NEUROPrelims - History Taking in Neurology

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MEDAUF HISTORY TAKING IN NEUROLOGYDr. Romeo Y. Enriquez | July 14, 2015 | NEUROLOGY

PROPERTY OF AUFSOM BATCH 2017v3.1 s2015-2016

PI – Arellano | Gagui | Galvan | Pamintuan | Timbang

HISTORY TAKING IN NEUROLOGYOutline

Objectives

Procedureso Introductions

o Chief Complainto History of Present Illness (Body of the

History)o Past History

Past Medical History (PMH) Drug History (DH) Family History (FH) Social History

o Review of Systemso Summaryo Patient Questions/Feedback

Clinical Pearls

Challenge among medical clerks: What am I going to asknext? Are my questions appropriate for these particularkinds of patients?

The most important tools in history taking:

- Know ledge of Neuroanatomy

- Physica l Examinat ion

- Approach to th e Diagnosis

o Where is the lesion?o What kind of lesion?

After the history, ascertain things that were not part of thediscussion (Review of Systems, Family History, etc.)

Objectives

To gather as much clues and evidence to arrive ata logical diagnosis

o If there are no evidences then it is notconsidered a part of the history, instead, itis only hearsay and it does not meananything. Anything that is hearsay will leadaway from the diagnosis.

To validate information gatheredo By doing a physical examination (hard

evidence) o Watch out for inconsistencies (lying

patients )

To correlate the evidence obtained with theworking diagnosis most especially withpathophysiologic mechanisms

o Look for certain signs and symptoms o While interviewing patient, localize or try

to develop any biochemical or physiological abnormality (small clues thatwould lead to diagnosis)

To achieve rapport with patient or significantothers

Sometimes you have small clues that will lead you to anunderlying diagnosis. Achieve rapport with your patient orsignificant others (NEVER ABBREVIATE).

INTRODUCTIONS

- Introduce yourself, identify your patient and gain

consent to speak with them.

The moment the patient enters the room, you greet them“Good morning sir, good afternoon sir” then introduceyourself. “I am Dr. E nriquez, I am the neurologist, DrBalajadia asked me to see you.”

- Should you wish to take notes as you proceed, askthe patients permission to do so.

- For experienced physicians, when they interview apatient, expecially in patient’s rooms, there is noroom for them to make notes as they interview, sothey only rely on the proper structure of what theyare trying to get. When they get out of the roomthey have to write the notes because they mighforget.

- In the office, you don’t have to compose thenarrative immediately or even in the emergencyroom, you just “doodle”.

Example:HEADACHE

- Is this headache continuous up to now or does icome and go?

- Over the past two weeks, over 2-3 times a week.

Headache (if CONTINUOUS):

Headache (if INTERMITTENT):Vomited Vomited

Even if it takes ten years, you have an idea when thedifferent signs and symptoms progress. We do not make

the note taking interfere with the continuity of theconversation.

- Be respectful as much as possible and do no“Talk Down” on patients or relatives. (Use SirMa’am, or “Po”) regardless of age or socialeconomic status.

As soon as the patient enters, the history taking startsthere. You evaluate the gait, general appearance, posturemood, feelings, affect. Even if you are interviewing

Onset:

July 1st

Present:

July 14



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evaluate the patient (physical exam) while taking thehistory.

The history is the cornerstone of medical diagnosis;

neurologic diagnosis is no exception. In many instances, thephysician can learn more from what the patient says and how hesays it than from any other avenue of inquiry. A skillfully takenhistory will frequently indicate the probable diagnosis, evenbefore physical, neurologic, and neurodiagnostic examinationsare carried out. The most important aspect of history taking is

attentive listening.

(From DeJong ’ s The Neurologic Examination, 6 th Edition, 2013).

CHIEF COMPLAINT

- What is the reason for seeing the doctor?- What made the family bring the patient to the

emergency room?- Use the exact words the patient used.- You may use vernacular if necessary.

- The rest of the initial questions in the history shallbe based on the chief complaint.

- Example:D: Ano po ang nararamdaman nyo? Bakit kayo

nagpunta dito?P: Masakit po ang ulo ko.

BODY OF THE HISTORY

- Gain as much information you can about thespecific complaint.

- Sticking with pain as an example you should ask:(SOCRATES)o Site: Where exactly is the pain?o Onset: When did it start, was it

constant/intermittent, gradual/ sudden?o Character: What is the pain like e.g. sharp,

burning, and tight?o Radiation: Does it radiate/move anywhere?o Associations: Is there anything else

associated with the pain e.g. sweating,vomiting

o Time course: Does it follow any time pattern,how long did it last?

o Exacerbating/relieving factors: Does anythingmake it better or worse?

o Severity: How severe is the pain, considerusing the 1-10 scale?

- The SOCRATES acronym can be used for anytype of pain history.

If there is multitude of symptoms, you can work on one paragraph per symptom plus associated signs orsymptoms.

You can also do one paragraph per major symptom byorgan.

Comprehensive history may also be written chronologicallywhich is usually done among clinicopathologicconferences.

PAST HISTORY1. Past Medical History (PMH)

- Gather information about a patients other medicaproblems (if any).

- The past history is important because neurologicsymptoms may be related to systemic diseases.

- Relevant information includes a statement abougeneral health; history of current, chronic and pasillnesses; hospitalizations; operations; accidentsor injuries, particularly head trauma; infectiousdiseases; venereal diseases; congenital defectsdiet; and sleeping patterns.

2. Drug History (DH)

- Find out what medications the patient is takingincluding dosage and how often they are takingthem e.g. once-a-day, twice-a-day, etc. At thispoint it is a good idea to find out if the patient hasany allergies.

- Ex. Are you taking any maintenance medications?Since when?

3. Family History (FH)

- Gather some information about the patient’s familyhistory, e.g. diabetes or cardiac history. Find out ithere are any genetic conditions within the familye.g. polycystic kidney disease.

- You may also do a genogram.

- The family history (FH) is essentially an inquiry intothe possibility of heredofamilial disorders andfocuses on the patient’s lineage.

- In addition to the usual questions about cancerdiabetes, hypertension, and cardiovasculadisease, the FH is particularly relevant in patientswith migraine, epilepsy, cerebrovascular diseasemovement disorders, myopathy, and cerebella

disease, to list a few.- In some patients, it is pertinent to inquire about an

FH of alcoholism or other types of substanceabuse.

- Family size is also important.

4. Social History

- This is the opportunity to find out a bit more abouthe patient’s background.

- Remember to ask about smoking and alcohol.- Depending on the PC it may also be pertinent to

find out whether the patient drives, e.g. followingan MI patient cannot drive for one month.

- You should also ask the patient if they use anyillegal substances, e.g. cannabis, cocaine, etc.

- Also find out who lives with the patient.o You may find that they are the caregiver for an

elderly parent or a child and your duty wouldbe to ensure that they are not neglectedshould your patient be admitted/remain inhospital.

- The social history includes such things as thepatient’s marital status, educational leveloccupation, and personal habits.



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- The marital history should include the number ofmarriages, duration of present marriage, andhealth of the partner and children.

REVIEW OF SYSTEMS

- These are the main systems you should cover:o CVSo Respiratoryo GIo Neurologyo Genitourinary/renalo Musculoskeletalo Psychiatry

- In primary care medicine, the review of systems(ROS) is designed in part to detect healthproblems of which the patient may not complain,but which nevertheless require attention.

- In specialty practice, the ROS is done more todetect symptoms involving other systems of whichthe patient may not spontaneously complain butthat provide clues to the diagnosis of thepresenting complaint.

SUMMARY- Complete your history by reviewing what the

patient has told you.- Repeat back the important points so that the

patient can correct you if there are anymisunderstandings or errors.o Repeat back what they say so that there is no

misinterpretation.o If you are in a hurry and you take the history

very fast, chances are, when you review thehistory, you have the wrong diagnosis.

o Even if you speak the same language, astatement may have different meanings.

- You should also address what the patient thinks iswrong with them and what they areexpecting/hoping for from the consultation.o There are some situations when a patient has

many things to say. Ask the patientdirectly/bluntly: WHAT HELP ARE YOU

EXPECTING FROM ME ? Some patientsrequire psychological help, counselling, orneed for a witness to testify for them in courtor to certify that they are sick.

- A good acronym for this is ICE - Ideas, Concernsand Expectations.o Take time to EXPLAIN to the patient what is

wrong with them. o Use words that a patient will understand. o It is also best to use ILLUSTRATIONS. o When you explain, correlate the explanation of

the pathophysiology with the normal anatomy. o Provide the patient with a sound rationale of

the DIAGNOSTICS needed and theTREATMENT applicable.

o For example:

If a patient went to the clinic becauseof severe headache, and you suspect

a medulloblastoma of the cerebellumexplain that the patient has a tumor othe middle of the cerebellum, point outhrough a diagram the location of thetumor.

Explain that the basis is that the patient cannot walk unless the patient ’ s feet are apart and that hecannot maintain balance.

Explain to the patient that a CT Scanis needed to confirm the diagnosis.

Since the patient is alreadyexperiencing severe headachesaccompanied by vomiting, tell the patient that confinement is advised.

Provision of medicines to reduce pressure in the brain is also needed.

Assure the patient that once he isstabilized, you will discuss with himtherapeutic options (What can bedone?).

o VERY IMPORTANT: DO NOT PROMISE

THE PATIENT ANYTHING !o For example:

“ Migraine lang yan! ” ANALGESICS The patient is in coma.

o We often take for granted the signs andsymptoms of family memebrs

o For example:“ Wala yan, migraine lang yan! ” It turns outo be a ruptured aneurysm.

o At the end of the interview, THANK the patienfor their time.

o In the clinic, inform the patient of their nexschedule.

When taking the history, all questions are meant toSTRENGTHEN the diagnosis. The history may alsohelp in identifying differential diagnoses and rule themout.

PATIENT QUESTIONS/FEEDBACK

- During or after taking their history, the patient mayhave questions that they want to ask you.

- It is very important that you don’t give them anyfalse information. As such, unless you areabsolutely sure of the answer it is best to say thayou will ask your seniors about this or that you wilgo away and get them more information (e.g

leaflets) about what they are asking.- When you are happy that you have all of the

information you require, and the patient has askedany questions that they may have, you must thankthem for their time and say that one of the doctorslooking after them will be coming to see themsoon.



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PEARLS

- When taking the history, all questions are meantto strengthen your working diagnosiso In asking the pain scale rating of the patient,

assume that the patient knows what eachrating means and do not underestimate the patient’s subjective pain rating.

- Subsequent questions are also meant to rule outother diagnostic procedureso “Kill” your diagnosis – Differential Diagno ses o List down all possible other diagnosis and rule

out each as the interview and assessment proceeds.

o When you see a patient, based on the chiefcomplaint, come up of an “imaginary yellow pad listing all your differentials: congenital,inherited, infection, trauma, vascular,demyelinating, immunologic, metabolic, toxic,and degenerative diseases.”

For example, a patient comes in with a headache, localizeand assess further. Ask the patient since when was the“headache” and if the patient reports that it had been for 3

days already, rule out the category of DegenerativeDiseases; then continue evaluating, say, it turns out theheadache was related to chronic hyperglycemia, therefore,it is a Metabolic Disorder.

o As a medical student, the working diagnosismay be: “ This pat ient has a les ion on thevermix o f the cerebel lum or a cerebel lar

tumor ” – presenting the Localized problem,based on the assessment and mentioning the“Anatomic Area”

- You should have a working anatomical and

etiologic diagnosis before performing theneurological examinationo Develop clinical assessment by strengthening

History Taking and Physica l Examinat ion . In 85% of patients: history alone will lead

to a diagnosis 10% of patients will require a neurologic

examination for clues 5% of cases requires ancillary procedures

95% requires CT Scan alone forobjective assessment

5% necessitates other imagingmodalities

OTHER NOTES:The following points about taking the neurologic history deservefurther comment:

1. Special care must be taken to avoid suggesting tothe patient the symptoms that one seeks.

o Errors and inconsistencies are as often thefault of the physician as of the patient.

o The patient should be discouraged fromframing his symptom(s) in terms of a diagnosisthat he may have heard.

o He should be urged to give a description of thesymptom-being asked, for example, to choosea word that best describes his pain and todescribe precisely what he means by aparticular term such as dizziness, imbalanceor vertigo.

o The patient who is given to highlycircumstantial and rambling accounts can bekept on the subject of his illness by directivequestions that draw out essential points.

2. The setting in which the illness occurred, its mode

of onset and evolution, and its course are oparamount importance.

o One must attempt to learn precisely how eachsymptom began and progressed.

o The nature of the disease process can bedecided from these data alone, such as instroke.

o If such information cannot be supplied by thepatient or his family, it may be necessary to

judge the course of the illness by what thepatient was able to do at different times or bychanges in the clinical findings betweensuccessive examinations.

3. In general, one tends to be careless in estimatingthe mental capacities of patients. Attempts aresometimes made to take histories from patients whoare cognitively impaired or so confused that theyhave no idea why they are in a doctor's office or ahospital.

o Asking the patient to give his own interpretationof the possible meaning of symptoms maysometimes expose unnatural concern, anxietysuspiciousness, or even delusional thinking.

o Young physicians and students also have anatural tendency to "normalize" the patientoften collaborating with a hopeful family in themisperception that no real problem exists.

o This attempt at sympathy does not serve thepatient and may delay the diagnosis of a

potentially treatable disease.

Reference:Adam and Victor ’ s Pr inc iples of Neurolog y (10 th Edit ion

2014)

NEUROPrelims - History Taking in Neurology

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