History taking

Introduction

Taking a patient’s history (Fig. 1) is the most important part of the clinical assessment. The history is used to find out the nature of the neurological problem, and how it is affecting the patient. It also puts this in the context of previous medical problems, medical problems in the family, occupation and social circumstances, and other aspects of the patient’s life. The elements of a neurological history are the same as for any other subject, but because many neurological diagnoses are based solely on the history it carries greater emphasis (Box 1).

Fig. 1 How to take a neurological history.

The history is usually presented in a conventional way (Box 2) so that doctors being told, or reading, the history know what they are going to be told about next. Doctors often adapt their method depending on the clinical problem with which they are faced. This section is organized in the usual way in which a history is presented, recognizing that sometimes the history can be obtained in a different order.

Basic background information

It is worthwhile establishing initially some basic background information: the age, sex, handedness and occupation, or previous occupation, of the patient. These factors change the patient’s risk of different diseases.

Handedness is important. The left hemisphere controls language in almost all right-handed individuals, and in 70% of patients who are left-handed or ambidextrous.

Presenting complaint

Give the patient the opportunity to describe the problem in his or her own words. This is best done with an open question such as ‘tell me all about it …’ and then avoiding interrupting. Most patients will describe their problems in less than a minute. It is remarkable how often patients will use the same form of words to describe particular problems. For ‘It was like being hit on the head with a bat’, read subarachnoid haemorrhage until proved otherwise. ‘My hands go dead at night. When I wake it helps if I shake them’ suggests carpal tunnel syndrome. ‘The pain in my cheek is sudden, like a red hot needle’ suggests trigeminal neuralgia.

Frequently patients have trouble describing the feelings or sensations that they have experienced. This will require you to help interpret what they tell you – from everyday language into medical English. Patients find some sensations particularly difficult: for example, dizziness can mean light-headedness, a sensation of rotational vertigo or a feeling of being distant, among others (p. 46); the term numbness can be used by patients to mean weakness, loss of sensation or stiffness. Your knowledge of the range of symptoms that people feel will help to sort out what the patient means.

After clarifying the nature of the symptoms you need to determine the time course. Establish the onset of the symptoms (sudden or gradual), their progression (progressive, stepwise or intermittent) and their duration. If possible, some sort of measure should be used: how far the patient could walk at various times, when the patient started to use a walking stick, and so on. The time course is critical to interpretation of the history. For example, a 50-year-old woman has had an episode of unilateral visual loss:

If it was of sudden onset (‘like a shutter coming down’) and resolved over 5 min, she has had amaurosis fugax (a retinal transient ischaemic attack).