NEUROLOGY AND NEUROSURGERY - Y. V. ALEKSEEENKO - 2014
CASE HISTORY OUTLINE
General Patient Information
• Patient's full name
• Year of birth
• Place of residence
• Place of employment
• Date of admission
• Date of discharge
Chief Complaints
Listed in order of significance and grouped by systems and syndromes. The severity and duration of leading symptoms, as well as their interrelationship, should be specified.
History of Present Illness
Onset of the disease, causative and triggering factors, sequence of occurrence and dynamics of individual clinical manifestations, and the course of the disease. Previous treatments and their outcomes.
Personal History
Information regarding the perinatal period and developmental stages across age groups. Education. Marital status and family composition. Living conditions. Occupational history and working conditions. Past illnesses, injuries, intoxications, and surgeries. Allergic reactions or intolerances to medications, chemicals, or food products. Physical activity and intellectual workload at various age levels, along with overall work capacity. Bad habits. Health status of close relatives. Genealogical chart.
General Status
General condition of the patient (satisfactory, moderately severe, severe, extremely severe). Patient's posture and position (active, passive, forced). Body build, height, and weight. Body Temperature. Condition of the Skin, mucous membranes, Hair, and Nails. Subcutaneous adipose tissue and Lymph Nodes.
Skull shape (normal, dolichocephaly, brachycephaly, etc.) and dimensions (normal, microcephaly, macrocephaly). Presence of soft tissue scars, bone defects, and local tenderness upon Palpation or Percussion of the HEAD. Spinal configuration (normal, Kyphosis, Scoliosis, kyphoscoliosis, hyperlordosis, etc.), range of motion in various spinal segments, tenderness upon palpation of paravertebral points, paravertebral Muscle tension, and tenderness upon palpation or percussion of the spinous processes. Joints: deformities, pain during movement and palpation, contractures. Minor congenital anomalies.
Respiratory system. Depth and rhythm of breathing. Cardiovascular system. Blood pressure, pulse. Digestive System. Genitourinary and endocrine systems.
Neurological Examination
State of consciousness and specific mental Functions
Quantitative Assessment of the level of consciousness (alert, moderate obtundation, deep obtundation, sopor, moderate coma, deep coma, terminal coma), evaluated using the Glasgow Coma Scale. Qualitative alterations of consciousness: delirium, twilight state of consciousness, delusions and hallucinations, psychomotor agitation, etc. Orientation to person, place, and time. Evaluation of the patient's ability to maintain full contact with the physician and others, as well as the appropriateness of their attitude toward their condition. Correspondence of intellect to age and educational level. Attention span and memory for recent and remote events. Amnesia. Mood (stable, depressed, depression, apathy, tearfulness, euphoria, increased irritability, anxiety, etc.). Hypochondria, obsessive fears, thoughts, and actions. Sleep: depth and duration, ease of falling asleep and waking, adequacy of rest.
Speech, Praxis, Gnosis
Spontaneous speech and speech comprehension. Accuracy, clarity, and expressiveness of speech. Note any scanned or monotonous speech patterns, slurring, bradylalia, stuttering, and other defects. Preservation of articulation (dysarthria in bulbar and pseudobulbar disorders). Aphasia (motor, sensory, amnesic, semantic, total, etc.) in hemispheric lesions. Assessment of writing, reading, and calculation. Preservation of The ability to execute sequences of purposeful actions (praxis). Comprehension of visual and auditory stimuli, and orientation to body scheme (gnosis).
Class="center">Cranial Nerve Functions |
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Cranial Nerves and Their Functions |
Possible Disorders |
I. Olfaction. |
Anosmia, hyposmia, hyperosmia, olfactory agnosia, olfactory hallucinations. |
Decreased visual acuity, blindness. Concentric constriction of visual fields, scotomas. Hemianopia: homonymous, heteronymous (bitemporal, binasal) hemianopias. Achromatopsia, color blindness. Retinal vascular changes, papilledema, signs of primary or secondary optic atrophy. |
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[II, IV, VI Width and Symmetry of palpebral fissures. Position and range of motion of the eyeballs. Shape, size, and symmetry of pupils, reaction to light, accommodation, and convergence. |
Ptosis, Asymmetry of palpebral fissures. Divergent or convergent strabismus, gaze palsy. Double vision (diplopia). Miosis, mydriasis, anisocoria. Impaired (sluggish or absent) pupillary reactions to light, accommodation, and convergence. Exophthalmos or enophthalmos. Horner's syndrome. Nystagmus. |
V. Pain, temperature, and tactile sensation of the facial and scalp skin, oral mucosa, and Tongue. Sensitivity of Trigeminal nerve exit points. Function of masticatory Muscles. Corneal and mandibular Reflexes. |
Pain and sensory disturbances (hypesthesia, paresthesia, hyperesthesia) within the innervation zones of trigeminal nerve branches or facial segmental areas. Tenderness at trigeminal points. Weakness and atrophy of masticatory muscles. Diminished corneal and mandibular reflexes. |
VII. Symmetry of the frontal, nasolabial folds, palpebral fissures, and Mouth corners. Frowning of the eyebrows, wrinkling of the forehead, eye closure, cheek puffing, showing Teeth. Hearing, lacrimation, salivation, taste. |
Facial asymmetry, impaired movement of the facial musculature. Lagophthalmos. Bell's sign. Tics, fibrillary or fascicular twitching of the facial muscles. Hyperacusis. Dry eye. Dry mouth. Taste disturbances in the anterior 2/3 of the tongue. Symptoms of oral automatism (pout reflex, palmomental reflex, etc.) in hemispheric lesions. |
VIII. Hearing, air and bone conduction of sound, vestibular functions. |
Hearing loss, tinnitus, auditory hallucinations. Lesions of the sound-conducting or sound-perceiving apparatus. Dizziness, nystagmus, vestibular ataxia. |
IX, X. Swallowing, phonation, mobility of the soft palate. Palatal and pharyngeal reflexes. Taste sensitivity on the posterior third of the tongue. |
Dysphagia, dysphonia. Decreased pharyngeal reflex, soft palate reflex. Taste disturbance on the posterior third of the tongue. |
XI. Head rotation and tilting, shoulder elevation. |
Atrophy and weakness of the sternocleidomastoid and upper portions of the trapezius muscles. |
XII. Tongue movements and articulation. |
Impaired tongue mobility, deviation to the side in unilateral lesions, muscle atrophy, fibrillary twitching. Dysarthria. |
Motor system |
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Possible types of disorders |
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Muscle volume, relief, and proper development. |
Atrophy, hypotrophy, pseudohypertrophy, fibrillary and fascicular muscle twitching. |
Volume and character of active (voluntary) movements. Range of passive movements. Certain forms of habitual motor activity (walking, etc.). |
Limited range of motion. Contractures. Akinesia, oligokinesia, bradykinesia. Gait — spastic, paretic, hemiparetic, ataxic, parkinsonian, etc. |
Strength of the neck, limb, and trunk muscles. |
Decreased muscle strength. Pathological fatigability, either diffuse or localized to a specific muscle group. |
Muscle tone. |
Hypertonia of the pyramidal or extrapyramidal type, atonia, muscle hypotonia. |
Tendon and periosteal reflexes (biceps, triceps, brachioradialis, knee, Achilles). Superficial reflexes (upper, middle, and lower abdominal, plantar, cremasteric, anal). |
Loss, reduction, or exaggeration of reflexes. Asymmetry (anisoreflexia), expansion of reflexogenic zones. FOOT clonus, patellar clonus, etc. Pathological plantar reflexes (Babinski, Oppenheim, Rossolimo, etc.). Pathological hand reflexes. Protective reflexes. Pathological synkinesia. |
Presence and nature of pathological motor phenomena. |
Hyperkinesia (tics, choreic hyperkinesia, athetosis, torsion dystonia, etc.). Tremor of the extremities, head. Myotonic phenomena. Forced laughter and crying. Cramps. Convulsions. |
Coordination of movements: accuracy of certain forms of habitual motor activity (speech, writing, walking, etc.), Romberg tests (simple and complex), finger-to-Nose and heel-to-knee tests. Diadochokinesia test. Pronator test. Stewart-Holmes and Babinski tests. |
Scanned speech. Megalography. Swaying while walking. Instability in the Romberg pose. Uncertainty or past-pointing, intention tremor during pointing tests. Adiadochokinesia. Asynergia, dysmetria. Ataxia: static, dynamic; cerebellar, vestibular, frontal, sensory, hysterical. |
Sensory system
Pain, paresthesia. Their character, localization, periodicity. Trigger conditions. Antalgic postures. Palpation of tender points along Nerve Trunks and roots. Signs of nerve trunk and ROOT stretch (Lasegue, Wassermann, Matskevitch, Neri, etc.).
Possible types of disorders
Superficial sensitivity — pain, temperature, tactile. Deep sensitivity — joint-muscle, vibration. Complex sensitivity — discriminative, localization sense, two-dimensional spatial sense, stereognosis, etc. |
Nature of sensory disorders: anesthesia, hypesthesia, hyperesthesia, hyperpathia, paresthesia, dissociated disorders, etc. Type of sensory impairment: peripheral, polyneuritic, segmental (posterior horn, radicular, etc.), tract-related (pathway), cortical. |
The exact localization of sensory disorders is indicated. The boundaries of sensory impairments are described using the segmental and peripheral innervation distribution chart.
Meningeal signs
Nuchal rigidity, Kernig's sign, Brudzinski's signs (upper, middle, and lower).
Autonomic f |
unctions |
Possible types of disorders |
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Condition of the skin, its appendages, and soft Tissues. Skin temperature. Perspiration. Dermographism (local and reflex). Pilomotor reflex. Pelvic organ functions. |
Pallor, tendency to flushing, cyanotic or marbled skin tone. Greasy or dry skin. Hair distribution patterns, alopecia, hypertrichosis, premature graying. Nail fragility and deformity. General or local changes in body or skin temperature. Decreased or increased sweating. Pressure ulcers. Trophic ulcers. Arthropathy. Diffuse, elevated, persistent red or white dermographism. Absence of the pilomotor reflex and reflex dermographism within the zone of segmental lesion. Atonic or spastic constipation, tendency toward flatulence, increased peristalsis, diarrhea. Polyuria, frequent urination, changes in urine concentration. Urinary and fecal retention or incontinence, urgency, sexual dysfunction. |
Laboratory and instrumental investigations
General blood and urine tests. Biochemical and serological blood tests. Neuro-ophthalmological examination. Otoneurological examination. CEREBROSPINAL FLUID analysis with manometric (CSF dynamics) tests. Electroencephalography. Echoencephaloscopy. Rheoencephaloscopy. Electroneuromyography. X-ray imaging — craniography, spondylography, etc. Contrast X-ray Methods (angiography, myelography). Computed tomography or Magnetic Resonance imaging.
Topical Diagnosis and its rationale
Taking into account the complaints and neurological examination results, the leading syndromes of Nervous system lesions are identified. By analyzing and correlating the combination of symptoms and syndromes, the localization of the pathological process is determined.
Clinical diagnosis and its rationale
Prognosis
Work (military) expertise
Epicrisis
Last update: 10/08/2026
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