– History, Physical Examination, and Overview of the Neurologic
Examination > Chapter 2 – The Neurologic History
physical diagnosis cover the basic aspects of medical interviewing.
This chapter addresses some aspects of history taking of particular
relevance to neurologic patients. Important historical points to be
explored in some common neurologic conditions are summarized in the
tables.
neurologic diagnosis is no exception. In many instances the physician
can learn more from what the patient says and how he says it than from
any other avenue of inquiry. A skillfully taken history will frequently
indicate the probable diagnosis, even before physical, neurologic, and
neurodiagnostic examinations are carried out. Conversely, many errors
in diagnosis are due to incomplete or inaccurate histories. In many
common neurologic disorders the diagnosis rests almost entirely on the
history. The most important aspect of history taking is attentive
listening. Ask open ended questions and avoid suggesting possible
responses. Although patients are frequently accused of being “poor
historians,” there are in fact as many poor history takers as there are
poor history givers. While the principal objective of the history is to
acquire pertinent clinical data that will lead to correct diagnosis,
the information
obtained
in the history is also valuable in understanding the patient as an
individual, his relationship to others, and his reactions to his
disease.
skill and experience than performing a good neurologic examination.
Time, diplomacy, kindness, patience, reserve, and a manner that conveys
interest, understanding, and sympathy are all essential. The physician
should present a friendly and courteous attitude, center all his
attention on the patient, appear anxious to help, word questions
tactfully, and ask them in a conversational tone. At the beginning of
the interview it is worthwhile to attempt to put the patient at ease.
Avoid any appearance of haste. Engage in some small talk. Inquiring as
to where the patient is from and what they do for a living not only
helps make the encounter less rigid and formal, but often reveals very
interesting things about the patient as a person. History taking is an
opportunity to establish a favorable patient-physician relationship;
the physician may acquire empathy for the patient, establish rapport,
and instill confidence. The manner of presenting his history reflects
the intelligence, powers of observation, attention, and memory of the
patient. The examiner should avoid forming a judgment about the
patient’s illness too quickly; some individuals easily sense and resent
a physician’s preconceived ideas about their symptoms. Repeating key
points of the history back to the patient helps insure accuracy and
assure the patient the physician has heard and assimilated the story.
At the end of the history, the patient should always feel as if he has
been listened to. History taking is an art; it can be learned partly
through reading and study, but is honed only through experience and
practice.
educational and cultural background of the patient. The physician
should meet the patient on a common ground of language and vocabulary,
resorting to the vernacular if necessary, but without talking down to
the patient. This is sometimes a fine line. The history is best taken
in private, with the patient comfortable and at ease.
a logical, well-organized manner. It is important to focus on the more
important aspects and keep irrelevancies to a minimum; the essential
factual material must be separated from the extraneous. Diagnosis
involves the careful sifting of evidence, and the art of selecting and
emphasizing the pertinent data may make it possible to arrive at a
correct conclusion in a seemingly complicated case. Recording negative
as well as positive statements assures later examiners that the
historian inquired into and did not overlook certain aspects of the
disease.
during the initial encounter. There is direct information from the
patient describing the symptoms, information from the patient regarding
what previous physicians may have thought, and information from medical
records or previous care givers. All these are potentially important.
Usually, the most essential is the patient’s direct description of the
symptoms. Always work from information obtained firsthand from the
patient when possible, as forming one’s own opinion from primary data
is critical. Steer the patient away from a description of what previous
doctors have thought, at least initially. Many patients tend to jump
quickly to describing encounters with caregivers, glossing over the
details of the present illness. Patients often misunderstand much or
most of what they have been told in the past, so information from the
patient about past evaluations and treatment must be analyzed
cautiously. Patient recollections may be flawed because of faulty
memory, misunderstanding, or other factors. Encourage the patient to
focus on symptoms instead, giving a detailed account of the illness in
his own words.
as possible, but it is often necessary to lead the conversation away
from obviously irrelevant material, obtain amplification on vague or
incomplete statements, or lead the story in directions likely to yield
useful information. Allow the patient to use his own words as much as
possible, but it is important to determine the precise meaning of words
the patient uses, clarifying any ambiguity that could lead to
misinterpretation. Have the patient clarify what he means by lay terms
like “kidney trouble” or “dizziness.”
control the pace and content of the interview is a frequent problem.
Patients do not practice history giving. Some are naturally much better
at
relating the pertinent information than others. Many patients digress
frequently into extraneous detail. The physician adopting an overly
passive role under such circumstances often prolongs the interview
unnecessarily. When possible, let the patient give the initial part of
the history without interruption. In a primary care setting, the
average patient tells his story in about five minutes. The average
doctor interrupts the average patient after only about 18 seconds. In
44% of interviews done by medical interns, the patient was not allowed
to complete their opening statement of concerns. Female physicians
allowed fewer patients to finish their opening statement. Avoid
interrogation, but keeping the patient on track with focused questions
is entirely appropriate. If the patient pauses to remember some
irrelevancy, gently encourage them not to dwell on it. A reasonable
method is to let the patient run as long as they are giving a decent
account, then take more control to clarify necessary details. Some
patients may need to relinquish more control than others. Experienced
clinicians generally make a diagnosis through a process of hypothesis
testing. At some point in the interview, the physician must assume
greater control and query the patient regarding specific details of
their symptomatology in order to test hypotheses and help to rule in or
rule out diagnostic possibilities.
special techniques. The timid, inarticulate, or worried patient may
require prompting with sympathetic questions or reassuring comments.
The garrulous person may need to be stopped before getting lost in a
mass of irrelevant detail. The evasive or undependable patient may have
to be queried more searchingly, and the fearful, antagonistic, or
paranoid patient questioned guardedly to avoid arousing fears or
suspicions. In the patient with multiple or vague complaints, insist on
specifics. The euphoric patient may minimize or neglect his symptoms;
the depressed or anxious patient may exaggerate, and the excitable or
hypochondriacal patient may be overconcerned and recount his complaints
at length. The range of individual variations is wide, and this must be
taken into account in appraising symptoms. What is pain to the anxious
or depressed patient may be but a minor discomfort to another. A blasé
attitude or seeming indifference may indicate pathologic euphoria in
one individual, but be a defense reaction in another. One person may
take offense at questions which another would consider commonplace.
Even in a single individual such factors as fatigue, pain, emotional
conflicts, or diurnal fluctuations in mood or temperament may cause a
wide range of variation in response to questions. Patients may
occasionally conceal important information. In some cases, they may not
realize the information is important; in other cases, they may be too
embarrassed to reveal certain details.
patient’s manner, attitude, behavior, and emotional reactions. The tone
of voice, bearing, expression of the eyes, swift play of facial
muscles, appearance of weeping or smiling, or the presence of pallor,
blushing, sweating, patches of erythema on the neck, furrowing of the
brows, drawing of the lips, clenching of the teeth, pupillary dilation,
or muscle rigidity may give important information. Gesticulations,
restlessness, delay, hesitancy, and the relation of demeanor and
emotional responses to descriptions of symptoms or to details in the
family or marital history should be noted and recorded. These and the
mode of response to the questions are valuable in judging character,
personality, and emotional state.
complete. He may not possess full or detailed information regarding his
illness, may misinterpret his symptoms or give someone else’s
interpretation of them, wishfully alter or withhold information, or
even deliberately prevaricate for some purpose. The patient may be a
phlegmatic, insensitive individual who does not comprehend the
significance of his symptoms, a garrulous person who cannot give a
relevant or coherent story, or have multiple or vague complaints that
cannot be readily articulated. Infants, young children, comatose or
confused patients may be unable to give any history. Patients who are
in pain or distress, have difficulty with speech or expression, are of
low intelligence, or do not speak the examiner’s language are often
unable to give a satisfactory history for themselves. Patients with
nondominant parietal lesions are often not fully aware of the extent of
their deficit. It may be necessary to corroborate or supplement
the
history given by the patient by talking with an observer, relative, or
friend, or even to obtain the entire history from someone else. Family
members may be able to give important information about changes in
behavior, memory, hearing, vision, speech, or coordination of which the
patient may not be aware. It is frequently necessary to question both
the patient and others in order to obtain a complete account of the
illness. Family members and significant others sometimes accompany the
patient during the interview. They can frequently provide important
supplementary information. However, the family member must not be
permitted to dominate the patient’s account of the illness unless the
patient is incapable of giving a history.
minimal prior review of the medical records. Too much information in
advance of the patient encounter may bias one’s opinion. If it later
turns out that previous caregivers reached similar conclusions based on
primary information, this reinforces the likelihood of a correct
diagnosis. So, see the patient first, review old records later.
past caregivers, whether from medical records or as relayed by the
patient. In the first instance, the physician takes too much at face
value and assumes that previous diagnoses must be correct. An opposite
approach, actually used by some, is to assume all previous caregivers
were incompetent, and their conclusions could not possibly be correct.
This approach sometimes forces the extreme skeptic into a position of
having to make some other diagnosis, even when the preponderance of the
evidence indicates that previous physicians were correct. The logical
middle ground is to make no assumptions regarding the opinions of
previous caregivers. Use the information appropriately, matching it
against what the patient relates and whatever other information is
available. Do not unquestioningly believe it all, but do not
perfunctorily dismiss it either. Discourage patients from grousing
about their past medical care and avoid disparaging remarks about other
physicians the patient may have seen. An accurate and detailed record
of events in cases involving compensation and medicolegal problems is
particularly important.
notes with talking directly with the patient. If the record contains a
reasonably complete history, review it with the patient for accuracy.
For instance, read from the record and say to the patient, “Dr. Payne
says here that you have been having pain in the left leg for the past 6
months. Is that correct?” The patient might verify that information, or
may say, “No, it’s the right leg and it’s more like 6 years.” Such an
approach can save considerable time when dealing with a patient who
carries extensive previous records. A very useful method for
summarizing a past workup is to make a table with two vertical columns,
listing all tests which were done, with those that were normal in one
column and those that were abnormal in the other column.
interview. Contemporaneous note taking helps insure accuracy of the
final report. A useful approach is simply to “take dictation” as the
patient talks, particularly in the early stages of the encounter. A
note sprinkled with patient quotations is often very illuminating.
However, one must not be fixated on note taking. The trick is to
interact with the patient, and take notes unobtrusively. The patient
must not be left with the impression that the physician is paying
attention to the note taking and not to them. Such notes are typically
used for later transcription into some final format. Sometimes the
patient comes armed with notes. The patient who has multiple complaints
written on a scrap of paper is said to have la maladie du petit papier; tech savvy patients may come with computer printouts detailing their medical histories.
usual demographic data, but must also include handedness. The
traditional approach to history taking begins with the chief complaint
and present illness. In fact, many experienced clinicians begin with
the pertinent past history, identifying
major underlying past or chronic medical illnesses at the outset. This
does not mean going into detail about unrelated past surgical
procedures and the like. It does mean identifying major
comorbidities
which might have a direct or indirect bearing on the present illness.
This technique helps to put the present illness in context and to
prompt early consideration about whether the neurologic problem is a
complication of some underlying condition or an independent process. It
is inefficient to go through a long and laborious history in a patient
with peripheral neuropathy, only to subsequently find out in the past
history that the patient has known, long standing diabetes.
counterproductive to give short shrift to the details of the present
illness. History taking should concentrate on the details of the
presenting complaint. The majority of the time spent with a new patient
should be devoted to the history and the majority of the history taking
time should be devoted to the symptoms of the present illness. The
answer most often lies in the details of the presenting problem. Begin
with an open ended question, such as, “what sort of problems are you
having?” Asking “what brought you here today?” often produces responses
regarding a mode of transportation. And asking “what is wrong with
you?” only invites wisecracks. After establishing the chief complaint
or reason for the referral, make the patient start at the beginning of
the story and go through more or less chronologically. Many patients
will not do this unless so directed. The period of time leading up to
the onset of symptoms should be dissected to uncover such things as the
immunization that precipitated an episode of neuralgic amyotrophy, the
diarrheal illness prior to an episode of Guillain-Barre syndrome, or
the camping trip that lead to the tick bite. Patients are quick to
assume that some recent event is the cause for their current
difficulty. The physician must avoid the trap of assuming that temporal
relationships prove etiologic relationships.
It is important to clarify important elements of the history that the
patient is unlikely to spontaneously describe. Each symptom of the
present illness should be analyzed systematically by asking the patient
a series of questions to clear up any ambiguities. Determine exactly
when the symptoms began, whether they are present constantly or
intermittently, and if intermittently the character, duration,
frequency, severity, and relationship to external factors. Determine
the progression or regression of each symptom, whether there is any
seasonal, diurnal, or nocturnal variability, and the response to
treatment. In patients whose primary complaint is pain, determine the
location; character or quality; severity; associated symptoms; and, if
episodic, frequency, duration, and any specific precipitating or
relieving factors. Some patients have difficulty describing such things
as the character of a pain. Although spontaneous descriptions have more
value, and leading questions should in general be avoided, it is
perfectly permissible when necessary to offer possible choices, such as
“dull like a toothache” or “sharp like a knife.”
paid to determining the time course of the illness, as this is often
instrumental in determining the etiology. An illness might be static,
remittent, intermittent, progressive, or improving. Abrupt onset
followed by improvement with variable degrees of recovery are
characteristic of trauma and vascular events. Degenerative diseases
have a gradual onset of symptoms and variable rate of progression.
Tumors have a gradual onset and steady progression of symptoms, with
the rate of progression depending on the tumor type. With some
neoplasms hemorrhage or spontaneous necrosis may cause sudden onset or
worsening. Multiple sclerosis is most often characterized by remissions
and exacerbations, but with a progressive increase in the severity of
symptoms; stationary, intermittent, and chronic progressive forms also
occur. Infections usually have a relatively sudden, but not
precipitous, onset followed by gradual improvement, and either complete
or incomplete recovery. In many conditions symptoms appear some time
before striking physical signs of disease are evident, and before
neurodiagnostic testing detects significant abnormalities. It is
important to know the major milestones of an illness: when the patient
last considered himself to be well, when he had to stop work, when he
began to use an assistive device, when he was forced to take to his
bed. It is often useful to ascertain exactly how and how severely the
patient considers himself disabled, as well as what crystallized the
decision to seek medical care.
patient may have forgotten or may not attach significance to. A history
consistent with past vascular events, trauma or episodes of
demyelination may shed entirely new light on the current symptoms. In
the patient with symptoms of myelopathy, the episode of visual loss
that occurred five years previously suddenly takes on a different
meaning.
worrying him. It occasionally turns out that the patient is very
concerned over the possibility of some disorder that has not even
occurred to the physician to consider. Patients with neurologic
complaints are often apprehensive about having some dreadful disease,
such as a brain tumor, ALS, multiple sclerosis, or muscular dystrophy.
All these conditions are well known to the lay public, and patients or
family members occasionally jump to outlandish conclusions about the
cause of some symptom. Simple reassurance is occasionally all that is
necessary.
symptoms may be related to systemic diseases. Relevant information
includes a statement about general health; history of current, chronic,
and past illnesses; hospitalizations; operations; accidents or
injuries, particularly head trauma; infectious diseases; venereal
diseases; congenital defects; diet; and sleeping patterns. Inquiry
should be made about allergies and other drug reactions. Certain
situations and comorbid conditions are of particular concern in the
patient with neurologic symptomotology. The vegetarian or person with a
history of gastric surgery or inflammatory bowel disease is at risk of
developing vitamin B12 deficiency, and the neurologic
complications of connective tissue disorders, diabetes, thyroid
disease, and sarcoidosis are protean. A history of cancer raises
concern about metastatic disease as well as paraneoplastic syndromes. A
history of valvular heart disease or recent myocardial infarction may
be relevant in the patient with cerebrovascular disease. In some
instances, even in an adult, a history of the patient’s birth and early
development is pertinent, including any complications of pregnancy,
labor and delivery, birth trauma, birth weight, postnatal illness,
health and development during childhood, convulsions with fever,
learning ability and school performance,
over the counter, is always important. Many drugs have significant
neurologic side effects. For example, confusion may develop in an
elderly patient simply from the use of beta blocker ophthalmic
solution; nonsteroidal anti-inflammatory drugs can cause aseptic
meningitis; many drugs may cause dizziness, cramps, paresthesias,
headache, weakness, and other side effects; and headaches are the most
common side effect of proton pump inhibitors. Going over the details of
the drug regimen may reveal that the patient is not taking a medication
as intended. Pointed questions are often necessary to get at the issue
of over the counter drugs, as many patients do not consider these as
medicines. Occasional patients develop significant neurologic side
effects from their well-intended vitamin regimen. Patients will take
medicines from alternative health care practitioners or from a health
food store, assuming these agents are safe because they are “natural,”
which is not always the case. Having the patient bring in all
medication bottles, prescribed and over the counter, is occasionally
fruitful.
the possibility of heredofamilial disorders, and focuses on the
patient’s lineage; it is occasionally quite important in neurologic
patients. Information about the nuclear family is also often relevant
to the social history (see below). In addition to the usual questions
about cancer, diabetes, hypertension, and cardiovascular disease, the
FH is particularly relevant in patients with migraine, epilepsy,
cerebrovascular disease, movement disorders, myopathy, and cerebellar
disease, to list a few. In some patients, it is pertinent to inquire
about
a FH of alcoholism or other types of substance abuse. Family size is
important. A negative FH is more reassuring in a patient with several
siblings and a large extended family than in a patient with no siblings
and few known relatives. It is not uncommon to encounter patients who
were adopted and have no knowledge of their biological family.
negative. Some diseases may be rampant in a kindred without any
awareness of it by the affected individuals. With Charcot-Marie-Tooth
disease, for example, so many family members may have the condition
that the pes cavus and stork leg deformities are not recognized as
abnormal. Chronic, disabling neurologic conditions in a family member
may be attributed to another cause, such as “arthritis.” Sometimes,
family members deliberately withhold information about a known familial
condition.
relationship between the parents, exploring the possibility of
consanguinity. In some situations, it is important to probe the
patient’s ethnic background, given the tendency of some neurologic
disorders to occur in particular ethnic groups or in patients from
certain geographic regions.
marital status, educational level, occupation, and personal habits. The
marital history should include the number of marriages, duration of
present marriage, and health of the partner and children. At times it
may be necessary to delve into marital adjustment and health of the
relationship as well as the circumstances leading to any changes in
marital status.
routine. A detailed occupational history, occasionally necessary,
should delve into both present and past occupations, with special
reference to contact with neurotoxins, use of personal protective
equipment, working environment, levels of exertion and repetitive
motion activities, and co-worker illnesses. A record of frequent job
changes or a poor work history may be important. If the patient is no
longer working, determine when and why he stopped. In some situations,
it is relevant to inquire about hobbies and avocations, particularly
when toxin exposure or a repetitive motion injury is a diagnostic
consideration. Previous residences, especially in the tropics or in
areas where certain diseases are endemic, may be relevant.
reference to the use of alcohol, tobacco, drugs, coffee, tea, soft
drinks and similar substances, or the reasons for abstinence. Patients
are often not forthcoming about the use of alcohol and street drugs,
especially those with something to hide. Answers may range from mildly
disingenuous to bald-faced lies. Drugs and alcohol are sometimes a
factor in the most seemingly unlikely circumstances. Patients
notoriously underreport the amount of alcohol they consume; a commonly
used heuristic is to double the admitted amount. To get a more
realistic idea about the impact of alcohol on the patient’s life the
CAGE questionnaire is useful (Table 2.1). Even
one positive response is suspicious; four are diagnostic of alcohol
abuse. The HALT and BUMP are other similar question sets (Table 2.1).
Some patients will not admit to drinking “alcohol” and will only
confess when the examiner hits on their specific beverage of choice,
e.g., gin. Always ask the patient who denies drinking at all some
follow-up question: why he doesn’t drink, if he ever drank, or when he
quit. This may uncover a past or family history of substance abuse, or
the patient may admit he quit only the week before. In the patient
suspected of alcohol abuse, take a dietary history.
Tactful opening questions might be to ask whether the patient has ever
used drugs for other than medicinal purposes, ever abused prescription
drugs, or ever ingested drugs other than by mouth. The vernacular is
often necessary: patients understand “smoke crack” better than “inhale
cocaine.” It is useful to know the street names of commonly abused
drugs, but these change frequently as both slang and drugs go in and
out of fashion. A less refined type of substance abuse is to inhale
common substances, such as spray
paint,
airplane glue, paint thinner, and gasoline. It is astounding what some
individuals will do. One patient was fond of smoking marijuana and
inhaling gasoline, leaded specifically, so that he could hallucinate in color.
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TABLE 2.1 Questions to Explore the Possibility of Alcohol Abuse
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sexual behavior is sometimes important, and the subject always
difficult to broach. Patients are often less reluctant to discuss the
topic than the examiner. Useful opening gambits might include how often
and with whom the patient has sex, whether the patient engages in
unprotected sex, or whether the patient has ever had a sexually
transmitted disease.
designed in part to detect health problems of which the patient may not
complain, but which nevertheless require attention. In specialty
practice, the ROS is done more to detect symptoms involving other
systems of which the patient may not spontaneously complain but that
provide clues to the diagnosis of the presenting complaint. Neurologic
disease may cause dysfunction involving many different systems. In
patients presenting with neurologic symptoms, a “neurologic review of
systems” is useful after exploring the present illness to uncover
relevant neurologic complaints. Some question areas worth probing into
are summarized in Table 2.2. Symptoms of depression are often particularly relevant and are summarized in Table 2.3. A more general ROS may also reveal important information relevant to the present illness (Table 2.4).
Occasional patients have a generally positive ROS, with complaints in
multiple systems out of proportion to any evidence of organic disease.
Patients with Briquet syndrome have a somatization disorder with
multiple somatic complaints which they often describe in colorful,
exaggerated terms.
Another efficient method is to do the ROS during the physical
examination, asking about symptoms related to each organ system as it
is examined.
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TABLE 2.2 A Neurologic System Review; Symptoms Worth Inquiring About in Patients Presenting with Neurologic Complaints
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There are too many potential neurologic presenting complaints to cover
them all, so these tables should be regarded only as a starting point
and an illustration of the process. Space does not permit an
explanation of the differential diagnostic relevance of
each
of these elements of the history. Suffice it to say that each of these
elements in the history has significance in ruling in or ruling out
some diagnostic possibility. Such a “list” exists for every complaint
in every patient. Learning and refining these lists is the challenge of
medicine.
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TABLE 2.3 Some Symptoms Suggesting Depression
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TABLE
2.4 Items in the Review of Systems of Possible Neurologic Relevance, with Examples of Potentially Related Neurologic Conditions in Parentheses |
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TABLE
2.5 Important Historical Points in the Chronic Headache Patient; if the Patient Has More Than One Kind of Headache, Obtain the Information for Each Type |
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some of the specific important historical points helpful in evaluating
the chronic headache patient. The following features are general rules
and guidelines, not absolutes. Patients with migraine tend to have
unilateral hemicranial or orbitofrontal throbbing pain associated with
GI upset. Those suffering from migraine with aura (classical migraine)
have visual or neurologic accompaniments. Patients usually seek relief
by lying quietly in a dark, quiet environment. Patients with cluster
headache tend to have unilateral nonpulsatile orbitofrontal pain with
no visual, GI, or neurologic accompaniments and tend to get some relief
by moving about. Patients with tension or muscle contraction headaches
tend to have nonpulsatile pain which is bandlike or occipitonuchal in
distribution, and unaccompanied by visual, neurological, or GI upset.
important elements in the history in patients with neck and arm pain.
The primary differential diagnosis is usually between cervical
radiculopathy and musculoskeletal conditions such as bursitis,
tendinitis, impingement syndrome, and myofascial pain. Patients with a
cervical disc usually have pain primarily in the neck, trapezius ridge,
and upper shoulder region. Patients with cervical myofascial pain have
pain in the same general distribution. Radiculopathy patients may have
pain referred to the pectoral or periscapular regions, which is unusual
in myofascial pain. Radiculopathy patients may have pain radiating in a
radicular distribution down the arm. Pain radiating below the elbow
usually means radiculopathy. Patients with radiculopathy have pain on
movement of the neck; those with shoulder pathology have pain on
movement of the shoulder. Patients with radiculopathy may have weakness
or sensory symptoms in the involved extremity.
summarize some important historical particulars to consider in some of
the other complaints frequently encountered in an outpatient setting.
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TABLE
2.6 Important Historical Points in the Patient with Neck and Arm Pain; the Differential Diagnosis Is Most Often Between Radiculopathy and Musculoskeletal Pain |
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TABLE
2.7 Important Historical Points in the Patient with Back and Leg Pain; the Differential Diagnosis Is Most Often, as with Neck and Arm Pain, Between Radiculopathy and Musculoskeletal Pain |
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TABLE 2.8 Important Historical Points in the Dizzy Patient
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TABLE
2.9 Important Historical Points in the Patient with Hand Numbness; the Primary Considerations in the Differential Diagnosis Are Carpal Tunnel Syndrome and Cervical Radiculopathy |
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TABLE
2.10 Important Historical Points in the Patient with a Suspected Transient Ischemic Attack; this Arises in Patients Who Have Had One or More Spells of Weakness or Numbness Involving One Side of the Body, Transient Loss of Vision, Symptoms of Vertebrobasilar Insufficiency, and Similar Problems |
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TABLE
2.11 Important Historical Points in the Patient with Episodic Loss of Consciousness; the Differential Diagnosis of Syncope v. Seizure |
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TABLE
2.12 Important Historical Points in the Patient with Numbness of the Feet; the Differential Diagnosis Is Usually Between Peripheral Neuropathy and Lumbosacral Radiculopathy; there Is a Further Extensive Differential Diagnosis of the Causes of Peripheral Neuropathy |
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TABLE
2.13 Important Historical Points in the Patient Complaining of Memory Loss; the Primary Consideration Is to Distinguish Alzheimer Disease From Conditions (Especially Treatable Ones) that May Mimic It |
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