History and Examination
HISTORY
The history is the most important part of the neurological evaluation. Just as detectives gain most information about the identity of a criminal from witnesses rather than from the examination of the scene of the crime, neurologists learn most about the likely pathology from the history rather than the examination.
The general approach to the history is common to all complaints. Which parts of the history prove to be most important will obviously vary according to the particular complaint. An outline for approaching the history is given below. The history is usually presented in a conventional way (below) so that doctors being informed of or reading the history know what they going to be told about next. Everyone develops their own way of taking a history and doctors often adapt the way they do it depending on the clinical problem facing them. This section is organised according to the usual way in which a history is presented—recognising that sometimes elements of the history can be obtained in a different order.
Many neurologists would regard history taking, rather than neurological examination, as their special skill (though you obviously need both). This indicates the importance attached to history taking within neurology, and reflects that it is an active process, requiring listening, thinking and reflective questioning rather than simply passive note taking. There is now evidence that it is not just what the patient says, but the way he says it that can be diagnostically useful (for example in the diagnosis of non-epileptic attack disorder).
The neurological history
• Age, sex, handedness, occupation
• History of present complaint
Basic background information
Establish some basic background information initially—the age, sex, handedness and occupation (or previous occupation) of the patient.
Handedness is important. The left hemisphere contains language in almost all right-handed individuals, and in 70% of patients who are left-handed or ambidextrous.
Present complaint
Start with an open question such as ‘Tell me all about it from the very beginning’ or ‘What has been happening?’. Try to let patients tell their story in their own words with minimum interruption. The patient may need to be encouraged to start from the beginning. Often patients want to tell you what is happening now. You will find this easier to understand if you know what events led up to the current situation.
Whilst listening to their story, try to determine (Fig. 1.1):
TIP
It is better to get an exact description for specific events, particularly the first, last and most severe events, rather than an abstracted summary of a typical event.
• The time course. This tells you about the tempo of the pathology (Table 1.1 and Fig. 1.2).
– The pattern: If intermittent, what was its duration and what was its frequency?
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It can be useful to summarise the history, thinking about how you would describe the time course, as the terms used can point towards the relevant underlying pathological process. For example: sudden onset or acute suggests vascular; subacute suggests inflammation, infection or neoplasia; progressive suggests neoplasia or degenerative; stepwise or stuttering suggests vascular or inflammation; relapsing–remitting suggests inflammation.
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