Neurological medical history taking
We will now describe neurological medical history taking. As with all medical history taking ..
Listen to your patient, he is telling you the diagnosis”. Dr William Osler (1849-1919)
.. and 90% of the diagnosis is in the medical history. Full stop.
Careful examination is important after a careful history. Do not shy away from assessing perianal sensation and doing a rectal examination if required (e.g. spinal cord compression?).
Remember neuroanatomy is different in different people. This may be due to variation in spinal anatomy.
It is important to ask questions about all of the nervous system – do not restrict it to upper or lower limbs, or cranial nerves. These questions can be used in a clinical or examination setting.
Pre-introduction observation (before questions)
Before you start, stop, slow down and think. Just for 15 seconds.
Right. Antennae up. Observe the patient and environs around the patient. Why?
Observation is 90% of medicine”
What can you see? What’s their biological age? Walking pace? What is their gait like? Are they weak in one side? How are they dressed (and why)? What are they reading (and why)? Are they in pain (from where)? What’s their mood?
Wash hands. Now you can ask questions. Clock on. Here we go ..
How to take a neurology medical history
These are ten questions you can ask, and the words to use. They can be asked in ten minutes.
1. Introduction – Start with a diagnostic handshake. “Hello, my name is XX and I’m a student doctor YY. You are Mr/Mrs ZZ and you are AA years old. Is that correct?” You can ask date of birth but that takes longer and you have to do mental arithmetic to calculate the age. The handshake is also a diagnostic tool. Do they have a tremor? Cerebellar or Parkinsonian?
2. PC – “What is the current problem?” Listen very (very) carefully. The diagnosis is often in the patient’s first few words. Write it down. Come back to that at the end.
3. HPC – “Please tell me more about the problem”. Ditto.
Some neurological symptoms are vague and not that specific to neuro disease, e.g. weakness or stiffness (the latter can be the first symptom of increased tone). Though some are ‘red flag symptoms’ (e.g. back pain with leg weakness or loss of bowel or urinary function).
Alternatively symptoms may be very non-specific, as there are other (non-neuro) causes, e.g. fatigue and collapse.
To save time, ask relevant questions from systems review here. These include questions about loss of vision or hearing, and loss of sensation and balance.
It may be important to ask about mood, sleep and anxiety, and do a limited mental health assessment. Some neurological symptoms are due to psychosomatic disease.
4. PSH – “What major operations have you had?”. You are especially interested in brain or spinal surgery.
5. PMH – “Have you ever had .. diabetes, jaundice, anaemia, tuberculosis, heart attacks, strokes, high blood pressure, epilepsy, rheumatic fever, or ulcers in your tummy?”
Specific GI questions include: “do you have long-term neurological diseases like MS, Parkinson, Epilepsy or muscular disorder?”
You need to have finished PMH by 5 mins
6. Drugs/Allergies – “Please show me a list of your current medication? And have you had a major allergic reaction to any medication?”
The medication history is important in neurological disease, e.g. as causes of peripheral neuropathy. You need to take it carefully.
7. SH – “Are you married, how many children have you had, and what is/was your current/last job?”
Occupation is not especially relevant for disease. Nonetheless you should ask about current and all previous jobs.
8. SH – “Have you ever smoked, and have you ever been a regular heavy drinker?”
If there is any hint of excess alcohol use, take a precise alcohol history (units per day, binge or not etc), including CAGE questions. Alcohol can cause a variety of neurological problems including peripheral neuropathy, dementia and cerebellar syndrome.
9. FH – (depending on age of patient) “Are your parents alive fit and well? OR “Are your parents still with us?” Depending on answer, “what did they die of?” OR “What did your parents die of?” AND “Are there any diseases that run in the family?”
“Has anyone in your family ever had any neurological problems?” (e.g. muscular dystrophy or Huntingdon’s Chorea)
“Has anyone in your family had any funny or rare diseases?” (autoimmune, e.g. SLE).
You need to have finished SH/FH by 8 mins, to give time for ..
10. ICE – “What are your ideas about what’s going on, and what are your concerns and expectations (of us)?” This also gives time for you to think what have you forgotten .. did you ask about medication/allergies and/or smoking/alcohol?
At this point, the patient may give you crucial information like they have a known chronic neurological disease like MS or muscular dystrophy.
Summary
We have described neurological medical history taking. The history is important in neurology but the examination is just as or more important. We hope you have found it useful. Like all history taking, the only way to get good at it, is to practice alot (alot).
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