Fundamentals of Neurology: An Illustrated Guide

2. The Clinical Interview in Neurology

General Principles of History Taking

Special Aspects of History Taking

Image  General Principles of History Taking

The clinical history is of paramount importance in neurology, perhaps more so than in any other medical specialty. It is indispensable as a diagnostic instrument, it serves to establish a doctor-patient relationship built on trust, and it is a prerequisite for the success of any treatment that will follow. The history should always be taken with utmost care.

The type of neurological disturbance from which a patient is suffering can usually be determined from a carefully obtained clinical history even before the physical examination or any further tests are performed. In many patients, the history alone permits the assignment of a precise diagnosis, but only if the physician has been listening closely to the patient.

Image “A blind neurologist is better than a deaf neurologist.”

Skillful history taking is the distinguishing mark of a good clinician.

General prerequisites for good history taking. In any branch of clinical medicine, not just in neurology, a good history can be obtained only if the patient has confidence in the physician. Introduce yourself to the patient and take the history in a place offering the necessary privacy and discretion. The patient should be comfortably seated and emotionally at ease, as far as the circumstances allow, and must not feel rushed. If someone else is present during the interview, e. g., a medical student, introduce this person and make sure the patient really has no objection to his or her presence. Persons other than the physician taking the history should behave discreetly and keep themselves somewhat in the background. The history should be detailed and complete and should be taken by, or under the supervision of, an experienced clinician, as far as possible.

General principles of the clinical interview. While interviewing the patient, observe these principles: in the beginning the patient should be doing most of the talking and you should say as little as possible. You do indeed have to elicit all of the important historical data by specific inquiry, but only after the patient has finished describing the problem in his or her own words. The patient's story may be rambling or vague; even so, you should take care not to seem impatient or irritated. Once your turn comes, however, you must amplify and refine this initial information by persistent or even stubborn questioning, until at last you have obtained a clear picture of the present illness. Never reject the patient's own interpretation of his or her symptoms, even if it seems implausible or absurd. You will then come across as a scoffing know-it-all and will have broken your line of communication with the patient.

Your demeanor toward the patient. Every patient has the right to be treated courteously and tactfully and to receive the physician's full attention during an appropriately set period. You should perform a meticulous physical examination only after you have listened carefully to the patient's story and filled it out with further, detailed questioning. The patient has the right to a full explanation of your findings and of what they imply about his or her illness. You should explain these matters truthfully, in language that the patient can understand and with due respect for his or her feelings. You will often find yourself having to steer a difficult course between bluntness and euphemism.

If the patient is accompanied by another person, such as a spouse, parent, other relative, or friend, the patient should remain the focus of your attention, even if he or she is a child or adolescent. You should communicate mainly with the patient. You might have to ask accompanying persons to leave the room for part of the clinical interview or physical examination, but do not neglect their needs, either; the persons nearest to the patient, after all, may have an important role to play later on, during treatment. Courtesy and consideration for the patient as a fellow human being, palpable respect for his or her dignity, and genuine understanding and sympathy are the foundations of a trusting relationship between the patient and the physician and are therefore essential preconditions for successful treatment.

The history and physical examination are two independent and equally important components of clinical diagnostic assessment. They must complement each other and should, to some extent, be performed in parallel. The experienced clinician, while listening to the patient's history, will already be thinking of specific abnormalities to look for on physical examination. If the examination should then reveal other, perhaps unexpected findings, the clinician can amplify the history by asking further, specific questions. Ideally, the clinician will be able to make the diagnosis from the history and physical examination alone.

Image  Special Aspects of History Taking

The “classic” history has certain standard components and is meant to provide a complete picture of the patient, including his or her present complaints, past medical history, personality, and life situation.

The present illness. When taking a clinical history, always first give the patient a chance to describe his or her current complaints and the reason for the consultation. Only afterward should you begin interrogating the patient systematically to make the history complete, in accordance with the principles presented above. Systematic history taking is performed in standard fashion in all branches of clinical medicine; a basic outline is provided in Table 2.1. In each specialty, however, there are further important issues that tend to arise regularly and these should be asked about specifically. The important questions to ask in the neurological history are summarized in Table 2.2.

Past medical history, family history, and social history. Once you have a clear and complete picture of the patient's current complaints, you can begin to ask about earlier symptoms and illnesses, starting with general questions and then proceeding into greater detail. Always ask about problems that might bear a relation to the present illness: a patient suffering from ischemic stroke, for instance, should be asked about hypertension, heart disease, and smoking. Inquire into the health of the patient's blood relatives, particularly with regard to neurological and other hereditary diseases. Finally, ask about the patient's familial and social setting: marriage or other partnership, children, occupation, and any potential problems or conflicts in these areas. Ascertain how the patient's current (or earlier) medical problems affect him or her in everyday life, both at home and in the workplace. Broach these matters as unobtrusively as possible, however, because overzealous questioning might make the patient wrongly think that you believe his or her problems to be primarily psychogenic. Of course, if a thorough diagnostic evaluation reveals that a psychogenic mechanism is the likely cause, then this, too, should be discussed openly with the patient.

Table 2.1 Outline of the general clinical history

1 The patient's spontaneous description of his or her current complaints —more precise information can be elicited by direct questioning

2 Systematic analysis of the current complaints (see Table 2.2)

3 Prior illnesses (past medical and surgical history)

Image information spontaneously provided by the patient

Image specific questioning by the physician, particularly about earlier conditions of potential relevance to the current complaints

Image gestational and birth history, when indicated

4 Life Habits

Image alcohol and tobacco

Image medications

Image illicit drugs

Image potentially toxic environmental influences

5 Neurovegetative functions

Image sleep, digestion, urination, sexual dysfunction

6 Personality and social situation

Image the patient's personal and social setting: education, occupation, familial/social/financial position, and any current problems or conflicts (information of this type enables the physician to assess all of the factors affecting the patient's ability to deal with his or her medical problems successfully)

Image the patient's behavior, manner of speaking, gestures, facial expressions, emotional responses, and reactions to questions, etc., give the examiner an overall impression of the patient's personality

7 Family history

Table 2.2 History of the present illness

Major symptom(s)

Image The patient's spontaneous description, refined by specific questioning

Image How long have the symptoms been present? Where are they located?

Image How did they begin? (suddenly, gradually, or after a specific inducing event?)

Image How have they developed over time? (constant, increasing, decreasing, fluctuating?)

Image What influences the symptoms? (ameliorating/aggravating influences, medications?)

Image Effects

Image How severe are the symptoms in terms of their effect on everyday life at home and at work, and on the patient's emotional well-being? Is treatment required?

Current accompanying symptoms

Image Here it is particularly important to supplement the patient's spontaneous complaints with specific questioning. An experienced clinician knows what questions to ask even if the patient has provided very little information.

Relevant past medical history

Image Did the patient already have earlier symptoms or conditions that might be relevant to the current complaints? (e. g., earlier transient ischemic attacks in a patient suffering from acute stroke?)

Image Does the patient have any predisposing factors for conditions that might account for the current complaints? (e. g., cigarette smoking leading to a Pancoast tumor of the apex of the lung?)

Relevant family history

Image This may lend support to a conjectural diagnosis: e. g., similar symptoms in blood relatives of the patient's parents, if a recessively inherited condition is suspected, or hemicranial headaches in the mother of a patient with suspected migraine

A carefully elicited clinical history ought to enable the experienced clinician to formulate a tentative diagnosis even before proceeding to the physical examination. With the tentative diagnosis in mind, he or she can then devote particular attention to certain aspects of the examination. Of course, the clinician must not allow his or her findings to be so colored by prior expectations that they are no longer reliable. The tentative diagnosis should inform the physical examination, not convert it into a pointless exercise.