February 15th, 2021
Careful history-taking can be used to identify and localise a patient's neurological pathology. By understanding the circumstances and natural history of a neurologic event, it is possible to narrow down the list of likely causes for a patient's presentation.
Start by asking the patient what their main reason for presenting was.
- Common neurological presenting complaints include:
- Presyncope or syncope
- Muscular symptoms - weakness, tremor, spasm
- Peripheral sensory symptoms - numbness, paraesthesia
- Visual changes - blurring, diplopia
- Hearing changes - hearing loss, tinnitus
- Olfactory changes - loss of olfactory sensation, altered olfaction
- Vertigo (sensation of the room spinning)
History of Presenting Complaint
Ask for more information about the patient's presentation. Start by asking general questions, and then narrow down your questioning over the course of history-taking.
- Ask the patient if they are left or right-handed. This is an indicator of the dominant hemisphere (usually contralateral to the dominant hand).
Description of a Single EpisodeFollowing a seizure, headache, syncope, presyncope or other concerning episode, certain questions can help to narrow down the list of differential diagnoses:
- Before the episode - palpitations, lightheadedness, visual changes, other sensory changes
- During the episode - length of the episode, loss of consciousness, arm / leg movement, eye movement, loss of consciousness, tongue biting
- After the episode - focal limb weakness, fatigue, confusion
Pattern of Events over Time
- If the type of episode has happened before, attempt to understand the natural history of these episodes. Ask about when the first event was, then the latest event was, the approximate frequency of events, and whether they remain complement normal between events.
- Ask about what brings on the episodes. For example, any changes in position; preceding trauma; whether the events happen during the day or at night; and whether the patient was indoors or outdoors.
Past Medical History
Ask about whether the patient has been diagnosed with any medical conditions. If so, ask about the management of these conditions, and any complications.
Ask about what medications the patient takes regularly, what they take them for, and what side effects they have had.
Ask whether anyone in the family has had any neurologic conditions in the past. Attempt to determine whether any conditions have a clear pattern of transmission - autosomal dominant, autosomal recessive or X-linked.
- Inherited neurologic disorders include:
- Dementias - familial Alzheimer's, CADASIL
- Ataxia - friedreich ataxia, ataxia-telangiectasia, spinocerebellar ataxia
- Hereditary neuropathies - Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies
- Muscular dystrophies - Duchenne, Becker, facioscapulohumeral, myotonic dystrophy
- Spinal muscular atrophy
- Inherited forms of epilepsy
- Hereditary spastic paraplegia
- Huntington's disease
- Tuberous sclerosis
- Mitochondrial disorders
It is important to understand any patient's social situation when taking their history. This includes key aspects such as their occupation (or previous occupation, if retired), living situation, mobility, ability to perform activities of daily living, diet and exercise.
Patients with neurologic disease may be significantly functionally impacted by their disease.
Take a detailed smoking history: identify how many years the patient has smoked for, how many they smoked per day, and how long since they quit (if applicable.
Ask about alcohol intake: how many drinks the patient has per week, what type of drinks, and whether they have considered cutting down their intake if heavy.
Finally, ask about recreational drug use, and particularly intravenous drug use.
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Ascherio A, Munger KL. Environmental risk factors for multiple sclerosis. Part II: Noninfectious factors. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society. 2007 Jun;61(6):504-13.Belbasis L, Bellou V, Evangelou E, Ioannidis JP, Tzoulaki I. Environmental risk factors and multiple sclerosis: an umbrella review of systematic reviews and meta-analyses. The Lancet Neurology. 2015 Mar 1;14(3):263-73.Dharmadasa T, Henderson RD, Talman PS, Macdonell RA, Mathers S, Schultz DW, Needham M, Zoing M, Vucic S, Kiernan MC. Motor neurone disease: progress and challenges. Medical Journal of Australia. 2017 May;206(8):357-62.Ferlisi M, Shorvon S. Seizure precipitants (triggering factors) in patients with epilepsy. Epilepsy & Behavior. 2014 Apr 1;33:101-5.Hajat C, Dundas R, Stewart JA, Lawrence E, Rudd AG, Howard R, Wolfe CD. Cerebrovascular Risk Factors and Stroke Subtypes: Differences Between Ethnic Groups. Stroke. 2001; 32: 37-42.Hayes MW, Fung VS, Kimber TE, O'Sullivan JD. Current concepts in the management of Parkinson disease. Medical Journal of Australia. 2010 Feb;192(3):144-9.
Jankovic J. Parkinson's disease: clinical features and diagnosis. Journal of neurology, neurosurgery & psychiatry. 2008 Apr 1;79(4):368-76.Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. InSeminars in neurology 2004 Mar (Vol. 24, No. 01, pp. 75-81). Copyright© 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA..Keesey JC. Clinical evaluation and management of myasthenia gravis. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 2004 Apr;29(4):484-505.Kennedy A, Zakaria R. Taking a Neurological History. Medicine. 2006; 36(10): 509-514.Lima, Marco A. What is the essential neurological examination?. Arquivos de neuro-psiquiatria. 2012 Dec; 70(12): 939.McDermott CJ, Shaw PJ. Diagnosis and management of motor neurone disease. Bmj. 2008 Mar 20;336(7645):658-62.Murthy JM, Meena AK, Chowdary GV, Naryanan JT. Myasthenic crisis: clinical features, complications and mortality. Neurology India. 2005 Jan 1;53(1):37.
O'Brien MD. Taking a Neurological History. The Foundation Years. 2006; 2(1): 1-6.
Palace J. Making the diagnosis of multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry. 2001 Dec 1;71(suppl 2):ii3-8.Pearl PL. Neurological Problems of Jazz Legends. Journal of Child Neurology. 2009 Aug; 24(8): 1037-1042.
Perlmutter JS. Assessment of Parkinson disease manifestations. Current protocols in neuroscience. 2009 Oct;49(1):10-.Sanders DB, Wolfe GI, Benatar M, Evoli A, Gilhus NE, Illa I, Kuntz N, Massey JM, Melms A, Murai H, Nicolle M. International consensus guidance for management of myasthenia gravis: executive summary. Neurology. 2016 Jul 26;87(4):419-25.Shorvon SD. The etiologic classification of epilepsy. Epilepsia. 2011 Jun;52(6):1052-7.Simpson S, Blizzard L, Otahal P, Van der Mei I, Taylor B. Latitude is significantly associated with the prevalence of multiple sclerosis: a meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry. 2011 Oct 1;82(10):1132-41.
Talbot K. Motor neurone disease. Postgraduate medical journal. 2002 Sep 1;78(923):513-9.