The art of history taking in neurology.
The history is the story 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, history is the critical first step to the correct diagnosis in neurology. In the majority of cases, a good history gives an accurate diagnosis. Physical examination and investigation often confirm the diagnosis we arrive at from history. According to a study conducted by Peterson et al. in 1992, in 76% of patients, the history led to the final diagnosis. In 12%, the physical examination and 11% laboratory findings helped clinch the definitive diagnosis. This demonstrates that the traditional art of history-taking remains relevant even in this age of advanced investigations. The critical skill required to take a good history is to be a good listener. Make the patient comfortable, gain their confidence, and listen to them. Remember that the medical interview is not just a data-gathering process but an essential step in building a therapeutic relationship with the patient. The doctor’s tone, body language, and demeanor make a lasting impression on the patient. The patient evaluates the doctor as the doctor is assessing the patient.
Often, students complain that the patient is not giving a proper history. Remember, a hopeless historian is as much a command of 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 the patient’s story.
A neurological diagnosis consists of 4 parts: the functional deficit, anatomical localization, etiology, and comorbidities. We aim to get all four components of diagnosis from history. The functional deficit is the patient’s deficit — for example, hemiplegia or paraplegia. Anatomical localization is wherein the neuroaxis is the lesion that produces the functional deficit. For instance, in a hemiplegia case, the lesion is in the opposite cortex, corona radiata, internal capsule, or brainstem. Etiology is the cause of the lesion in the anatomical site, such as stroke, demyelination, or tumor. The clue to etiology is often obtained from the history of the past illness. For instance, a patient with atrial fibrillation or rheumatic heart disease who presents with hemiplegia, the history of past illness suggests an embolic stroke. While presenting the case, it is always better to stick to the classical teaching and headings as most examiners like.
Patient information
The first step in history-taking is collecting the patient’s details. It includes name, age, sex, marital status, handedness, educational status, and occupation. It is crucial to note whether the patient or a family member provides the patient’s medical history. If a relative is sharing this information, we should consider its reliability. Are they living with the patient and familiar with the timeline of the disease’s progression?
Presenting complaint
Record only the most important symptoms as presenting complaints. When listing symptoms, it’s best to present 2 or 3 chronologically. Some prefer to opt for a single chief presenting complaint. Either way is acceptable as long as you describe all symptoms in chronological order in the history of the present illness. Please remember that we will base our provisional diagnosis on the history of the present illness. So it is essential to decide what is to be told in presenting complaints, what the history of present illness is, and what is in the history of past illness. In the history of past illnesses, we cannot describe the symptoms in as much detail as in the history of present illness. It is the presenter’s discretion to decide what is in the presenting complaint and what is to be told in the history of past illness. It is always better to discuss the main neurological issue as the history of the present illness, and whatever else before it falls in the history of past illness. For example, a patient with ataxia of 6 months presents with diarrhea of one-week duration. It is better to put ataxia and diarrhea as presenting complaints, as ataxia is the main problem we must solve from a neurological perspective. We need to describe that symptom in detail.
History of present illness.
The history of present illness is the body of our history. When someone hears the history of present illness, they should feel like a flashback video of the patient running before 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 storytelling part, and science is how you analyze a symptom thoroughly. I don’t mind making the art part a little better. Facts are true statements, and information consists 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 as if they were a movie or a novel. A good history immediately tells you the caliber of the student.
Medical students just starting their clinical posting should never forget two basic things while taking history.
1. Never use medical terms, e.g., hemiplegia or hypertonia. According to Sir William Osler, we must use the patient’s own words. History is his story. The patient is not aware of medical jargon, and they should not creep into your history.
2. Describe the event or symptom — never tell your own or the patient’s interpretation while giving a history. For example, a patient may be slipping a chappal from the leg due to a sensory deficit, which the patient interprets as weakness. So, we need to describe the symptom of slipping chappal and not the patient’s interpretation of weakness, which can be wrong.
It is always good to start with the patient’s premorbid functional status. It provides an excellent benchmark for analyzing the progression of the disease. For example, in a patient presenting with progressive weakness of all four limbs of 1-week duration, if we start with- ‘The patient was asymptomatic until one week back when he used to go to his workplace 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 quickly understand the gravity of situation and rapidity of progression of the disease.
Take each symptom in the presenting complaint and analyze it thoroughly in all its dimensions for a reasonable interpretation. If the patient presented with a headache, ask if it was abrupt onset or slowly evolved, as well as the location of the 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 about a symptom covering its dimensions. When you keep doing this for some time, you will no longer require the book, and these questions about any symptom will naturally come to you.
By carefully analyzing each symptom, we can also reach the anatomical localization of that symptom. For example, if the patient has diplopia, you must ask if it’s present when closing one eye. Are the images horizontally or vertically separated, and in which direction is seen maximum and more on near or far vision? Binocular diplopia with horizontally separated image more on looking to the left suggests a left lateral rectus palsy. Thus, by correctly analyzing the symptoms of diplopia, we can come to neurological localization.
Analyze each symptom and make a timeline. This helps to understand the chronological onset of symptoms and to find differentials, especially if the patient has multiple symptoms. It is how we change the facts in our story to information.
After elaborating on each symptom, narrating the complete negative medical history is essential. This ensures that any critical details the patient may forget to share are not overlooked. It’s always better to ask it in the order of examination so you don’t forget to ask about all symptoms. Higher function history includes seizures, LOC, disorientation, memory impairment, delusion, hallucination, slurring of speech, and difficulty in comprehension and word output.
Cranial nerve history includes decreased smell, parosmia, reduced vision, bumping onto objects on one side, ptosis, diplopia, squint, oscillopsia, paresthesia of the face, difficulty chewing, difficulty closing the eyes, facial deviation, swallowing difficulty, nasal regurgitation, tracheal aspiration, difficulty turning the neck, and difficulty maneuvering food in the mouth.
The motor system history includes wasting, tipping over a fine obstacle, heaviness of limbs, difficulty getting up from squatting, slipping of chappals, difficulty raising arms overhead, 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 a tendency to fall while washing the face. Cerebellar history includes swaying while walking, smearing the face while eating, tremors of hands, and dysarthria. Autonomic nervous system history includes postural hypotension, bowel and bladder dysfunction, erectile dysfunction, and excessive sweating. Skull spine history includes LBA, neck pain, headache, and vomiting.
In the negative history, you can also include symptoms about other cardiovascular, respiratory, and gastrointestinal systems so that you don’t miss the neurological manifestation of systemic disease. The history of presenting illness ends with the current functional status of the patient and course in the hospital after admission, which may also give an important diagnostic clue. For example, a patient presented with quadriparesis improving with plasma exchange suggests a possible demyelinating disease like GBS.
History of past illness
Any symptoms or diseases before those discussed in the presenting complaint and history of present illness should be recorded in the history of past illnesses. Students often mix the history of past illness and presenting complaints. It is better to avoid it as many examiners don’t take it in good spirits. It’s always better to tell the past illness that might have a bearing on the current disease before elaborating on all the patient’s past illnesses. The history of past illness often gives a clue to the etiology of the present condition. For example, in a patient presenting with spastic quadriparesis, the history of rheumatoid arthritis may be the only clue to an underlying atlantoaxial dislocation causing the spastic quadriparesis. It is always better to note diabetes mellitus, hypertension, coronary artery disease, rheumatic heart disease, cerebrovascular disease, and dyslipidemia.
Look for a history of similar illnesses 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 history of any infection, including tuberculosis, HIV, 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, and multiple unprotected sexual intercourse. Note the dietary history and, if required, a complete nutritional assessment. Note menstrual history in females.
Drug history and allergy
Make a note of the medications the patient is currently taking. Antipsychotics and levosulpride may cause Parkinsonism, salbutamol may cause tremors, and levodopa may cause hallucinations. Look for drug compliance and note if the patient is taking any Indigenous medication. Stoppage of AED or antiplatelets may cause 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 the 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 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 a cheaper alternative even if it is not the drug of choice, considering the low chance of compliance with expensive medication? These are essential questions to answer, especially in a low-resource setting, and often consume our time and energy more than diagnosing the disease itself.
That finishes the history-taking. Before going into a 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. Sometimes, the patient may not have revealed some personal information, they may be holding back. Most of the time, they ventilate that with this question. They can also come up with some helpful information that they might have thought trivial initially.
A few things that are better avoided during history taking include repeatedly looking at the clock, turning your body away from the patient, not looking up from the notes, 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 the patient answers the first. The patient usually answers only the second question, and often, the examiner forgets to ask the first question again.
Here, we discussed the importance of history taking in neurology, some salient tips, and how to go through the headings in an orderly manner. It is better for a medical student just starting his clinical posting 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. To discuss this topic, follow episode one of the ‘Clinical Neurology with KD’ podcast. For more topics, visit the website Neurology teachingclub.com.