SURVIVAL GUIDE TO THE HISTORY, EXAM, and ORAL PRESENTATION
Rob Naismith, M.D.
The Neurological History
The history is the most important part of your work-up. By the end of the history, you should have a clear picture of the person, their problem, and the likely etiologies. The history is also how we learn about disease and how it affects people. Reading a textbook can never replace personally hearing the story and examining multiple people with a certain disease. View each experience as a chance to learn more about a disease process, and to make personal observations that will be memorable.
A proper history takes time, typically at least 15-20 minutes, longer for more complex and acutely ill patients. Always sit-down when speaking to patients, and ensure their comfort and privacy. Always provide a proper introduction for the patient and each family member, while giving a brief overview of how things work in the hospital, and what to expect over the next 45+ minutes.
Ask open-ended questions and do not interrupt. Begin by eliciting their chief complaints. Some introductory questions might include, “How can I help you?”, “What would you like to discuss?”, or “What is troubling you the most?” If they begin to mention numerous symptoms, let them. Note the symptoms so you can return to each of these to get the necessary details. If you interrupt after the first, you may not get back to the rest.
Ask clarifying questions where appropriate, because your vocabulary may differ from the patient. While we understand vertigo and dizziness to mean different things, patients may not have that distinction. When you are not sure what ‘dizzy’, ‘fatigue’, ‘weak’, or ‘zoning-out’ means, ask in an open manner, “You mentioned you felt dizzy. Please describe that more so I could better understand.” Try to minimize multiple choice answers, because the real answer may be none-of-the-above. As an example of what not to ask, “When you say dizzy, do you mean the room is moving or that you felt light-headed?” Having the patient attempt to describe the symptom in their own words will give you new insights and bring you closer to what happened.
If they go on a tangent, use a redirecting question. The redirecting question lets the patient know that they said something important, and more information is required. For example, “A moment ago you mentioned that you couldn’t move. Please tell me more about the circumstances and what you experienced.” Some patients are very adept at telling a logical story with minimal interruption; other patients are nervous or unsure what is important, so they begin to discuss things that are not relevant to their symptoms or experience.
What if the patient appears unenthusiastic about providing the history, and says, “It’s all in my chart.” or “I just told all this to someone, do I have to do it again?” Put yourself in their shoes, which may mean feeling tired, anxious, and helpless. Think of how you can acknowledge their frustration while stressing the importance of reviewing the history once again. Let them know that you want to hear what happened directly from them. You might say, “I can only imagine how frustrating it must be to not feel well, and to have to repeat yourself to so many people. I really want to hear about your problems directly from you, so I can best understand what is happening.”
While asking direct questions may appear to save time, the thoroughness and quality of the data will not be sufficient to consider all diagnostic possibilities. Direct questions often reflect your bias towards a particular disease, and at this stage of gathering the data, you must keep an open mind. Direct questions severely restrict the patient’s ability to elaborate or correct. When you shift to a yes-or-no question format, the interview will be compromised because the patient now believes you know exactly what is important. Occasionally, you do need to ask a specific yes/no question, or pin-down a vague symptom, but then you need to work to get the conversation flowing again.
Occasionally, some patients simply do not elaborate upon their answers. You can give verbal and non-verbal signals to keep talking, “Please tell me more.”, “That’s very interesting.”, “And then what happened?” Your posture, eye contact, and head nodding can all be used to get the person to speak more prolifically.
How you ask something is also crucial. Make sure the question is non-leading, so do not ask, “You didn’t have any dizziness, did you?” Even the directed questions should be framed in a non-leading way. Sometimes we have to provide a choice to make sure we know what the patient means, but this shouldn’t happen too often. Including your interpretation of the word may help when things are vague, so instead of asking, ”Did you have vertigo or just dizziness?”, say, “Did it feel like the room was moving or spinning, much like on an amusement park ride, or did you feel woozy or light-headed, like you just heard some really bad news or felt faint.”
You should seek additional informants when indicated. These might include family, the nurse at the nursing facility, the manager at work who witnessed the seizure, etc. Patients with impaired consciousness or attention, those with seizures, and those with dementia always need an additional informant. The history is incomplete until you track down all available sources.
Your job is to recreate a chronological line of all their symptoms starting from the very beginning. If someone has had MS for 10 years, and they are coming in with an exacerbation over the past 2 weeks, then their history really begins 10 years ago. Delve into each symptom to obtain all the details. These include things such as the ‘PQRST’ questions – provocative factors, quality, relieving factors, severity, and time line. Include historical details when informative, such as what they were doing at the time. You want to ask how things resolved. If they fell, were they able to get up by themselves, did they have to lay there for 2 hours until someone came in, or did they have to crawl over to the phone to call someone. Quantify whenever possible – how many times did they fall last year, how many times did they fall this year. Include hard measures of disability – 3 years ago they started using a walker, last year they started to use a wheelchair, this year they cannot transfer out of the wheelchair without assistance. Inquire on how the symptoms have led to changes in work, relationships, taking care of the home, and in hobbies and travel.
In addition to the PQRST, think about localization and the differential. Inquire about co-localizing symptoms, “You mentioned your right arm suddenly felt weak. Did you notice any slurred speech, or did anyone mention that your face was also weak? Did you have any trouble speaking or understanding?” Symptoms in the differential might include, “Did you lose consciousness during the event? Did you have any shaking or tremor?” A superior oral presentation will be peppered with positive and negative localizing and differential symptoms.
One needs to be very cautious about interpreting the perceived benefits of prescribed treatments, because disease can fluctuate and medicines have placebo effects. Likewise, be cautious about other doctors’ opinions about the diagnosis. We want to take a fresh and independent approach to the patient’s complaints. Do not assume the existing diagnosis to be the correct one. Perhaps the diagnosis was made years ago, but new symptoms suggest a different disorder.
You also need to have a sense of the patients social and support structure. If someone is a single mother of 3, doesn’t have a high school education, is 3 months behind on paying her utilities, and is not on good terms with her family, then this is important. If someone lives on the 5th floor of an apartment without an elevator, then this is important.
Lastly, a good history will provide clues as to what you will find during the exam. If they are complaining of stiffness and weakness in the legs, then you would expect brisk reflexes and weakness. If they are complaining of numbness of the hand, ask them whether it is the whole hand or just part of it. If they are having double vision, ask if it is worse looking in a certain direction, and how are the 2 objects oriented. Being able to make a ‘telephone diagnosis’ takes some skill in asking the right questions that will allow the patient to accurately report what you will find objectively.
By the end of the history, you should have a clear picture of their symptoms and how they have unfolded over time. You should also have some hypotheses about what you will find on exam and a start to your differential. You should also have some inside knowledge about who is this person, how has their disease affected them, and what is their social support and living situation.