symmetrical or asymmetrical) الضعف فى الناحية اليمين و

لا الشمال و لا الاتنين؟ مين الاكتر؟ و فين الاول؟

(3) Distal or Proximal

Upper Limb

Distal هل فيه صعوبة عندك فى الكتابة او فى التسبيح او عصر الليمونة فى الاكل..الخ؟

Proximal هل فيه صعوبة عندك فى رفع ايدك لفوق او فى السواقة .. الخ؟

Lower Limb

Distal الشبشب يفلت من رجلك؟

Proximal هل عندك صعوبة فى الوقوف من على الارض او من على الكرسى؟

(4)Flexors or Extensors:

Upper Limb

Flexion فتح الدرج او الباب؟

Extension قفل الباب او الدرج؟

Lower Limb

Flexion بداية لبس البنطلون

Extension فرد الرجل فى البنطلون لاستكمال اللبس

(5)Adductors or Abductors

Upper Limb

Abduction خلع القميص او الجاكت

Adduction وضع الجرايد تحت الابط

*LL

Adduction يحط رجل على رجل

Abduction ينزل رجل من على رجل

#Character انتزع المعلومات من المريض (استخدم التخيير: شبه كذا و لا كذا؟)

(1) Degree اللى عندك ضعف و لا شلل كلى؟

Paresis (UMNL)

Paralysis complete (LMNL)

(2) Tone عضلاتك ماسك او متخشبة ولا سايبة او مرخية؟

Hypertonic (UMNL)

Hypotonic (LMNL)

N.B. Do not write hypertonic or hypotonic in the sheet But

*Hypertonic »»» stiffness (stiff muscles)

*Hypotonic »»» flaccidity (flaccid or flail muscles)

(3) Atrophy عضلاتك خست و لا طبيعى؟ و بعد قد اية من من بداية المرض؟ خست قوى و لا

بسيط؟

Early and severe »»» LMNL

Late and mild »»» UMNL

N.B. Atrophy is wrote (Wasting)

(4) Fasciculation عضلاتك بترف ولا لأ او فيه رفه تحت الجلد ولا لأ؟

N.B. Fasciculation is wrote (Twitches)

(5) Trophic changes more with LMNL

Brittle nails ضوافرك بتتقصف لوحدها و لا لأ ؟

Falling of hair شعر ايديك و رجليك بيقع و لا لأ؟

Trophic ulcers فيه قرح فى رجلك و لالأ؟

N.B. Items 1-2-3-4 discuss either if negative or positive.

Item 5 discuss only if positive.

(II)Involuntary Movement:

Fixed

Variable

* Onset, course, duration

* Precipitating and relieving factors

* Associated symptoms

* Distribution

* Character

#Distribution:

Uni or bilateral

Proximal or distal

#Character

(1) Static or kinetic الحركة او الرعشة اكتر مع السكون و لا مع الحركة؟

(2) Regular or not. منتظمة ولا لأ او هى هى ولا بتتغير؟

(3) Form (e.g. bill rolling) اوصف لى شكلها او زى اية؟

(4) What increase it and what decrease it? ايه اللى بيزودها و ايه بيقللها؟

(5) Associated symptoms (i.e. tone) عضلاتك سايبة ولا ممتخشبة؟

(III) Incoordination:

#Cerebellum:

Unsteady gait (deviation from side to side) بتمشى طبيعى و لا بتطوح؟

Kinetic tremors ع الملعقة بتترعش لما توصلها لبقك؟

Dysmetria صعوبة فى استعمال جرس الباب او وضع الفيشة فى البريزة؟

صعوبة في توصيل الملقة للبق أثناء الأكل ع

Dysdiadokokinesia صعوبة فى تقليب الشاى

صعوبة في تزرير وفك الزراير

Chang of character of voice

#Deep sensation:

Unsteadiness during eye closure

History of increase intracranial tension:

Headache

Early morning
Dull aching diffuse
Partially relieved by vomiting

Vomiting

Projectile
Without nausea
Not related to meal

Visual symptoms

Blurring of vision
Diplopia
Squint

Convulsions

History of sensory system disorder

Patients express their symptoms of sensory dysfunction in a multitude of ways, and only careful enquiry by the neurologist will determine their likely pathophysiological relevance.

*+ve symptoms*	Pain
*-ve symptoms*	Hypothesia

A-Superficial

Numbness

Def.

* Most doctors mean by it ‘a loss of sensation’, but many patients really mean weakness or clumsiness.

* It is less ambiguous to ask about ‘deadness of skin sensation’.

* Some patients with numb feet describe a feeling of walking on cotton wool.

* Those with numb hands may feel as though they are touching things through a plastic bag.

E.g.

· Polyneuropathy produces numbness in a glove-and-stocking distribution.

· Myelitis due to multiple sclerosis produces numbness described as ‘pins and needles’ extending on to the trunk.

Paraesthesiae

Def.

* Paraesthesiae are spontaneous abnormal sensations, most usually described as ‘pins and needles’.

E.g.

· Physiological paraesthesiae may occur especially during hyperventilation, but in such cases they are generalized, especially perioral, and only intermittent.

· Continuous paraesthesiae are an important indicator of acquired, rather than congenital disease of the nervous system. They are particularly likely in idiopathic demyelinating polyneuropathy, and less commonly in lesions of central sensory pathways.

· Intermittent focal paraesthesiae can occur in

- focal epilepsy of the sensory cortex.

- compressive mononeuropathy, a common example being the finger paraesthesiae at night and after hand usage in carpal tunnel syndrome.

Dysaesthesiae

*Def.*	* Dysaesthesiae are unpleasant distorted sensations resulting from actual sensory stimuli.
*E.g.*	· Usually they occur in focal peripheral nerve damage or polyneuropathies that involve axonal degeneration.

Spontaneous pain

Def.

E.g.

· Spontaneous pain can occur in association with paraesthesiae in peripheral nerve disorders. It is a particular and early feature in the sensory territory of a nerve affected by vasculitis.

· Lancinating pain radiating in a dermatomal distribution down a limb, like an electric shock, suggests spinal-nerve root compression by prolapsed intervertebral disc.

· Painful disorders of an internal viscus, joint, or muscle may be referred to an area of skin either overlying or remote to the abnormality.

· Spontaneous pain in the limbs, trunk, or face can arise from posterior thalamic lesions and has a particularly unpleasant burning character, often with ‘tearing’ or ‘grinding’ qualities.

· Similar sensations of continuous burning, warmth, or cold may result from a spinothalamic-tract lesion, but are clearly localized to within an area of altered skin sensation.

· Spontaneous pain occurs in causalgia and reflex sympathetic dystrophy.

Analgesia and thermoanaesthesia

Def.

E.g.

· Reduced ability to feel pain and temperature sensations occurs in peripheral neuropathies affecting unmyelinated and small myelinated fibres and in lesions of the spinothalamic tract, including syringomyelia and posterior thalamus.

· Painless burns, or unfelt wounds, may occur in the analgesic area.

Lhermitte's symptom

*Def.*	* Lhermitte's symptom consists of an electric shock or strong paraesthesiae radiating down the trunk, and often into the limbs, on sudden flexion of the neck.
*E.g.*	· It is particularly common in myelitis due to multiple sclerosis, and also occurs in cervical spondylitic myelopathy, vitamin B12 deficiency, and some sensory neuropathies involving both the central and peripheral axons of the dorsal root ganglia.

Tight bands and size distortions

*Def.*	* Tight bands and size distortions, such as feeling that the toes are swollen, are abnormal sensations occurring in the fingers and feet of patients
*E.g.*	· They with acquired demyelinating polyneuropathy and lesions of the dorsal columns in the spinal cord.

B-Deep sensation

Clumsiness and Rombergism

Def.

* Clumsiness and Rombergism are due to loss of kinaesthetic feedback via large myelinated peripheral nerve sensory fibres or the dorsal column–medial lemniscus system.

* Hand clumsiness particularly affects the complex motor–sensory integration involved in activities such as doing up buttons or underwear clips, particularly when the eyes cannot monitor the action.

* ‘Dropping things’ may be an associated complaint; although this symptom in isolation rarely denotes disease. Loss of joint position sense from the legs causes gait unsteadiness.

* This is particularly noticeable when the patient tries to walk in the dark or close their eyes in the shower, and is known as Rombergism.

E.g.

C-Cortical sensation

Astereognosis

*Def.*	* Inability to identify coins manually in their pockets or with their eyes closed.
*E.g.*	· Astereognosis occurs in patients with parietal lobe lesions.

Pain should be defined in terms of the following:

Fixed

Variable

* Onset, course, duration

* Precipitating and relieving factors

* Associated symptoms

Distribution (location, radiation)
Character (quality)
Severity (quantity

History of sphincteric disturbance

Urinary

Stool

Incontinence

Urgency

Precipitancy

Partial incontinence

Complete incontinence

Retention

Painful retention.

Painless retention.

UMNL	Partial cord affection →loss of sympathetic inhibitory fibers	1. Urgency: inability to hold micturation 2. Precipitancy: difficulty to hold micturation 3. Hesitancy: difficulty to initiate micturation (post. column affection )
UMNL	Complete cord lesion	} First retention then autonomus bladder
LMNL	Motor	} Painful→ Retention
LMNL	Sensory	} Painless → Retention
Local causes	Weakness of pelvic floor muscle	} Stress incontinence

History of other body systems

(Contributory general medical disorders)

Underlying cancer

Suspect when	Progressively deteriorating neurological symptoms should prompt questions about a possible underlying cancer affecting the nervous system
Ask for	smoking, weight loss, haemoptysis, bowel symptoms, and recent breast and gynaecological check-ups.

Risk factors for stroke

Suspect when	In a patient with stroke
Ask for	a previous history of ischaemic or valvular heart disease, hypertension, diabetes, oral contraceptive usage, migraine, or cocaine abuse

Risk factors for immunosuppression

Suspect when	Unusual neurological disorders, such as opportunistic infections or lymphoma of the central nervous system, are particularly likely in the increasing numbers of immunosuppressed patients.
Ask for	HIV infection, or organ transplantation.

Neurological side-effects of medicines

Suspect when	Typical neurological side-effects of medicines are headache, giddiness, tremulousness tinglings, and peripheral neuropathy;
Ask for	a patient's drugs should be checked in a pharmacopoeia for side-effects, and the onset of the symptoms related to the introduction of the drug.

The travel history

	The travel history may increase the likelihood that a patient's symptoms are due to an underlying infection such as leprosy, schistosomiasis, malaria, diphtheria, or borreliosis.

Drug Abuse

	Patients addicted to alcohol or recreational drugs are notorious for underestimating or denying consumption, which may be directly relevant to disorders such as ataxia and stroke, respectively.

Important miscellaneous factors of the history include the following:

Results of previous attempts to diagnose the condition
Any previous therapeutic intervention and the response to those treatments

Past history

Similar condition

Other neurologic psychiatric disorder

Previous neurological history

This is vital for establishing the diagnosis of multiple sclerosis, a neurological disorder which is disseminated in space and time. Thus, a history of temporary unilateral visual loss due to optic neuritis a decade previously suggests multiple sclerosis in a 30-year-old woman with unsteady gait and urgency of micturition due to an incomplete spinal cord lesion.

Other systemic disorder: medical (cardiac, HTN, DM, TB) surgical (trauma, operations)

Drug intake

Family history

Similar condition: many neurological disorders are genetic, although each of these is usually rare.

History of the relatives of a patient with longstanding muscle wasting and weakness below the knees, and with high foot arches (pes cavus), may reveal autosomal dominant inheritance of a similar disorder, so allowing diagnosis of hereditary motor and sensory neuropathy, otherwise known as Charcot–Marie–Tooth disease.

Sex-linked recessive disorders, transmitted on the X chromosome and occurring in males, will not manifest in the mother, but may be present in the males of earlier or parallel generations.

Consanguinity: first-cousin marriage between the parents may be a clue to autosomal recessive disorders in offspring with neurological disease.

Common Clinical Features of Neurologic Illness by Neuroanatomic Site

Muscle

Weakness without sensory loss
Proximal muscles weaker than distal muscles
Weakness that is often slowly progressive
Muscle atrophy

Neuromuscular Junction

Fatigue (especially to chewing and in proximal limb muscles)
Weakness without sensory loss
Ptosis with changing diplopia
No muscle atrophy

Peripheral Nerve

Mixture of motor and sensory findings
Distribution of signs either in a single nerve or in many nerves
Distal limb signs more pronounced than proximal signs
Trunk uncommonly involved
Pain in feet or along a single nerve distribution
Sensory loss pain and temperature, or vibration and position sense, or to all modalities
Muscle atrophy and occasionally fasciculations corresponding to involved nerve

Nerve Root

Dermatomal distribution of sensory loss
Neck or back pain that may extend into limb
Loss of deep tendon reflex associated with that root
Weakness only in muscles supplied by that root

Spinal Cord

Sensory level is present
Weakness that may involve both legs or all limbs
Bowel and bladder signs
Autonomic nervous system dysfunction
Loss of reflexes at the level of cord involvement with hyperactivity below that level
Babinski's signs
Leg spasticity

Brainstem

Cranial nerve involvement (especially facial weakness, facial sensory loss, dysphagia, dysarthria, hoarseness, and diplopia)
Vertigo
Tetraparesis with four limb weakness and spasticity
Coma or semicoma
Changes in blood pressure, heart rate, and respiratory rate

Cerebellum

Ataxia of limbs and gait
Vertigo
Nystagmus

Basal Ganglia and Thalamus

Extrapyramidal signs (bradykinesia, shuffling gait, masked facies, etc.)
Movement disorder (chorea, athetosis, or tremor, which may be unilateral or bilateral)

Cerebral Cortex

Unilateral focal neurologic signs such as hemiparesis, hemihyposthesia, homonymous hemianopia
Aphasia
Memory loss
Apraxia
Dementia
Seizures

Meninges and Cerebrospinal Fluid

Headache—usually diffuse
Meningismus
Cranial nerve signs—often with multiple nerves involved

Common Clinical Features of Neurologic Illness by Etiologic Group

Vascular

Sudden onset
Asymmetrical signs
Symptoms worse at beginning and then improve
Hemiparesis and hemihyposthesia (but not anesthesia) are common

Inflammatory/Infectious

Fairly rapid onset and progression
Fever common
Signs usually involving meninges or cerebral cortex
White blood cell count and erythrocyte sedimentation rate elevated

Neoplastic

Slowly progressive
In adults, mainly involving cerebral cortex, while in children, mainly involving cerebellum and brainstem
Unilateral focal signs common early in disease

Degenerative / Hereditary

Slowly progressive
Symmetrical signs
Diffuse signs
Pain seldom prominent
Family history of similar illness may be present
Clinical features varying, but often including dementia, parkinsonism, and weakness

Intoxication or Withdrawal

Gradual onset of symptoms over hours to weeks
History of unusual drug or substance usage
Altered mental activity (confusion, delirium, stupor, or coma)
Distal symmetrical polyneuropathy common
Focal neurologic signs less common

Congenital/Developmental

Present at birth or early childhood
Family history of similar disease common
Mainly static but can appear progressive in childhood as child fails to gain developmental milestones
Mental retardation, seizures, and spasticity common

Autoimmune/Demyelinating