Introductory textbooks of physical diagnosis cover the basic aspects of medical interviewing. This chapter addresses some aspects of history taking of particular relevance to neurologic patients. Important historical points to be explored in some common neurologic conditions are summarized in the tables.

The history is the cornerstone of medical diagnosis, and neurologic diagnosis is no exception. In many instances the physician can learn more from what the patient says and how he says it than from any other avenue of inquiry. A skillfully taken history will frequently indicate the probable diagnosis, even before physical, neurologic, and neurodiagnostic examinations are carried out. Conversely, many errors in diagnosis are due to incomplete or inaccurate histories. In many common neurologic disorders the diagnosis rests almost entirely on the history. The most important aspect of history taking is attentive listening. Ask open ended questions and avoid suggesting possible responses. Although patients are frequently accused of being “poor historians,” there are in fact as many poor history takers as there are poor history givers. While the principal objective of the history is to acquire pertinent clinical data that will lead to correct diagnosis, the information
obtained in the history is also valuable in understanding the patient as an individual, his relationship to others, and his reactions to his disease.

Taking a good history is not simple. It may require more skill and experience than performing a good neurologic examination. Time, diplomacy, kindness, patience, reserve, and a manner that conveys interest, understanding, and sympathy are all essential. The physician should present a friendly and courteous attitude, center all his attention on the patient, appear anxious to help, word questions tactfully, and ask them in a conversational tone. At the beginning of the interview it is worthwhile to attempt to put the patient at ease. Avoid any appearance of haste. Engage in some small talk. Inquiring as to where the patient is from and what they do for a living not only helps make the encounter less rigid and formal, but often reveals very interesting things about the patient as a person. History taking is an opportunity to establish a favorable patient-physician relationship; the physician may acquire empathy for the patient, establish rapport, and instill confidence. The manner of presenting his history reflects the intelligence, powers of observation, attention, and memory of the patient. The examiner should avoid forming a judgment about the patient’s illness too quickly; some individuals easily sense and resent a physician’s preconceived ideas about their symptoms. Repeating key points of the history back to the patient helps insure accuracy and assure the patient the physician has heard and assimilated the story. At the end of the history, the patient should always feel as if he has been listened to. History taking is an art; it can be learned partly through reading and study, but is honed only through experience and practice.

The mode of questioning may vary with the age and educational and cultural background of the patient. The physician should meet the patient on a common ground of language and vocabulary, resorting to the vernacular if necessary, but without talking down to the patient. This is sometimes a fine line. The history is best taken in private, with the patient comfortable and at ease.

The history should be recorded clearly and concisely, in a logical, well-organized manner. It is important to focus on the more important aspects and keep irrelevancies to a minimum; the essential factual material must be separated from the extraneous. Diagnosis involves the careful sifting of evidence, and the art of selecting and emphasizing the pertinent data may make it possible to arrive at a correct conclusion in a seemingly complicated case. Recording negative as well as positive statements assures later examiners that the historian inquired into and did not overlook certain aspects of the disease.

Several different types of information may be obtained during the initial encounter. There is direct information from the patient describing the symptoms, information from the patient regarding what previous physicians may have thought, and information from medical records or previous care givers. All these are potentially important. Usually, the most essential is the patient’s direct description of the symptoms. Always work from information obtained firsthand from the patient when possible, as forming one’s own opinion from primary data is critical. Steer the patient away from a description of what previous doctors have thought, at least initially. Many patients tend to jump quickly to describing encounters with caregivers, glossing over the details of the present illness. Patients often misunderstand much or most of what they have been told in the past, so information from the patient about past evaluations and treatment must be analyzed cautiously. Patient recollections may be flawed because of faulty memory, misunderstanding, or other factors. Encourage the patient to focus on symptoms instead, giving a detailed account of the illness in his own words.

In general, the interviewer should intervene as little as possible, but it is often necessary to lead the conversation away from obviously irrelevant material, obtain amplification on vague or incomplete statements, or lead the story in directions likely to yield useful information. Allow the patient to use his own words as much as possible, but it is important to determine the precise meaning of words the patient uses, clarifying any ambiguity that could lead to misinterpretation. Have the patient clarify what he means by lay terms like “kidney trouble” or “dizziness.”

Deciding whether the physician or the patient should control the pace and content of the interview is a frequent problem. Patients do not practice history giving. Some are naturally much better
at relating the pertinent information than others. Many patients digress frequently into extraneous detail. The physician adopting an overly passive role under such circumstances often prolongs the interview unnecessarily. When possible, let the patient give the initial part of the history without interruption. In a primary care setting, the average patient tells his story in about five minutes. The average doctor interrupts the average patient after only about 18 seconds. In 44% of interviews done by medical interns, the patient was not allowed to complete their opening statement of concerns. Female physicians allowed fewer patients to finish their opening statement. Avoid interrogation, but keeping the patient on track with focused questions is entirely appropriate. If the patient pauses to remember some irrelevancy, gently encourage them not to dwell on it. A reasonable method is to let the patient run as long as they are giving a decent account, then take more control to clarify necessary details. Some patients may need to relinquish more control than others. Experienced clinicians generally make a diagnosis through a process of hypothesis testing. At some point in the interview, the physician must assume greater control and query the patient regarding specific details of their symptomatology in order to test hypotheses and help to rule in or rule out diagnostic possibilities.

History taking in certain types of patients may require special techniques. The timid, inarticulate, or worried patient may require prompting with sympathetic questions or reassuring comments. The garrulous person may need to be stopped before getting lost in a mass of irrelevant detail. The evasive or undependable patient may have to be queried more searchingly, and the fearful, antagonistic, or paranoid patient questioned guardedly to avoid arousing fears or suspicions. In the patient with multiple or vague complaints, insist on specifics. The euphoric patient may minimize or neglect his symptoms; the depressed or anxious patient may exaggerate, and the excitable or hypochondriacal patient may be overconcerned and recount his complaints at length. The range of individual variations is wide, and this must be taken into account in appraising symptoms. What is pain to the anxious or depressed patient may be but a minor discomfort to another. A blasé attitude or seeming indifference may indicate pathologic euphoria in one individual, but be a defense reaction in another. One person may take offense at questions which another would consider commonplace. Even in a single individual such factors as fatigue, pain, emotional conflicts, or diurnal fluctuations in mood or temperament may cause a wide range of variation in response to questions. Patients may occasionally conceal important information. In some cases, they may not realize the information is important; in other cases, they may be too embarrassed to reveal certain details.

The interview provides an opportunity to study the patient’s manner, attitude, behavior, and emotional reactions. The tone of voice, bearing, expression of the eyes, swift play of facial muscles, appearance of weeping or smiling, or the presence of pallor, blushing, sweating, patches of erythema on the neck, furrowing of the brows, drawing of the lips, clenching of the teeth, pupillary dilation, or muscle rigidity may give important information. Gesticulations, restlessness, delay, hesitancy, and the relation of demeanor and emotional responses to descriptions of symptoms or to details in the family or marital history should be noted and recorded. These and the mode of response to the questions are valuable in judging character, personality, and emotional state.

The patient’s story may not be entirely correct or complete. He may not possess full or detailed information regarding his illness, may misinterpret his symptoms or give someone else’s interpretation of them, wishfully alter or withhold information, or even deliberately prevaricate for some purpose. The patient may be a phlegmatic, insensitive individual who does not comprehend the significance of his symptoms, a garrulous person who cannot give a relevant or coherent story, or have multiple or vague complaints that cannot be readily articulated. Infants, young children, comatose or confused patients may be unable to give any history. Patients who are in pain or distress, have difficulty with speech or expression, are of low intelligence, or do not speak the examiner’s language are often unable to give a satisfactory history for themselves. Patients with nondominant parietal lesions are often not fully aware of the extent of their deficit. It may be necessary to corroborate or supplement
the history given by the patient by talking with an observer, relative, or friend, or even to obtain the entire history from someone else. Family members may be able to give important information about changes in behavior, memory, hearing, vision, speech, or coordination of which the patient may not be aware. It is frequently necessary to question both the patient and others in order to obtain a complete account of the illness. Family members and significant others sometimes accompany the patient during the interview. They can frequently provide important supplementary information. However, the family member must not be permitted to dominate the patient’s account of the illness unless the patient is incapable of giving a history.

It is usually best to see the patient de novo with minimal prior review of the medical records. Too much information in advance of the patient encounter may bias one’s opinion. If it later turns out that previous caregivers reached similar conclusions based on primary information, this reinforces the likelihood of a correct diagnosis. So, see the patient first, review old records later.

There are three approaches to utilizing information from past caregivers, whether from medical records or as relayed by the patient. In the first instance, the physician takes too much at face value and assumes that previous diagnoses must be correct. An opposite approach, actually used by some, is to assume all previous caregivers were incompetent, and their conclusions could not possibly be correct. This approach sometimes forces the extreme skeptic into a position of having to make some other diagnosis, even when the preponderance of the evidence indicates that previous physicians were correct. The logical middle ground is to make no assumptions regarding the opinions of previous caregivers. Use the information appropriately, matching it against what the patient relates and whatever other information is available. Do not unquestioningly believe it all, but do not perfunctorily dismiss it either. Discourage patients from grousing about their past medical care and avoid disparaging remarks about other physicians the patient may have seen. An accurate and detailed record of events in cases involving compensation and medicolegal problems is particularly important.

One efficient way to work is to combine reviewing past notes with talking directly with the patient. If the record contains a reasonably complete history, review it with the patient for accuracy. For instance, read from the record and say to the patient, “Dr. Payne says here that you have been having pain in the left leg for the past 6 months. Is that correct?” The patient might verify that information, or may say, “No, it’s the right leg and it’s more like 6 years.” Such an approach can save considerable time when dealing with a patient who carries extensive previous records. A very useful method for summarizing a past workup is to make a table with two vertical columns, listing all tests which were done, with those that were normal in one column and those that were abnormal in the other column.

Many physicians find it useful to take notes during the interview. Contemporaneous note taking helps insure accuracy of the final report. A useful approach is simply to “take dictation” as the patient talks, particularly in the early stages of the encounter. A note sprinkled with patient quotations is often very illuminating. However, one must not be fixated on note taking. The trick is to interact with the patient, and take notes unobtrusively. The patient must not be left with the impression that the physician is paying attention to the note taking and not to them. Such notes are typically used for later transcription into some final format. Sometimes the patient comes armed with notes. The patient who has multiple complaints written on a scrap of paper is said to have la maladie du petit papier; tech savvy patients may come with computer printouts detailing their medical histories.