Zbieranie wywiadu z zakresu układu nerwowego | Taking a Nervous System History

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Opening Consultation

Before starting, review the patient’s medical records for relevant neurological history if available.

Confirm the patient’s identity politely.

Introduce yourself warmly, stating your name and role.

Chief Complaint (CC)

The Chief Complaint (CC) refers to the main neurological symptom or concern that prompts a patient to seek medical care. Complaints related to the nervous system can reflect a range of disorders impacting the brain, spinal cord, peripheral nerves, or sensory systems. Understanding these common complaints aids in forming an initial clinical impression and guiding a focused neurological examination. Typical complaints include:

Complaint	Description
Headache	Headaches vary in type and severity, from mild tension headaches to severe migraines. Tension headaches often feel like a tight band around the head, while migraines may be throbbing, unilateral, and associated with symptoms like nausea, vomiting, or sensitivity to light and sound. Severe, sudden-onset headaches (e.g., “thunderclap” headaches) may signal more serious conditions like subarachnoid hemorrhage and require urgent evaluation.
Dizziness and Vertigo	Dizziness can refer to a general feeling of lightheadedness or imbalance, while vertigo is a sensation of spinning or movement. Vertigo often suggests issues in the inner ear or vestibular system, while dizziness may indicate blood flow changes, dehydration, or neurological conditions like multiple sclerosis. Symptoms may be episodic or continuous, impacting daily functioning and safety, particularly in elderly patients.
Seizures	Seizures are episodes of uncontrolled electrical activity in the brain, resulting in symptoms ranging from brief staring spells to full-body convulsions. Causes can include epilepsy, infections, traumatic brain injury, or metabolic abnormalities. A detailed seizure history (type, duration, frequency, and triggers) is essential for diagnosis and management.
Numbness and Tingling	Numbness or paresthesia often presents in specific areas (e.g., hands, feet) and may indicate peripheral neuropathy, spinal nerve compression, or systemic conditions like diabetes or vitamin deficiencies. Sudden onset or hemibody numbness could suggest a stroke or transient ischemic attack (TIA) and requires immediate attention.
Weakness	Weakness can be generalized or focal, affecting specific muscles or muscle groups. Conditions causing weakness range from neuromuscular disorders (e.g., myasthenia gravis) to stroke, spinal cord injury, and multiple sclerosis. Differentiating true weakness from fatigue or pain-limited strength is crucial for accurate diagnosis.
Memory Loss	Memory impairment varies from mild forgetfulness to severe amnesia. Common in aging, mild cognitive impairment (MCI) can progress to dementia. Conditions like Alzheimer’s disease, stroke, or head injury can contribute to memory loss. A detailed history of the progression, associated symptoms, and impact on daily life is essential.
Speech Disturbances	Speech issues include aphasia (difficulty in speaking or understanding language) and dysarthria (difficulty articulating words). Aphasia often results from damage to specific brain areas, like in stroke, while dysarthria may stem from nerve or muscle weakness affecting speech. Evaluation of onset, progression, and associated symptoms is key to diagnosis.
Visual Changes	Visual complaints range from blurry vision and double vision (diplopia) to partial or complete vision loss. Causes include optic neuritis, retinal detachment, stroke, or brain tumors. A sudden or progressive pattern, along with associated symptoms like eye pain or headaches, can provide diagnostic clues.
Sleep Disorders	Sleep disturbances encompass insomnia, hypersomnia, and disorders like restless legs syndrome. They may stem from neurological, psychiatric, or environmental factors and affect overall quality of life. In severe cases, sleep apnea may cause significant daytime fatigue and cardiovascular risk.
Gait and Balance Problems	Difficulty with walking or balance may indicate issues with the cerebellum, inner ear, spinal cord, or peripheral nerves. Conditions like Parkinson’s disease, stroke, or cerebellar ataxia may present with abnormal gait patterns. History of falls, unsteadiness, and progression of symptoms aid in diagnosis.

History of Present Illness

Headaches are a common neurological complaint, and their causes range from benign tension headaches to serious, life-threatening conditions. A systematic approach using the OLD CARTS mnemonic is essential to comprehensively evaluate headache characteristics, identify potential red flags, and guide clinical decision-making.

OLD CARTS Assessment of Headaches

O – Onset: Understanding when the headache began can help differentiate between primary and secondary headache disorders. Sudden onset, such as a “thunderclap” headache, may indicate a subarachnoid hemorrhage or vascular cause, while gradual onset is more typical of tension-type or cluster headaches.

L – Location: The location of the headache can offer clues about the type. Migraines are often unilateral, while tension-type headaches tend to be bilateral and band-like. Cluster headaches are typically localized around one eye, and sinus headaches are commonly felt in the forehead or cheek area.

D – Duration: Duration helps in distinguishing between episodic and chronic headaches. Migraine episodes can last from a few hours to several days, while cluster headaches occur in shorter, repetitive bursts. Chronic headaches, such as chronic migraine, occur on more than 15 days per month for at least three months.

C – Character: Describing the nature of the pain is crucial. Migraines are often throbbing or pulsating, whereas tension-type headaches are usually dull and pressing. A stabbing or excruciating quality around one eye might indicate a cluster headache.

A – Associated Symptoms: Symptoms accompanying the headache can provide diagnostic clues. Migraines often involve nausea, vomiting, and sensitivity to light and sound, while cluster headaches may present with tearing, nasal congestion, or restlessness. Neurological signs, such as vision changes or weakness, may suggest more serious conditions like stroke or tumor.

R – Radiation: While headaches don’t typically radiate like pain from musculoskeletal issues, asking if the pain spreads to other areas, such as the neck or face, can help identify cervicogenic or referred headache pain.

T – Timing: Timing and pattern of the headache are important. Migraines often have identifiable triggers and follow a predictable pattern, while cluster headaches occur in cyclical patterns, commonly at the same time each day. Timing can also relate to situational factors, like increased headaches in the morning in patients with sleep apnea.

S – Severity: Assessing the severity on a scale from 0 to 10 helps quantify the headache’s impact on daily life and provides a benchmark for future comparison. Severe headaches that disrupt daily activities, require bed rest, or prompt emergency visits may indicate the need for specialized evaluation.

Past Medical History

Understanding the patient’s past medical history is crucial for identifying underlying neurological conditions or other factors contributing to nervous system complaints:

• Migraine or Other Headaches: A history of migraines or other chronic headaches can provide insight into recurrent or familial neurological conditions.
• Seizures or Epilepsy: A past diagnosis of epilepsy or seizure disorder may indicate a need for ongoing management and adjustments in medication.
• Stroke or Transient Ischemic Attacks (TIAs): A history of stroke or TIAs suggests increased risk of neurological complications, particularly in older adults or those with cardiovascular conditions.
• Multiple Sclerosis (MS): MS, a chronic disease that affects the central nervous system, can cause symptoms like numbness, vision changes, and weakness that fluctuate over time.
• Neuropathy: Previous diagnoses of peripheral neuropathy or diabetic neuropathy provide context for sensory or motor symptoms in the extremities.
• Parkinson’s Disease or Other Movement Disorders: A history of Parkinson’s or related conditions may explain symptoms such as tremors, gait issues, or muscle rigidity.
• Demyelinating Diseases: Conditions that damage nerve coverings (e.g., MS or Guillain-Barré Syndrome) impact motor and sensory functions and may result in recurrent neurological symptoms.

Medications

Evaluating the patient’s current and past medications offers insights into their neurological health and identifies potential side effects affecting the nervous system:

• Neurological Medications: Medications such as anticonvulsants, antidepressants, or migraine treatments may indicate an underlying neurological disorder. Assess the efficacy and any side effects of these medications.
• Blood Pressure and Cardiovascular Drugs: Medications for blood pressure control, especially those with CNS effects (like beta-blockers), can impact neurological symptoms, including fatigue or dizziness.
• Medications with Neurological Side Effects: Some medications, such as antipsychotics or sedatives, can lead to neurological side effects, such as tremors or cognitive changes.
• Recent Changes in Medication: Changes in medications, particularly for blood pressure, diabetes, or psychological conditions, may influence neurological symptoms or affect cognitive functioning.

Family History

Family history can help uncover hereditary neurological conditions. Important conditions to inquire about include:

• Epilepsy: A genetic predisposition to epilepsy or seizure disorders suggests a familial risk.
• Neurodegenerative Diseases: Conditions like Parkinson’s disease, Alzheimer’s, or Huntington’s disease often run in families and may increase the patient’s risk.
• Migraine: A strong family history of migraines can indicate genetic factors in the development of chronic headaches.
• Multiple Sclerosis (MS): Although not strictly hereditary, MS has a genetic component and is more likely in those with a family history of the disease.

Social History

Social history helps to assess lifestyle factors that can influence neurological health:

• Substance Use: Alcohol, recreational drug use, and smoking can affect the nervous system and contribute to conditions such as peripheral neuropathy or cognitive impairment.
• Occupation: Jobs that involve exposure to chemicals or require repetitive physical tasks (e.g., bending, heavy lifting) may contribute to neurological symptoms or increase the risk of nerve damage.
• Stress and Mental Health: Chronic stress, anxiety, and depression may exacerbate neurological symptoms and are closely linked to conditions like migraines and tension headaches.
• Physical Activity: Regular physical activity is linked to better cognitive health and lower risks of neurodegenerative diseases. Sedentary behavior may contribute to poor circulation and neuropathy.

Allergies

Identifying allergies, especially to specific medications or environmental factors, is important for managing neurological conditions:

• Drug Allergies: Allergies to medications like anticonvulsants or NSAIDs may necessitate alternative treatments for managing neurological symptoms.
• Environmental Allergies: Some environmental allergens, particularly mold or pollutants, may exacerbate conditions like migraines or cognitive symptoms.

Environmental and Occupational Exposures

Environmental and occupational exposures can impact neurological health through long-term or repeated exposure:

• Chemical Exposure: Exposure to neurotoxic chemicals (e.g., solvents, heavy metals) at work or home may lead to symptoms like neuropathy or cognitive issues.
• Physical Demands at Work: Repetitive motion or activities that strain the body can contribute to carpal tunnel syndrome or other compressive neuropathies.

Closing the Consultation

Summarize the main points discussed during the history-taking to confirm understanding and ensure no details were missed.

Ask the patient if they have any remaining questions or concerns before moving forward with the examination.