Taking a Neurologic History

Ovid: Field Guide to the Neurologic Examination

Authors: Lewis, Steven L.
Title: Field Guide to the Neurologic Examination, 1st Edition
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Taking a Neurologic History

Chapter 4
Taking a Neurologic History
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
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.
See Chapter 2, Localization of Neurologic Disease.
  • 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


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:


  • 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
  • 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.
Patients without neurologic disease have no neurologic history to obtain.
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.
  • 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.
  • P.16

  • 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.

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