Neuropsychiatry Module 2010-2011

History and Topical Diagnosis in

Neurology

Dr Jofizal Jannis Sp.S(K)

Dr. Darma Imran SpS
Department of Neurology
Faculty of Medicine University of Indonesia
 Learning objectives

The importance of history taking in

neurology
Topical diagnosis in nervous system
Clinical method
Clinical Case
 Introduction
We enter medicine for many different reasons but
two most frequently reasons : we love humanity and
science.

Patients and family want a doctor with :

A doctor who is caring and who will understand the
patients problems and who will listen, advise and support
both the patients and their families.

Our job is not simply about making a diagnosis, it is

about helping and caring for patients with their
medical problems.
 History
History taking is usually your first contact with
the patient
It is establishes the foundation for your future
relationship with the patient and their family.
It is a time when you begin to build :
trust, confidence and authority.
 History taking requires :
1. time,
2. skill,
3. concentration
4. experience
5. tact and diplomacy
6. patience.

your only lack is only on point 4

 Coma
Coma history (from relatives or attendants)
Onset of coma (abrupt, gradual)
Recent complaints (headache, focal weakness,
vertigo etc)
Recent injury
Previous medical illnesses (e.g., diabetes, renal
failure, heart disease)
Previous psychiatric history
Access to drugs (sedatives, psychotropic drugs)
 The onset of coma
Sudden onset :
In a previously healthy, young patient : drug poisoning,
subarachnoid hemorrhage, or head trauma
In the elderly : cerebral hemorrhage or infarction.

Gradual onset :
A history of premonitory signs, including focal weakness
such as dragging of the leg or complaints of unilateral
sensory symptoms or diplopia, suggests a cerebral or
brainstem mass lesion.
Most patients with metabolic disorders
 Case 1
A 50 year old man with a sudden lost of
counsciouness while in the meeting at his
office
Physical examination :
Blood pressure 200/110 mmHg
GCS E1M4V1=6
Pin point pupil
Where is the possible lesion
Brain lesion : pons
Changes in pupils in patients with lesions at different
levels of the brain that cause coma
 Case 2
Sheet B1

A 40 year old man

with left lower limb
and upper limb
weakness :
Where is the
possible lesion
 Case 3
Sheet B1

A 30 year old man,

compos mentis but
had an all-four
limb weakness :
Where is the
lesion ?
 Case 4
A 73-year-old woman had a 4-days history of fever, nausea, and
vomiting.
she awoke on the third day and found it difficult to walk to the
bathroom, by the afternoon she had difficulty in swallowing

Physical examination :
Vital sign normal, E3M6V5.
Pupils were equal and constricted from 3 to 2 mm with light,
Diplopia when try to look to the left side
left-sided facial numbness
left lower motor neuron facial weakness.
the tongue deviated to the right
the left limbs were clumsy comparing to her right side
 Case 4 : question
1. Did the patients had a neurological problem ?
mention her deficits
2. Where is the lesion (anatomical diagnosis)
 Case 4 : answer
Left abducens palsy (N. VI)
Left facial palsy (N. VII)
Left trigeminal (sensory) nerve deficit (N.V)
Left hypoglossal palsy (N XII)
..

Where is the lesion ?

 Case 4 : answer

Look at
your C1
sheet

Peter Duus.2005
page65
 Case 4 : question
Is it possible to have brain stem lesion and at
the same time retain relatively good
consciousness ?
 Case 4 : answer
Look at your A1 and A2 sheet

Plum 2007 page29-30

 Case 5
History
A 28 year-old man was riding a motor cycles, when suddenly he
crash to another motor cycle approaching from the side.
Luckily After the accident he is alert, with out a significant injury.
Further inquiry from the doctor , revealed that in the past 6 several
times he bumped into something in his side while walking.
He also complaint that he can not get an erection since 3 month
ago.

Physical examination :
Vital sign normal
Visual acuity normal
Confrontation visual field testing : peripheral visual field lost on both side

What is his problem ? Eye problem or

Neurological problem ? Or both ?
 Case 5 : answer

Peter Duus.2005
page 131
 Case 5 : answer
What are the possible pathology underlying
this case ?
 Clinical method

Through case 1 - 5 we already exercise clinical

method to understand patients problem
 Clinical method

This is an orderly series of steps, as follows:

1. Symptoms and signs
2. Anatomic diagnosis
3. Pathologic and etiologic diagnosis
4. Prognosis and treatment
 Symptoms and signs
The fundamental steps in diagnosis always
involve the accurate elicitation of symptoms
and signs and their correct interpretation in
terms of disordered function of the nervous
system.

Most often when the diagnosis is wrong, it will be

found later that the symptoms were incorrectly
interpreted in the first place.
 Symptoms and signs
History and physical examination.
symptoms and physical signs considered relevant
to the problem at hand are interpreted in terms of
physiology and anatomy :
identifies the disorder(s) of function
pathophysiology -pathogenesis
the anatomic structure(s) that are implicated.
 Conclusion

Neurology is not a difficult subject, enjoy

taking care of your patients sign and
symptoms and give a solution to their
problem.
 Thank you

Dr Jofizal Jannis Sp.S(K)

Dr. Darma Imran SpS

Dep of Neurology Faculty of Medicine

University of Indonesia
correspondence
darma_imran@yahoo.com
 Hemiparesis
Phys reflexes
Patho reflexes Quadry/paraparesis
Phys reflexes
Cranial nerve palsy Path reflexes
Cortical brain fc dist Sensory level
Autonom disturb

Monoparesis
Phys reflexes
No path reflexes
Radiks Sensory ~ dermatome segment

Paralysis asendens
Symmetry GBS
Neuromuscular junction KPR -/-

Fluctuate, recurrent
Muscle Proxymal > distal Activity influences
Gower sign Palpebra, dysphagi-
Duck gait disphonia
No sensory disturbances
Miastenia Gravis