PITFALLS IN HISTORY TAKING
INTRODUCTION
Neurological examination (including history taking) is of paramount importance to us for proper diagnosis particularly when investigations are misleading. This should include following rational steps:
- Proper history
- Analysis of case from history
- List of differentials from history
- General examination
- Neurological examination
- Analysis of case after examination
- Corroborative evidence from examination and comparison with history, addition and alterations of list of differentials from history.
- List of provisional diagnosis
- Relevant and targeted investigations
- Diagnosis.
This proforma is very useful for neurological case diagnosis. Here we shall discuss some practical problems in execution of steps to clinch the goal.
PITFALLS IN HISTORY TAKING
- History from caregiver is often sufficient enough to derail the thought of system localization.
- Sometimes caregiver comes up with a popular diagnosis and cause effect relationship by their own like “stroke”, “gas”, “cerebral”, “sodium fall”, “migraine”. Do not waste time in chasing behind this diagnosis.
- Sometimes, all symptoms, according to caregiver, started acutely related to a specific event, but actually symptoms started much earlier. Frequently they associate symptoms with an acute event like fall, familial disharmony, fever (often typhoid—imaginary, no documents), previous wrong treatment (claimed by caregiver).
- Most of the time, accompanying person is not the caregiver or they are not fully aware of chronology of symptomatology.
- History of sensory complaints is totally unreliable.
- History of ataxia of acute onset is almost taken as weakness by caregiver.
- Most of the time if you ask history of fever, the answer is positive. Confirm, whether they have actually recorded body temperature.
- History of dementia cases often starts and ends with forgetfulness. For other domains, you have to be very careful.
- Recurrent strokes must be differentiated from poststroke seizure.
- In primary CNS demyelination, it is important to delineate time frame of attacks very carefully to differentiate between new attacks and residual neurodeficit.
- Family history elicitation is very difficult; often answer is negative. Same is true for family history of tuberculosis or history of close contact with tuberculosis patient.
When analyzing history you must indicate the following three facets:
- Anatomical localization
- Underlying pathology
- Etiology.
NEUROLOGICAL EXAMINATION: STEPS
Neurological examination—steps to be followed:
- Higher mental function (HMF)
- Cranial nerves
- Spine and cranium
- Motor system
- Sensory system
- Cerebellum
- Gait
- Trophic changes.
General examination is often forgotten in neurology. But by a proper general survey, we can diagnose at least 20% of neurological cases, or at least we can get some clue toward etiological diagnosis in a substantial number of cases.
Motor system includes assessment of nutrition, tone, power, reflexes (superficial and deep) and detection of involuntary movement, if any.
Sensory system includes assessment of spinothalamic sensations, posterior column sensation and cortical sensation.
Autonomic testing are needed according to merit of the case. During examination, one thing must be kept in mind that you must not be dogmatic, rather you should be a little bit flexible and give respect to alternative possibilities. Interindividual variations are wide in neurology. You need not to bother much about that. After examination, note down positive findings and compare it with history. After that you prepare a list of differentials combining both history and detailed neurological examination. This time you fix your targeted investigations to narrow down your differentials. Last but not the least, do not jump on to investigation reports without detailed history and examination. After investigations, if any discrepancy arises then you must keep trust on your clinical findings, the chance of doing right is more on that occasion.