SURVIVAL GUIDE TO THE HISTORY, EXAM, and ORAL PRESENTATION
Rob Naismith, M.D.
Your write-ups on neurology should be clear and concise. There is no reason to write a textbook summary as your assessment. The history should be very detailed and lengthy. This is because it is the most important part of your work-up. If the history is 1-2 short paragraphs, then this is not enough. The write-up is really an opportunity to organize all the data in an explicit manner, and then synthesize to come to a logically differential and plan. The write-up, while different that an oral presentation, should help you prepare for the oral presentation.
The social history should give an indication of the person’s living situation and social support. Even though alcohol, drug abuse, and tobacco use are really medical problems, they have been traditionally included under social history. The real social history will include educational level, job position with specific details, living situation, financial situation, important hobbies, etc.
Your assessment should contain a brief, 1-2 sentence statement which summarizes the entire work-up. Write this statement as if no one will read your write-up except the assessment. For example, “This is a 67 y/o man with cardiac disease who presents with sudden onset of slurred speech and left-sided weakness, and is found to have a left hemiparesis and neglect on exam. CT showed evidence of previous strokes, but nothing identified as acute”.
The next part of your assessment should include localization. Be only as specific as you can. For example, if there is left hemiparesis alone, then you could only say that it could be in the right hemisphere or brainstem. If someone has left hemiparesis densely involving arm and leg with a dense field cut and gaze deviation and a global aphasia, then you know that there is a stroke in the entire MCA territory on the right.
The next part of your assessment discusses the differential diagnosis. You should prioritize your differential, and not just make it into a long laundry list. What are the most possible diagnoses that are pertinent to this person’s story? That is, you need to integrate the whole story, and demonstrate that you understand what is going on here. Always include things that are common, treatable, and/or dangerous. Have a brief discussion as to why something is higher in the differential than another, or why it is less likely. This will include reviewing the diagnoses in a textbook and the medical literature. Review papers are a good place to start.
In constructing differentials, it is good to have a framework in working-through the different categories of disease. The following mnemonic is good to use:
D – Degenerative and hereditary
V – Vascular (infarct, ischemia, hemorrhage)
I – Infectious (immunocompetent, immunocompromised, bacterial, viral, fungal, parasitic)
C – Cancer (mass effect, paraneoplastic)
T – Trauma and surgical
I – Immunologic (autoimmune, allergic)
M – Metabolic (nutritional deficiency or excess, organ dysfunction, electrolyte disturbance)
Finally, put your plan and the reason for doing these things. For example, obtain MRI to see if there is evidence of acute infarcts in both hemispheres, consult PT to assist in gait training, obtain cardiac echo to evaluate for thrombus or valvular abnormality. Don’t put in plans for neurological emergencies if you aren’t going to do them. For example, don’t write to consider an LP if bacterial meningitis is a possibility, or consider EEG if non-convulsive status is a possibility. If you thought these were possibilities, you probably would have done the test before doing the write-up.