Role of the Neurologic History and Examination In Neurologic Diagnosis

The purpose of the neurologic history and examination is
to look for clues to the cause of a patient’s neurologic symptoms. In
neurologic diagnosis, this means that the history and examination are
used to try to determine the localization of the disease process (i.e.,
where in the nervous system is the problem?), as well as the mechanism
of the disease process (i.e., how is that problem occurring?), paving
the way for the most appropriate diagnostic studies, if needed.

A thorough neurologic history, followed by a neurologic
examination, should be performed on all patients who present with
symptoms suggestive of nervous system dysfunction.

Neurologic disease can occur due to dysfunction anywhere in the peripheral or the central nervous system (see Chapter 2, Localization of Neurologic Disease).

Although not all items are necessary for every
examination, the following are all of the items that you routinely
need, so you really should make sure you have them:

More information about these items and the clinical scenarios in which they are required can be found in Section 2, Neurologic Examination.

A neurologic history should always be performed first,
followed by the neurologic examination. Any other order is fraught with
hazard in the quest for the correct clinical diagnosis and is much less
efficient.

During the history, the examiner should be attempting to
hone the diagnostic considerations, so that by the time the history is
complete, the most likely and unlikely localizations and mechanisms of
the patient’s problem should be evident. A thorough neurologic
examination is then performed with the intent of searching for clues to
support or refute the diagnostic hypotheses developed from the history.

The specific elements of the thorough neurologic
examination may vary, however, depending on the patient’s presenting
symptoms. Knowing what you are looking for during the examination,
based on the findings from the history, allows you to include otherwise
optional examination elements that may be useful to answer the specific
diagnostic questions that are being entertained. Throughout this book,
the usefulness, or lack thereof, of examination elements in different
clinical scenarios is stressed. There are certain parts of the
neurologic examination, however, that should be performed on all new
patients who present with a neurologic complaint (see Chapter 40,
Performing a Complete Neurologic Examination) or as part of a routine
complete general medical examination in patients who have no neurologic
complaints (see Chapter 53, Examination of the Patient without Neurologic Symptoms: The Screening Neurologic Examination).

Patients without neurologic disease usually have normal
neurologic examinations; however, many patients with neurologic
disease, particularly those patients with transient symptoms, also have
normal neurologic examinations. This underscores the added importance
of the neurologic history in these patients.

It is also not uncommon for patients who do not have
neurologic symptoms or underlying neurologic disease to have subtle
findings that may be clinically insignificant. Although it takes a fair
amount of clinical experience to be comfortable in knowing when to
discard these incidental findings, the author’s hope is that readers of
this book will be a step closer to this important aspect of neurologic
diagnosis.

Throughout this book, each examination element is summarized with a description of its normal finding.

Many patients with neurologic disease, particularly
those with persistent (not transient) symptoms, have abnormal
neurologic examinations that provide clues to the diagnosis.

Throughout this book, individual components of the
examination are described with a description of the significant
abnormal findings for each, as well as a discussion of the most likely
interpretations of these findings.