Neurological symptoms

Headache (Migraine, Tension) : .Onset .Time .Character .Severity .Duration .Frequency .site .associated feature as vomiting or visual disturbances .aggravating factors .Relieving factors.

Visual disorder : . Impairment .Diplopia .Hallucination .Illusion . Loss of consciousness : .Tongue pitting .Incontinence .Limb twitching .Alcohol& drugs .head injury .CVS & Respiratory symptoms.

Speech disorder : .Difficult in forming words .Difficult in expression .Difficult in understanding. Motor disorder : .Inco-ordination (balance) .weakness .Involuntary movement. Sensory disorder : .Pain .Numbness .Tingling .Site.

Sphincter disorder : (anal, bladder) .Incontinence .retention. Lower cranial nerves disorder: .Deafness .Tinnitus .Vertigo .Balance .Swallowing difficulty .Voice change.

Mental disorder: .Memory disturbance .Intelligence .Personality .Behavior

Diagnosis of Nervous System disorders The most common diseases or clinical problems encountered in a general neurological outpatients clinic are: 1-Headache and face pain 2-Blackout and epilepsy 3-Peripheral nerve and root disorders 4-Cerebrovascular disease 5-Multiple sclerosis 6-Parkinsonism and movement disorders 7-Dementia 8-Giddiness and vertigo 10-Psychologically determined symptoms
(headache, facial pain, spinal pain, tremor, blackouts)

A-History taking .History taking is fundamental to neurological diagnosis (epilepsy, migraine). .The history is usually much more informative than examination, which generally is either reassuringly normal or merely confirms features anticipated from the history. . No particular list of questions to ask. .It is best to invite the patients to describe their symptoms in the order in which they occurred, with approximate dates. .Important detail can be clarified by special questioning during or after the patient's account.

Time course .Symptoms of abrupt or instantaneous onset (epilepsy, CVA, ) .Symptoms that deteriorate sub acutely over hours, days, or even a few weeks are generally caused by inflammatory or demyelinating disorders. .Slowly deteriorating symptoms over some weeks, months, or years point to the growth of tumor, or neurodegenerative process. .Relapsing and remitting symptoms, which come and go over weeks, are typically of MS.

Negative symptoms In which the normal neurological functions are lost, e.g. hemi paresis, memory loss in Alzheimer's disease, muscle weakness due to motor neuron degeneration, or loss of micturition control due to quada equina tumor.

Positive symptoms Positive symptoms are novel phenomena which often suggest specific diagnosis. .A pill-rolling tremor of the fingers and thumb at rest is characteristic of Parkinson's disease. .Flashing light (photopsia) or zigzag lines preceding a headache are diagnostic of classic migraine. .Repetitive twitching of the fingers or the corner of the mouth occur in focal motor seizures. .A hallucination of an odd smell, often like burning rubber, is typical of an epileptic discharge in the temporal lobe.

Neuroanatomical localization
Sometimes enquiry about other specific symptoms is necessary to localize the disease process anatomically. .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. .Question a patients with gait unsteadiness about vertigo or double vision, which would imply damage to the brain stem rather than to the cerebellum or somatosensory pathways.

Eye witness description Patients with blackout are unaware of what they did while unconscious and may not recollect the onset of the blackout. .The eye witness description of a convulsion or automatic behavior is diagnostic of epilepsy. .Patients with motor neuron disease are often unaware of their limb muscle fasciculation, yet their spouse may have notice their occurrence while in bed.

Previous neurological history This is vital for establishing the diagnosis MS, a neurological disorder which is disseminated in space and time. Familial disorders Many neurological disorders are genetic. Examination 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 (Charcot-MarieTooth disease).

Contributory general medical disorders Progressively deteriorating neurological symptoms should prompt questions about a possible underlying cancer affecting the nervous system: smoking, weight loss, haemoptysis, bowel symptoms, and recent breast and gynaecologic check-ups. .In patient with stroke, a previous history of ischemic or valvular heart disease, hypertension, diabetes, oral contraceptive usage, migraine, or cocaine abuse may be relevant.

Typical time course of neurological symptoms

Disorder
Epilepsy Vascular Migraine Infective

Onset
Acute (second) Acute (sec.- min.) Acute (min) Sub-acute (hrs-days)

Typical course
Recurrent attacks (minute) Recovery in hours- days Recurrent attacks (hrs) Worsening- Recovery Varying severity, site Gradual worsening

Demyelination Sub-acute (days- weeks) Tumor Slow (weeks- months)

Degenerative

Slow (months- years)

Gradual worsening

I- What is the lesion (History): Psychogenic (Hysterical) Organic .Congenital & heredity diseases .Acquired Traumatic Vascular Inflammatory Tumor

II- Where is the lesion (examination): A. In the nervous system 1-C.N.S.(UMNL) -Brain Cerebral hemisphere Brain stem Cerebellum -Spinal Cord cervical Thoracic Lumber Sacrococcygeal 2-Periphral N.S.(LMNL) B. In the neuromuscular junction C. In the muscle

Types of lesion as regard site: Focal ( infraction, tumors) Systemic (diffuse): selects anatomically & functionally related systems of cells & fibers as in M.N.D. (U.M.N. &L.M.N.) Disseminated (Multifocal): The lesion is scattered over affecting different sites in the N.S. as M.S., meningovascular, cerebral atherosclerosis, metastasis.

Evaluation + Association Examination Investigations