CNS - History taking

Objectives Where is the lesion? What is the pathology –inflammatory/vascular/tumor/infection Is it a CNS manifestation of a systemic disease?

Basic information Age –vascular / inherited / inflammatory Handedness –Left hemisphere dominant in almost all righthanded and 3/4 of lefthanded Chief complaints –Headache / Loss of consciousness / falls

Headache Most common symptom Ask (SOCRATES) –Site –Onset –Character –Radiation –Associated symptoms –Timing –Exacerbating/Relieving factors –Severity

Migraine –Episodic & severe - –with or without aura –unilateral or bilateral –throbbing or pounding –a/w nausea, vomiting, photo/phono phobia –lasts less than 24 hours

Onset & course Acute single episode –SAH, acute meningitis Acute recurrent –Migraine, cluster h, neuralgia, sinusitis Subacute single episode –Infectious, raised ICT, Temporal arteritis Chronic –C. spondylosis, depression

Subarachnoid hemorrhage Headache maximal at onset a/w loss of consciousness, seizures, photophobia, vomiting, neck stiffness

Meningitis/Encephalitis Less abrupt onset a/w fever, rash, photophobia, neck stiffness

Raised Intracranial pressure Poorly localized headache worse on waking up aggravated by stooping, coughing, straining

Neuralgia focal, knife like or burning pain recurrent paroxysms lasting seconds precipitated by activities such talking brushing teeth, shaving or eating

Temporal arteritis New onset headache in patients over 55 years. Tenderness over the temporal arteries

Loss of consiousness Syncope Seizures Dizziness/vertigo

Take history from the witness Where did the attacks take place Triggers, warning signs, Duration/frequency of attacks

Syncope Loss of consciousness due to inadequate cerebral perfusion Vasovagal syncope most common –pain, emotion, sight/thought Presyncope –lightheaded, tinnitus, nausea, feels faint Syncope during exercise suggests cardiac cause

Seizures Generalized or focal loss of consciousness Simple focal or complex focal Witness to seizure

Generalized seizure Prodrome - change of mood/aura Tonic –LOC, spasm, cyanosis, fall Clonic –jerking of limbs, tongue biting Postictal –flaccidity, confusion, headache, amnesia

Syncope vs seizure seizure –no warning –while lying flat –synchronized rhythmic jerking –cyanosis (pallor in syncope) –tongue biting –confusion & amnesion - post-event

Dizziness & vertigo Vertigo - illusion of movement –vestibular or brain lesions Dizziness - common in the elderly –postural hypotension –cerebrovascular disease, verterbrobasillar insufficiency –arrhythmia –hyperventilation

Vertigo migraine brainstem infarct multiple sclerosis meniere's Benign paroxysmal vertigo trauma drugs

Falls Accidental acute illness loss of consciousness multiple risk factors –disease: CVD, Alzheimer, Parkinson –disability: impaired balance/vision/gait –drugs

Nature & location of symptoms understand what the patient says - terms used by patient may be ambiguous

Witness When patient is unconscious or has cognitive disturbance

Time relationship When did the symptoms start constant or intermittent duration, if intermittent do they get better or worse was onset sudden or gradual

Precipitating, exacerbating or relieving factors Associated symptoms

Past history Past history - epilepsy risk factors for vascular disease –other sites, HTN, smoking, Family H

Drug history recent drug history drugs –anticonvulsants, sedatives, b-blockers

Family history genetic - cerebellar ataxia, huntington multifactorial - migraine, MS

Social history Alcohol - ataxia, seizures, peripheral neuropathy Smoking - malignancy, stroke drugs of abuse - seizures, strokes HIV - CNS symptoms