Neurology Long Case Notes

Common Cases

1. Stroke
2. Collapse
3. Seizures
4. Motor Neuron Disease
5. Multiple Sclerosis (Neurological decompensation or complication)
6. Parkinsons (Complications most likely fall)

1. Stroke
Definition of TIA: neurological deficit which resolves within 24 hours of onset and there is no
radiological features of a stroke.

Radiological evidence overrules timeline when trying to decide on diagnosis - Stroke Vs TIA

History of presenting complaint

Symptoms

Motor or sensory weakness or visual findings will be contralateral.

Cerebellar features are ipsilateral.

Need to illicit all of these in history: Cranial nerve, Motor nerve, sensory nerve or cerebellar
deficits.

Localise each of the symptoms to the side of the body and the specific limbs.

Timeline is important

o When did it start?

o How long before you got to the emergency department? (Thrombolysis)
o Once it started did it stay the same, get worse (NIHSS scale), or improve
(maybe just a TIA)?

NIHSS scale (do not need to know details of this score): it is a score that helps decide
whether you will thrombolyse and prognostic indicator. If score <4 or >21 then you dont
thrombolyse. <4 because risks of thrombolysis outweighs benefit and vice versa.

Few symptoms that patients do not articulate well:

Discoordination: Patients report cant pick stuff up, clumsy, drop stuff you must
get the timeline and localise it.
Start to put together the territory of the stroke (Anterior or Posterior and Dominant or Not
Dominant)

Right handed people Left lobe is dominant in 90% of the time

Left handed people 50/50

Anterior circulation means they have either anterior cerebral artery or middle
cerebral artery involvement and have a combination of contralateral sensory
motor and visual deficit. Speech deficit indicates that it is a dominant lobe stroke. If
there is no speech deficit you cannot exclude a dominant lesion because the lesion
could be small. In Anterior circulation stroke if symptoms worse in leg then superior
part of the MCA is affected and if worse in upper limbs then inferior part is affected.

Posterior Circulation involves posterior cerebral artery with all of its communicating
arteries. Classic features are contralateral motor loss, and less commonly a sensory
loss. Also have features of dysarthria, nausea, vomiting and vertigo. Posterior inferior
communicating artery syndrome(PICA) AKA lateral medullary syndrome: a specific
type of posterior circulation stroke where you have the symptoms above as well as
nystagmus and dissociated sensory loss, so ipsilateral sensory loss from the face up
and contralateral from the face down because of decussation.

Visual Defects:

Visual defects: most commonly homonymous hemianopia in anterior circulation

stroke usually in anterior cerebral artery.

Blurred vision: could be due to homonymous hemianopia, diplopia or nystagmus, you

can differentiate anterior from posterior circulation as the cause the on physical
examination.

Cortical blindness: Patient has poor insight in their loss of visual acuity, in occipital
lobe lesion of posterior circulation. Patient bumps into things commonly.

Amaurosis fugax: curtain coming down, precursor to an actual homonymous

hemianopia.

Risk Factors:

1. Diabetes (ask about details in past medical history)

2. Hypertension
3. Cholesterol
4. Family History Did your Mother, father or siblings have stroke, heart attack, high
blood pressure or sudden death in adult?
5. Smoking history
6. Personal Past History
o Have they had a previous stroke?
o Have they had a mini stroke? Did they get any medication through their arm
to break up the clots? Were you put on tablets? Did you have an operation in
your brain to take the clot out (embolectomy)?
 o A fib have you ever been told you have an irregular heartbeat? Are you on
warfarin?
o Have you ever had a heart attack? Have you ever had your heart stop? Have
you ever been told you have poor circulation? Have you ever been told you
have narrowing in the arteries of your neck?

Investigations since admission

- Did they put you on a BP monitor? Has it been high since you came in?
- Did they put a heart tracing on you? Did they say there was an irregular rate?
- Did they do an ultrasound of your heart? Did they find any clots there?
- Did they do an U/S of your neck? Did they find any narrowing there?
- Did they do a scan of your head? Did they just do a scan (CT) or did they put a wire
in to try and take out the clot(CTA/MRA)?
- Did they give you medication in your arm to try and break up the clot?

Past Medical and Surgical History

Need to get details of the relevant medical and surgical history

Medication

Ask the patient about each of these medications even if the patient doesnt know.

Antiplatelet Aspirin, Clopidogrel

Anticoagulants Heparin, Enoxaparin, Dabigatron, Warfarin

Statin

Folic Acid (To decrease homocysteine levels)

Anti-hypertensive

Diuretics

Diabetic Medication

Inhalers Smokers

Are these tablets you had before admission or since you came into hospital?

Social History

Very important in neurological Disease

Who is at home with you?

Are you working? What do you work as?

Drinking, smoking?
At the moment are you able to feed yourself, dress yourself, walk and go to the toilet by
yourself? If they answer no to any these then ask Bedroom and bathroom downstairs? Is
there a step into the bath? Is there a chairlift?

Who cooks for you at home? Who does the shopping? How far are the shops? Meals on
wheels? Home help?

Since youve been in hospital have you been seeing the physiotherapist, occupational
therapist, SALT? If yes then this gives you the sense that they are quite debilitated.

Stroke in a Young Patient <65

Causes

1. Dissections and aneurysms caused by poorly controlled hypertension (usually due to

a secondary cause of hypertension or illicit drug use), collagen vascular diseases,
Infections (syphilis, chronic IE, HepC, lyme disease), CTD vasculitis (lupus, GCA,
takayasu arthritis and trauma.
2. Thrombophilia Inherited (Protien C, protein S, factor V leidan, Anti-phospholipid
syndrome) or Acquired(more common obesity, smoking, malignancy, medications
(OCP HRT)
3. Structural heart disease Patent Foramen Ovale is most common, people have
PFO but most are asymptomatic
4. Infections - Encephalitis, Meningitis
5. Brain Malignancy Lymphoma, Mets

Risk Factors

As above but including:

1. Has anyone ever told you that you have marfans, SLE, etc?
2. Have you been told that you have any infections? Did they mention that there might
be any infection around the brain like meningitis or encephalitis?
3. Woman miscarriages? DVT? PE?
4. New medications like OCP?
5. Ever been told you have a murmur in your heart?
6. Were you in an accident?

2. Collapse
Cardiogenic: could be vasovagal, arrhythmia, structural heart disease

Neurogenic: mostly seizures, Haemorrhage (stroke is not a common cause of LOC)

Was it witnessed of not? Are you getting their history or the collateral?

Before the episode

 Where were they? What were they doing? (Postural hypotension)
Exertion? Ischemic event that could have caused hypoperfusion of the brain or threw
off the clot
Cardiogenic preceding symptoms Dizzy, lightheaded, did you know you were going
to faint?
Neurological preceding symptoms strange taste, smell, feeling beforehand?
Tinnitus? Tingling in arm of leg? Did you lose your ability to speak?
To rule out mechanical cause did you have your glasses on? Hearing aid in?
Shoes on or not? Was the floor slippy? s the floor carpeted or tiled? Were the lights
on?

During the Episode

How long did it last? Secs to mins cardiogenic syncope ( if not short lived its
cardiac arrest) Neurological tends to be longer
During the episode were you still and slumped on the floor or were your legs and
arms moving?
Were you aware of anything that is happening? LOC?
Incontinence and tongue biting?

After the Episode

Did it resolve spontaneously? Or did you need medication? Cardiogenic always

resolves spontaneously. Neurological you often are talking about seizures so you
would need to give them medication like benzodiazepines
When you woke up were you orientated did you know who you are, where you were,
and what time it was? Neurological they usually are disorientated.
Did you feel any weakness in your body? Cardiogenic have no residual symptoms.
Neurologic you can have residual todds paralysis

Risk factors for Cardiogenic Syncope

Have you ever been told you have a very fast/slow heart beat? An irregular heartbeat?

Have you ever been told your BP is low?

Have you had lots of fainting episodes before? Do they always occur when you go from
sitting to standing or lying to standing?

Have you been told you have a murmur in your heart? That you have narrow valves? Leaky
valves?

Have you been started on BP tablets recently? Or increased the dose?

Did you eat before the event? Hypoglycaemia

Do you have diabetes? What was your blood sugar before and after the event?

Did you have chest pain or palpitations (ischemic event?)

Have you had features of infection fevers? Cough?

Risk factors for Neurogenic Syncope

Do you have epilepsy?

Have you ever had seizures before?

Have you been diagnosed with any growths in the brain?

Have you told you have meningitis or encephalitis?

Have you hit your head? Or had an accident? Subdural haemorrhage: Trauma 6-8 weeks
ago?

Sudden thunderclap headache subarachnoid haemorrhage?

Medications:

Antihypertensive agents

Anti-epileptics

Anti-biotic

Ace inhibitors think PCOS and Subarachnoid haemorrhage

(If they have known postural hypotension treat Conservatively first then fludrocortisone or
midrodine)

Investigations since admission

Did they have a heart tracing? Fast/slow /irregular heartrate

Did they have a blood sugar tested?

Did they have an U/S of their heat done? Any narrowed or leaky valves?

Did anyone measure their BP sitting and standing? Was there a drop when you stood?

Did they do a test when you slept on a table and they strapped you onto it? And you were
brought up? Did you get dizzy or go unconscious?

Did they put a 24hr blood pressure monitor on you?

Did they put a monitor on you that you had to press when you felt dizzy? (helpful in
bradyarrhythmia)

3. Seizure
History similar to collapse history

Main cause of seizures in hospital epilepsy

Non-epileptic seizures are mainly caused by alcohol dependency

Risk Factors

1. Previous head trauma

2. Febrile seizures as a child
3. Family history of seizures
4. Family history of Tuberous sclerosis or Neurofibromatosis
5. History of prematurity
6. Alcohol history
7. Diabetic (hyper/hypo)

Investigations since admission

Have they had leads attached to their head to do tracing of your brain activity?

Have they done a brain scan?

Was their blood sugar tested?

Did they have an U/S of their liver done? (Evidence of underlying cirrhosis)

4. Multiple Sclerosis
Presentations

o Optic neuritis painful unilateral visual loss commonly first presentation

o Sensory deficits (in distribution of homunculus)
o Cerebellar deficit
o Motor deficits (upper motor neuron lesion)

No classical presentation, they present with a mixture of central nervous disease. The
lesions do not localise to one area in the brain.

Establish onset, periodicity and progression of symptoms

Most commonly relapsing remitting symptoms come on acutely, get worse for a few days
then resolve completely. They recur later on.

Secondary progressing begins at relapsing remitting at first but then left with some deficit
at later relapses

Primary progressive residual deficit since first incident, with each incident left with more
deficits

With each new episode is there anything new or extra that happened as well as the stuff you
described before?

Establish precipitants of each deficit

1. Infections (UTI due to urinary retention, skin infections due to sensory deficits,
aspiration pneumonia, Immunosuppressed on high dose steroids)
2. Uhtoffs phenomenon heat causes worsening symptoms. Have they been away on
holiday somewhere warm? Is Ireland warmer?
3. Stress
 4. Concurrent Illness

Do they have any other autoimmune diseases? Where the body attacks itself?
Hypothyroidism addisons etc.

Poor prognostic indicators

1. Female
2. Early age of onset
3. Time between index episode and the second episode
4. Severity of index episode

5. Motor Neuron Disease

History is similar to multiple sclerosis but no sensory deficits or cerebellar deficits, purely
motor deficits and is progressive. There are no eye features. Commonly have bulbar
involvement dysphagia, weight loss, and reflux. No treatment proven to cure it.

N.B. Clumsiness is due to weakness not discoordination.

Investigations since admission

CT brain

Brain tracing

Biopsy of muscle

Biopsy of nerve

Clinical Diagnosis - All to rule out other differentials