Taking a Neurologic History

By admin On Dec 15, 2024

Ovid: Field Guide to the Neurologic Examination

Authors: Lewis, Steven L.

Title: Field Guide to the Neurologic Examination, 1st Edition

> Table of Contents > Section 2
– Neurologic Examination > Neurologic History > Chapter 4 –
Taking a Neurologic History

Chapter 4

Taking a Neurologic History

PURPOSE

The purpose of the neurologic history—the most important
component of neurologic evaluation—is to obtain information helpful in
determining the localization and the mechanism of the patient’s disease
process.

WHEN TO PERFORM THE NEUROLOGIC HISTORY

A thorough neurologic history should be performed on all
patients who present with symptoms suggestive of nervous system
dysfunction. The history should always be taken before the examination
is performed.

NEUROANATOMY OF THE NEUROLOGIC HISTORY

See Chapter 2, Localization of Neurologic Disease.

EQUIPMENT NEEDED TO PERFORM THE NEUROLOGIC HISTORY

None.

HOW TO PERFORM THE NEUROLOGIC HISTORY

Introduction

Greet the patient.
Sit down and make yourself—the
examiner—comfortable. Don’t be hurried or cut corners; reserve enough
time for this important part of neurologic evaluation (obviously in the
rare, truly emergent situation, you need to make yourself less
comfortable and take a rapid, pointed, judicious history).
Take the history from the patient first, if possible, before talking to family members or other witnesses.

Chief Complaint

Don’t assume that you know why the patient is seeing you or what the complaint or problem is.
After greeting the patient, discern the
patient’s chief complaint by asking the patient a general question,
such as “What brings you here today?” Listen carefully to the patient’s
response.

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History of Present Illness

Once you have an idea of what the main complaint is, take your time to define the specific details of the patient’s history.
Ask the patient to start at the beginning
and tell you the story. If the problem began yesterday morning, ask the
patient to tell you the details, starting perhaps with the night
before. If the history is of recurrent events dating back weeks,
months, or years, try to get the specific details of each episode
starting from the initial one.
After listening to the patient tell the
history, ask specific, clarifying questions so you can better
understand the patient’s symptoms:
- Elucidate the nature of the patient’s
  symptoms by asking the patient to describe them. Symptoms such as
  weakness, numbness, and dizziness can mean different things to
  different patients at different times. When necessary, clarify the
  patient’s symptom by asking something like, “What do you mean by … ?”
  Try not to put words into the patient’s mouth; however, if you still
  have a difficult time understanding the nature of the patient’s
  symptoms, you may have to give the patient multiple choices to define
  his or her symptoms.
- Ask about the quality and intensity of
  symptoms. This is particularly appropriate for the complaint of pain,
  which may, for example, be sharp, dull, throbbing, or lancinating.
- Ask about the timing and duration of the
  symptoms. Was the onset sudden or gradual? Did the symptoms resolve
  and, if so, how quickly? Have the symptoms been progressively worsening
  or improving, or waxing and waning?
- What was the patient doing when the
  symptoms began or when the symptoms occur? Did the symptoms begin
  during rest or during exertion? If the symptoms are intermittent, do
  they occur more often in certain positions, such as while standing or
  lying down?
- Ask the patient to point to the area of involvement, particularly when there is a sensory symptom or pain.
- Are there any factors that make the symptoms better or worse?
Ask about the presence or absence of
additional neurologic or systemic symptoms that may help you
diagnostically in the given clinical scenario, as described in the
chapters in Section 3, Neurologic Examination in Common Clinical Scenarios.
Don’t just mechanically ask historical details while you take the
history, however. Remember that you’re trying to figure out what’s
wrong with the patient by finding historical clues to the localization
and the pathogenesis of the disease process. Think about what the
information could be telling you about what might or might not be
causing the patient’s symptoms as you listen to the patient and
formulate questions.
If appropriate, with the patient’s
permission, corroborate historical details or learn new historical
details from family members or other witnesses to the problem. Although
information volunteered from family members or friends accompanying the
patient can be helpful, when you ask the patient a subjective question
about the quality of a symptom that only the patient can really answer
(e.g., “What do you mean by numbness?”), don’t let anyone else answer
for the patient. Of course, if the patient is unable to give any
history (e.g., due to impairment of cognition or loss of
consciousness), all of the history may need to be obtained from others.

The Rest of the Story

As in any medical evaluation, complete the history by obtaining the following:

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Past medical history: Ask the patient about any chronic illnesses, other previous illnesses, previous hospitalizations, and operations.
Medications:
Ask the patient about any medications he or she may be taking. Don’t
forget to ask about over-the-counter medications, herbal preparations,
and, in women, oral contraceptives; many patients forget to include
these when asked to list their medications.
Allergies:
Ask the patient about allergies to medications or other significant
allergies. Also ask about any other previous adverse reactions to
medications.
Social history:
Learn about the patient. What is the patient’s occupation and
educational background? Is the patient currently working, retired, or
disabled? Ask about the home situation: Is the patient single, married,
divorced, or widowed? How many children, if any, does the patient have?
Has there been any recent stress? Don’t just limit your social history
to asking about tobacco, alcohol, and drug use—learning about the
patient as a person is interesting, may give important diagnostic
clues, may tell you information about cognitive baseline (when
appropriate), and is important in assessing social support.
Family history:
Ask about any significant illnesses (neurologic or otherwise) in the
patient’s parents, grandparents, siblings, and children. Ask the
patient specifically whether there is a family history of the
particular illnesses that you feel are important to be aware of in the
clinical scenario.
Review of systems:
As in any medical history, the initial evaluation of any patient should
include an appropriate and extensive review of systems; this, of
course, should not be limited to the neurologic system. Significant
clues to the cause of a patient’s problem may be found here, but do
watch out for red herrings.

NORMAL FINDINGS

Patients without neurologic disease have no neurologic history to obtain.

ABNORMAL FINDINGS

See Chapter 2, Localization of Neurologic Disease, and Chapter 3,
Mechanisms of Neurologic Disease, for discussions on using clues from
the neurologic history to determine the localization and mechanism of
neurologic disease.

ADDITIONAL POINTS

Although this book devotes only one
chapter specifically to the neurologic history, the neurologic history
is the single most important component of neurologic evaluation.
Without first taking an appropriate history, the examination is of
extremely limited value and the interpretation (and selection of)
diagnostic studies is fraught with peril.
Sometimes you need to aggressively search
for the appropriate witnesses to the patient’s event to clarify the
history. For example, if a patient presents because of an episode of
loss of consciousness that occurred at a store, call the store to try
to locate and speak to the individual who witnessed the problem. Think
and act like a detective when searching for historical clues. Taking a
few extra minutes to clarify the history from a firsthand witness can
ultimately save time and prevent unnecessary investigations.

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When using an interpreter, ask the
question to the patient and let the interpreter translate your question
to the patient and directly translate the patient’s response. The
interpreter should avoid simply paraphrasing the patient or giving a
subjective interpretation of what he or she thinks the patient’s answer
might mean medically. The interpreter is there only to translate the
patient’s language; your job is to translate the patient’s history and
examination into a diagnosis.