UNIVERSITY OF BAGHDAD

COLLEGE OF MEDICINE

HISTORY NOTES
2022-2023

THE NERVOUS SYSTEM

Grade: Three HISTORY NOTES
Module: CA
Speaker: Internal medicine department
Date: 30th October 2022
 THE NERVOUS
SYSTEM HISTORY
NOTES
Remember the two key questions:
where (in the nervous system) is the
lesion and what is the lesion?

Neurological symptoms may be difficult

for patients to describe, so clarify exactly
what they tell you.

Words such as ‘blackout’, ‘dizziness’,

‘weakness’ and ‘numbness’ may have
different meanings for different patients,
so ensure you understand what the
person is describing
 High duration

Persistent Less frequent

More period between each fit

Time relationships
Symptom free may be long or small
Migrain happen twice each month
Then remain sympton free for about a 5 months

◦ The onset, duration and pattern of symptoms over time often

provide diagnostic clues: for example, in assessing headache or
vertigo Intermittent
‫معناها بدون حاجة للتفصيل‬
‫ بني كل وحدة ووحدة قليلة ونحتاج نسال عنها‬period ‫انه اكو‬
Ask: ‫التكرار او الفركونسي غالبا عالي بايام قليلة واملدة الي يبقى بيها االلم هم قلبلة‬
‫وهنا حالة جدا خطرة‬

• When did the symptoms start (or when was the patient last well)?
• Are they persistent or intermittent?
• If persistent, are they getting better, getting worse or staying the
same?
• If intermittent, how long do they last,
and how long does the patient remain
symptom-free in between episodes? Periodicity
‫ الي بلش بي‬setting ‫تحتاج تسال عن املود اوف اونسيت او‬
‫االلم يعني شجان يسوي من بدة االلم وجذي‬

• Was the onset sudden or gradual/evolving?

‫تجي كلش سريعة عبالك الرعد من يطك‬

‫وتوصل للماكسيموم انتيستي هم بسرعة عالية‬
Precipitating, exacerbating or
relieving factors
• What was the patient doing when the symptoms occurred?

• Does anything make the symptoms better or worse, such as time of day,
menstrual cycle, posture or medication?
Associated symptoms Associated
symptoms
◦ Can aid diagnosis. For example, headache may be associated with nausea,
vomiting, photophobia (aversion to light) and/or phonophobia (aversion to
sound) in migraine; headache with neck stiffness, fever and rash may be
associated with meningitis
COMMON PRESENTING
SYMPTOMS
Headache
◦ Headache is the most common neurological symptom and may be either primary or
secondary to other pathology.
Primary (idiopathic) causes include:
• migraine
• tension-type headache
• trigeminal autonomic cephalalgias (including cluster headache)
• primary stabbing, cough, exertional or sex headache
Subarachnoid hemmorage
• primary thunderclap headache
• new daily persistent headache.

Secondary (or symptomatic) headaches are less common, but include potentially life-
threatening or disabling causes such as subarachnoid haemorrhage or temporal arteritis.
Clinical characteristics of headache syndromes
Transient loss of consciousness
Syncope is loss of consciousness due to inadequate cerebral perfusion and is the most
common cause of transient loss of consciousness (TLOC).
Vasovagal (or reflex) syncope (fainting) is the most common type and precipitated by
stimulation of the parasympathetic nervous system, as with pain or intercurrent illness.
Exercise-related syncope, or syncope with no warning or trigger, suggests a possible
cardiac cause.
TLOC on standing is suggestive of orthostatic (postural) hypotension and may be caused
by drugs (antihypertensives or levodopa) or associated with autonomic neuropathies,
which may complicate conditions such as diabetes
Seizure
The history from the patient and witnesses can help distinguish syncope from epilepsy

An epileptic seizure is caused by paroxysmal electrical discharges from either the whole
brain or part of the brain

Enumerate types of seizure , mention examples

Stroke and transient ischaemic attack
A stroke is a focal neurological deficit of rapid onset that is due to a vascular cause.

A transient ischaemic attack (TIA) is the same but symptoms resolve within 24 hours. TIAs
are an important risk factor for impending stroke and demand urgent assessment and
treatment.

Isolated vertigo, amnesia or TLOC are rarely, if ever, due to stroke.

In industrialised countries about 80% of strokes are ischaemic, the remainder

haemorrhagic.
◦ Factors in the history or examination that increase the
likelihood of haemorrhage rather than
ischaemia include ………………………………………….

use of anticoagulation, headache, vomiting, seizures and early

reduced consciousness

Define Spinal strokes and The anterior spinal artery syndrome

Dizziness and vertigo
Recurrent ‘dizzy spells’ affect approximately 30% of those over 65 years and can be due
to postural hypotension, cerebrovascular disease, cardiac arrhythmia or hyperventilation
induced by anxiety and panic

Vertigo (the illusion of movement) specifically indicates a problem in the vestibular

apparatus (peripheral) or, much less commonly, the brain (central)
Functional neurological symptoms

Many neurological symptoms are not due to disease. These symptoms are often called
‘functional’ but other (less useful and more pejorative) terms include psychogenic,
hysterical, somatisation or conversion disorders.

Presentations include blindness, tremor, weakness and collapsing attacks, and patients
will often describe numerous other symptoms, with fatigue, lethargy, pain, anxiety and
other mood disorders commonly associated
 Past medical history
Symptoms that the patient has forgotten about or overlooked may be important; for
example, a history of previous visual loss (optic neuritis) in someone presenting with
numbness suggests multiple sclerosis.

Birth history and development may be significant, as in epilepsy.

If considering a vascular cause of neurological symptoms, ask about important risk

factors, such as other vascular disease, hypertension, family history and smoking.
 Drug history
Always enquire about drugs, including prescribed, over-the counter,
complementary and recreational/illegal ones, as they can give rise to many
neurological symptoms

Give examples
for example, phenytoin toxicity causing ataxia; excessive intake of simple
analgesia causing medication overuse headache; use of cocaine provoking
convulsions
 Family history
In some communities, parental consanguinity is common, increasing the risk of autosomal
recessive conditions, so you may need to enquire sensitively about this.

Many neurological disorders are caused by single-gene defects, such as myotonic dystrophy or Huntington’s
disease. Others have important polygenic influences, as in multiple sclerosis or migraine.

Some conditions have a variety of inheritance patterns; for example, Charcot–Marie–Tooth disease may be
autosomal dominant, autosomal recessive or X-linked.

Mitochondria uniquely have their own DNA, and abnormalities in this DNA can cause a range of disorders that
manifest in many different systems (such as diabetes, short stature and deafness), and may cause common
neurological syndromes such as migraine or epilepsy.

Some diseases, such as Parkinson’s or motor neurone disease, may be either due to single-gene disorders or
sporadic.
 Social history
Alcohol is the most common neurological toxin and damages both the CNS (ataxia, seizures, dementia) and
the PNS (neuropathy)
Poor diet with vitamin deficiency may compound these problems and is relevant in areas affected by famine
and alcoholism or dietary exclusion. Vegetarians may be susceptible to vitamin B12 deficiency.
Recreational drugs may affect the nervous system; for example, nitrous oxide inhalation causes subacute
combined degeneration of the cord due to dysfunction of the vitamin B12 pathway
Smoking contributes to vascular and malignant disease.
Always consider sexually transmitted or blood-borne infection, such as human immunodeficiency virus (HIV)
or syphilis, as both can cause a wide range of neurological symptoms and are treatable.
A travel history may give clues to the underlying diagnosis, such as Lyme disease (facial palsy),
neurocysticercosis (brain lesions and epilepsy) or malaria (coma).
 Occupational history
Occupational factors are relevant to several neurological disorders.

For example, toxic peripheral neuropathy, due to exposure to heavy or organic metals
like lead, causes a motor neuropathy; manganese causes Parkinsonism.

Some neurological diagnoses may adversely affect occupation, such as epilepsy in

anyone who needs to drive or operate dangerous machinery.

For patients with cognitive disorders, particularly dementias, it may be necessary to

advise on whether to stop working.
Thank you