The Clinical Interview in Neurology

2.1 General Principles of History-Taking

2.2 Special Aspects of History-Taking

Is It in My Head?

A 47-year-old elementary-school teacher consults a neurologist after being referred by her family physician.

“Good morning. What seems to be the trouble?”

“Doctor, I’ve been having headaches for a while now. I’ve never had headaches before, and I’ve always been healthy, but now I’m getting a little worried.”

“How long have the headaches been bothering you?”

“About six months, I’d say. I’ve been having a lot of stress at work lately, and my mother died six months ago. I had to clear out her old apartment. Could that have something to do with it?”

“Perhaps, but let’s concentrate on the headaches for a moment. How would you describe them?”

“It’s as if my head’s going to explode. Everything feels so tight!”

“As if you were wearing a tight ring around your head, is that it?”

“Well, the pressure actually seems to be coming from the inside, but it’s sort of like a tight ring, too. Anyway, it’s a feeling of pressure. That’s the best way to describe it.”

“Do you have a headache all the time?”

“Not always. Some days are better, and I sometimes forget about the headaches entirely, but they always come back—sometimes for a couple of hours, but sometimes for a whole day or even two.”

“Are the headaches located anywhere in particular, such as only in the front of your head, behind your eyes, or on the right or left side?”

“No, they’re all over my head.”

“Do they keep you from doing things you want to do?”

“Well, of course.”

“I mean, can you go to work even when you have a headache?”

“Oh. Yes, I’ve been going to work anyway, and then I had all that stress with my mother’s apartment. No matter what, I still have to take care of my family and do my job, don’t I? I can’t take a holiday from life just because I have headaches.”

“Have you been having any other problems aside from headaches? Nausea or vomiting? Ringing in the ears? Oversensitivity to noise or bright light? Dizziness?”

“No, basically I just have headaches. That’s already bad enough, I think.”

“Have you taken anything for them?”

“No, I’m not a big fan of taking medicines. Thank God I never needed any regularly.”

“Are there situations in which the headaches are more likely to arise?”

“Well, yes, I think the stress of the last couple of weeks has had a lot to do with it, and then all that running around because of the apartment. My mother lived far away from here, I forgot to tell you, in the south of France.”

“Yes, I can imagine that gave you quite a lot of trouble. So, you think the headaches have to do with your mother’s death?”

“I suppose they do, somehow. By the way, my mother died of a brain tumor. Tell me, doctor … do you think I might have one, too?”

This dialogue exemplifies a typical headache history. Precise history-taking usually lets the physician formulate a tentative diagnosis that can serve as a basis for the physical examination and further testing (if indicated). To fulfill this purpose, history-taking should follow a few basic rules, particularly regarding the physician’s demeanor and a systematic approach to questioning. The emotional aspects and the patient’s own interpretation of the symptoms must never be ignored. The general aspects of history-taking are discussed in this chapter.

This patient’s history suggests she is most likely suffering from tension-type headaches, which may or may not be related to her mother’s death and the stressful situations she describes. The physician must nonetheless respect her interpretation and address the matter again once the diagnostic evaluation is complete. It was not till the very end of the interview that she revealed her likely motivation for the consultation—fear of a brain tumor, that is, fear of having (and perhaps dying from) the same disease her mother had. The physician should do his or her best to assuage this fear, even while the diagnostic evaluation is still in progress.

2.1 General Principles of History-Taking

Key Point

The clinical history is of paramount importance in neurology, perhaps more so than in any other medical specialty. It is indispensable as a diagnostic instrument, it helps establish a doctor–patient relationship built on trust, and it is a prerequisite for the success of any subsequent treatment. The history should always be taken with utmost care.

The general type of neurologic disturbance from which the patient is suffering can usually be determined from a carefully obtained clinical history even before the physical examination or any further tests are performed. Often, the physician can pinpoint the diagnosis from the history alone—but only after attentive listening and an adequate investment of time.

Note

“A blind neurologist is better than a deaf neurologist.”

2.1.1 General Prerequisites for Good History-Taking

In any branch of clinical medicine, not just in neurology, a good history can be taken only if the patient has full confidence in the physician. Introduce yourself to the patient and take the history in a place that offers the necessary privacy and discretion. The patient should be comfortably seated and emotionally at ease, as far as the circumstances allow, and must not feel rushed. If anyone else is present during the interview, for example, a medical student, introduce this person and make sure the patient has no objection to his or her presence. Persons other than the physician who is taking the history should behave unobtrusively. The history should be detailed and complete.

2.1.2 General Principles of the Clinical Interview

While interviewing the patient, observe these principles:

At first, the patient should be doing most of the talking, and you should say as little as possible.
You do indeed have to elicit all of the important historic data by specific inquiry, but only after the patient has finished describing the problem in his or her own words.
Even if the patient’s story is rambling or vague, you should take care not to betray any impatience or irritation.
Once your turn comes, you must amplify and refine this initial information by persistent or even stubborn questioning, until at last you have a clear picture of the present illness.
Never reject the patient’s own interpretation of his or her symptoms, even if it seems implausible or absurd. You will then come across as a scoffing know-it-all and will have broken your line of communication with the patient.

2.1.3 Your Demeanor toward the Patient

Every patient has the right to be treated courteously and tactfully and to have the physician’s full attention for an adequate period of time. You should perform a meticulous physical examination only after listening carefully to the patient’s story and rounding it out with further, detailed questioning. The patient has the right to be told what your findings are and what they imply about his or her illness. Explain these matters truthfully, in language that the patient can understand, and with due respect for his or her feelings. You will often find yourself having to steer a difficult course between bluntness and reassurance.

If the patient is accompanied by another person, such as a spouse, parent, other relative, or friend, the patient should remain the focus of your attention, even if he or she is a child or adolescent or is cognitively impaired. Communicate mainly with the patient. You may have to ask accompanying persons to leave the room for part of the clinical interview or physical examination, but do not neglect their needs, either; the persons closest to the patient, after all, may have an important role to play later on, during treatment. Courtesy and consideration for the patient as a fellow human being, palpable respect for his or her dignity, and genuine understanding and sympathy are the foundations of a trusting relationship between the patient and the physician and are therefore essential preconditions for successful treatment.

2.1.4 The History and Physical Examination

The patient history and the physical examination are independent and equally important components of the clinical diagnostic evaluation. They must complement each other and should, to some extent, be performed in parallel. An experienced clinician, while listening to the patient’s history, will already be thinking of specific abnormalities to look for on physical examination. If the examination reveals other, perhaps unexpected findings, the clinician can amplify the history with specific questions. Ideally, the clinician will be able to make the diagnosis from the history and physical examination alone.