Welcome to the clinical neurology podcast, where you will learn over 12 episodes, how to localise a lesion in neurology based on history taking and physical examination. The podcast is meant for medical students and to make them enjoy learning neurology. Medicine, paediatrics, psychiatry, critical care, neurology residents, general practitioners and nurse practitioners will find it beneficial. Notes, images and other clinical resources for the podcast are available in the show description and on the neurology teaching club.com website. I am your host Dr Krishnadas N C, and let’s get started.
History is the story that the physician composes to help himself and others understand the patient’s disease. This is how Sapira describes a medical history. As in other medical specialties, in neurology the history is the critical and important first step to correct diagnosis. In majority of cases a good history gives the correct diagnosis. Physical examination and investigation often confirm the diagnosis we arrive from history. According to a study conducted by Peterson et al in 1992, in 76% of patients the history led to final diagnosis. In 12% the physical examination and in 11% laboratory findings helped to clinch the final diagnosis. This shows that even in this age of high fi investigations the old art of history taking is holding its fort. The critical skill required in taking a good history is to be a good listener. Make the patient comfortable, gain their confidence and then just listen to them. Remember that the medical interview is not just a data gathering process but an important step in building a therapeutic relationship with the patient. The doctor’s tone, body language and demeanor make lasting impression on the patient. The patient evaluates the doctor as the doctor is evaluating the patient.
Many a time students complain that patient is not giving a proper history. Remember hopeless historian is as much a command on the doctor. Getting the history out of a difficult patient is a skill by itself and is as important as our clinical and diagnostic skills. The most important person in the room is the patient. Lean towards the patient, make eye contact, ask an open-ended question, and allow yourself to get lost in patients story.
A neurological diagnosis consists of 4 parts
Functional deficit
Anatomical localization
Etiology and
Comorbidities
Our aim is to get all 4 components of diagnosis from history
Functional deficit is the deficit patient is having. For example, hemiplegia or paraplegia. Anatomical localization is where in the neuroaxis is the lesion to produce the functional deficit. For example, in a hemiplegia case whether the lesion is in opposite cortex, corona radiata, internal capsule or brainstem. Etiology is what is the cause of lesion in anatomical site. Example, stroke or demyelination or tumor. The clue to etiology is often obtained from history of past illness. For example - somebody with AF or RHD presenting with hemiplegia, the history of past illness helps to suspect embolic stroke. While presenting case it is always better to stick on to the classical teaching and headings as most examiners like it that way.
The first step in history taking is collecting the Patient details. This includes
Name
Age
Sex
Married/ unmarried
Right/ left-handed
Educational status
Occupation
History given by patient himself or relative. If relative is giving the history, is it reliable or not. Is he/she living with the patient and knows the temporal course of progression of disease?
Presenting complaint
Only the most important symptoms need to be put as presenting complaints. Ideally 2 or 3 in chronological order. Some prefer to opt for a single chief presenting complaint. Either way is fine as long as you are going to describe all symptoms in chronological order in history of present illness. Remember our provisional diagnosis is going to be based on history of present illness. So very important to decide what is to be told in presenting complaints and history of present illness and what is to be told in history of past illness. In history of past illness, we cannot describe the symptoms in that much detail as in History of present illness. It is the presenter’s discretion to decide what is in presenting complaint and what is to be told in history of past illness. Its always better to discuss the main neurological issue as history of present illness and whatever else prior to it will fall in history of past illness.
Examples – patient with ataxia of 6 months presenting with diarrhea of one week duration. Its better to put ataxia as a presenting complaint along with diarrhea as that is the main problem we must solve from a neurological perspective, and we need to describe that symptom in detail.
History of present illness.
This is the body of our history. When someone hear the History of present illness, they should feel like a flash back video of patient running in front of them. No History of present illness is too long. The more vivid and descriptive it is, the better. There is an art and science to it. The art is the story telling part and science is how completely you analyze a symptom. Personally, I don’t mind making the art part a little better even at the cost of a bit of science. Facts are true statements and information consist of facts arranged in a useful manner. Make sure your history is filled with information rather than a collection of facts. You recreate the events that happened as if it is a movie or a novel. A good history immediately tells you the caliber of the student.
Medical students just starting their clinical posting should always remember two basic things while taking history
1. Never use medical terms e.g., hemiplegia, hypertonia. According to Sir William Osler we must use the patient’s own words. History is his story. Patient is not aware of medical jargons and they should not creep into your history.
2. Just describe the event or symptom- never tell your own or patients’ interpretation while telling history. For example- a patient may be having slipping of chappal from leg which the patient interprets as weakness when it may be due to a sensory problem. So, we need to describe the symptom slipping of chappal and not the patients interpretation weakness which can be wrong. Many silly mistakes can be avoided if we take care of this point.
It is always good to start with the premorbid functional status of the patient. It gives a good benchmark to analyze the progression of disease. For example, in a patient presenting with progressive weakness of all 4 limbs of 1 week duration if we start with ‘The patient was apparently asymptomatic until 1 week back when he used to go to his work place 1 km away walking’ immediately tells you that he had no significant premorbid motor problem and if he cannot walk without support now helps us to easily understand the gravity of problem and rapidity of progression of the disease.
Take each symptom in the presenting complaint and analyze it thoroughly in all its dimensions so that we can come to an interpretation reasonably. If the patient presented with headache, ask if it was abrupt onset or slowly evolved, the location of headache, the character, duration, and severity. Was it associated with aura, vomiting, photophobia or phonophobia? What were the aggravating and relieving factors? Was it disturbing sleep? Were there any associated features like nasal stuffiness or conjunctival congestion. Write a paragraph about each symptom. Students who have just started their clinical posting can carry a notebook containing all the questions to be asked about a symptom covering all its dimensions. When you keep doing this for some time you will no longer require the book and these questions pertaining to any symptom will naturally come to you.
By carefully analyzing each symptom we can also reach the anatomical localization of that symptom as well. For example, if the patient is having diplopia, you must ask if its present on closing one eye. Are the images horizontally or vertically separated and in which direction it is seen maximum and whether its more on near or far vision? A binocular diplopia with horizontally separated image more on looking to left suggest a left lateral rectus palsy. Thus, by properly analyzing the symptom of diplopia we can come to neurological localization of the symptom
Analyze each symptom and make a timeline. This helps to have an idea of the chronological onset of symptoms and helps to find the differentials especially if the patient has multiple symptoms. This is how we change the facts in our story to information.
Once each symptom is elaborated it’s a good idea to tell all the negative history. This makes sure you don’t miss any history the patient forgets to come up with. It’s always better to ask it in the order of examination so that you also don’t forget to ask all symptoms
Higher function history includes seizures, LOC, disorientation, memory impairment, delusion, hallucination, slurring of speech, difficulty in comprehension and word output
Cranial nerves history includes decreased smell, parosmia, decreased vision, bumping on to objects on one side, ptosis, diplopia, squint, oscillopsia, paresthesia of face, difficulty in chewing, difficulty in eye closure, facial deviation, swallowing difficulty, nasal regurgitation, tracheal aspiration, difficulty in turning neck and difficulty in maneuvering food in mouth
Motor system history include wasting, tipping over fine obstacle, heaviness of limbs, difficulty in getting up from squatting, slipping of chappals, difficulty raising arms overhead, difficulty making bolus of food, difficulty getting up from lying down position, walking difficulty, fasciculations and other involuntary movements
Sensory system history includes positive or negative sensory symptoms, including paresthesia, numbness, painless burns and tendency to fall while washing face.
Cerebellar history includes swaying while walking, smearing of face while eating, tremor of hands and dysarthria.
ANS history include Postural hypotension, bowel and bladder dysfunction, erectile dysfunction and excessive sweating
Skull spine history include LBA, neck pain, headache and vomiting
In the negative history you can also include symptoms pertaining to other systems like cardiovascular, respiratory and gastrointestinal so that you don’t miss the neurological manifestation of a systemic disease. The history of presenting illness ends with current functional status of the patient and course in hospital after admission which may also give important diagnostic clue. For example, patient presented with quadriparesis improving with plasma exchange suggest a possible demyelinating disease like GBS.
History of past illness
Any symptom or disease prior to what is discussed in presenting complaint and history of present illness will go into history of past illness. Many a time students tend to mix history of past illness and presenting complaints. Its better avoided as many examiners don’t take it in good spirits. It’s always better to tell the past illness which might have a bearing on the current illness before elaborating all the past illness the patient had. The history of past illness often gives a clue to the etiology of present illness. For example, a patient presenting with spastic quadriparesis, the past history of rheumatoid arthritis may be the only clue to an underling atlantoaxial dislocation causing the spastic quadriparesis. Its always better to make a note on
DM, HTN, CAD, RHD, CVD and Dyslipidemia
Look for h/o Similar illness in the past which can occur in MS, vasculitis or stroke
Document any past h/o Trauma, Surgery, Malignancies or COLLAGEN VASCULAR DISEASE
Ask for the past history of any infection including TB, HIV, COVID or sexually transmitted disease
Finally note Immunization history including any recent immunizations
Personal history
Make a note of Sleep, Bowel, bladder, appetite
Document any follies including
Smoking
Alcohol
Drugs
MUSIC
Note the dietary history and if required a full nutritional assessment.
Menstrual history in females
Drug history and allergy
Make a note of the medications the patient is currently taking
Antipsychotics and levosulpride may be the cause of parkinsonism
Salbutamol may be the cause of tremor
Levodopa may be the cause of patient's hallucinations
Look for drug compliance and note if they are taking any indigenous medication
Stoppage of AED or antiplatelets may be the cause of a seizure or stroke.
Look for any drug allergy and document it according to hospital protocol.
Family history
Ask for Consanguinity or Similar illness in family
Draw a family tree in relevant cases
Occupational history
Occupational health problems are rare these days due to better laws
Lead palsy in painters and battery workers and Nasopharyngeal carcinoma in furniture workers are some well documented neurological health hazards.
Socioeconomic status
Document the socioeconomic status of the patient and family. Does the patient afford investigations? Will they take costly medicines? Should we choose cheaper alternative even if it is not the drug of choice considering the low chance of compliance with costly medicines. These are important questions to answer especially in low resource setting and often consume our time and energy more than diagnosing the disease itself.
This finishes the history taking. Before going into physical examination, it is always a good idea to ask the patient ‘is there anything else you want to tell me?’ followed by a long pause. Sometime the patient may have not revealed some personal information which he may be holding back. Most of the time they ventilate that with this question. They can also come up with some useful information which they might have thought trivial initially.
Few things that should be avoided during history taking include
Repeatedly looking at clock
Turning your body away from the patient
Not looking up from the notes and not having eye contact with the patient
Continuously interrupting the patient while he is talking and
Asking double questions
A double question is asking a second question before patient gives answer to the first. The patient usually gives answer to the second question only and often the examiner also forgets to ask the first question again.
This finishes our first episode. Today we discussed the importance of history taking in neurology, some salient tips in history taking and how to orderly go through the headings. For a medical student who is just starting his clinical posting its better to be rigid with these headings. Once you follow this set pattern in your formative years it becomes a habit, and you will subconsciously continue to do it when you become a consultant. It’s nice to be a bit conservative with your history talking.
Thanks for listening to clinical neurology podcast. Kindly subscribe and review if you found it useful. You can follow neurology teaching club Instagram account for exclusive figures of this podcast. Sign up with your email at our website neurologyteachingclub.com to get a free neurology clinical examination template and for the notes of each podcast. The podcast and online content are meant for medical education only and should not be used to guide clinical decision making and treatment. You can find more of this podcast on Apple podcasts,Spotify, Google podcast or wherever you get your ear candy. Its KD signing off and until we meet next time, Spread Knowledge.