Prior to developing a natural sense of direction through clinical experience, students and residents will often forget to ask about a variety of important items during the history. This, I am told, becomes a great source of stress for students and residents when their attending physician needs the unavailable information to make a diagnosis (which they invariably do from time to time). However, when you use the NeurAxis as a roadmap, the right questions will come naturally as you begin to bracket the patient’s problem to a particular region. The diagnostic possibilities will be
narrowed down efficiently as you use your history-taking skills to scan the NeurAxis from head to toe. When distal weakness is reported, you will automatically ask about associated sensory loss and paresthesias. These symptoms combined with diminished muscle stretch reflexes (which you will also remember to check) suggest a problem of the peripheral nervous system (e.g., peripheral neuropathy). Taking a useful history is not a matter of collecting a long list of random facts in case the attending physician asks. It is simply a matter of compiling relevant information, including the distribution and type of symptoms, so you are confidently guided to the level of the lesion. It is a skill that improves with experience, so be patient.

Visualize a skilled linebacker intensely scanning up and down the offensive line and backfield looking for clues that will help identify the next play. You likewise will be scanning up and down the nervous system (NeurAxis) to determine where the “action” is. Start with the chief complaint, and then pick a reasonable level and go up and then down the axis from that point with your questions.

If the complaint is trouble swallowing, you might start at the brainstem level, asking about diplopia, speech difficulty, and balance trouble. Then go up to the cerebral hemispheres and ask about any seizures, language dysfunction, or cognitive changes. Soon you will work your way back down through the brainstem to the spinal cord and eventually to the neuromuscular junction. The list of potential diseases is long, but the NeurAxis is finite and well defined. There are a relatively small number of “high-yield” symptoms that have proven to be more useful when sorting out the level affected, and these are discussed in detail later in this chapter. In terms of where to actually begin, a tentative hypothesis based on the chief complaint is usually a good starting point, and the NeurAxis is your roadmap. When you use the NeurAxis levels as a guide, the most important questions will come naturally, and all of the information you collect will be useful.

Before you even have a chance to perform the formal examination, your initial clinical impression will be based primarily on the symptoms endorsed by the patient and his or her unique story surrounding the illness. If you try to proceed without these essential elements, which are vital to comprising a good history, you may be swimming in a sea of uncertainty when it comes to performing your exam. You will inevitably find yourself ordering unnecessary lab studies. However, when armed with a reliable history, the clinical examination and relevant laboratory tests can be performed with the confidence that comes with a true sense of direction. Extracting a history from a textbook case is easy, but obtaining one from a patient can be quite challenging. The following paragraphs include some of the more important concepts related to performing the clinical history that will help you out immediately.

This patient’s particular situation was confusing to the resident because the tests ordered for evaluation of his reported “weakness” were normal. These included EMG, lumbar spine MRI, serum CK, and TSH. Furthermore, the clinical examination actually revealed normal motor power. There was no muscle weakness at all! This type of discrepancy in reported symptoms and objective examination findings is common. Part of the reason is that patients usually report their symptoms in lay terms that make sense to them, but these do not always correlate with our medical terminology. More pointed
questioning during the history should ferret this out. In this particular case, additional clinical information obtained during a more focused history revealed that the patient had noticeable trouble ambulating. This was actually caused by gait unsteadiness (ataxia), which he reported as “weakness.”

Gait instability is often reported as “weakness” because patients may feel like their legs are “giving way.” However, patients sometimes label true weakness (loss of motor power) as “falling spells” or “dizziness” because of difficulty with ambulation. “Numbness” is a term used by patients to describe a variety of problems, including tingling or burning (paresthesias), loss of sensation (true numbness), trouble controlling an arm or leg (limb ataxia), or even loss of strength (weakness).