• Carefully identify the chief complaint or major problem. Not only is the chief complaint
important in providing the first clue to the physician as to the differential diagnosis, it is also
the reason why the patient is seeking medical advice and treatment. If the chief complaint is
not properly identified and addressed, the proper diagnosis may be missed and an
inappropriate diagnostic work-up may be undertaken. Establishing a diagnosis that does
not incorporate the chief complaint frequently focuses attention on a coincidental process
irrelevant to the patient’s concerns.
• Listen carefully to the patient for as long as is necessary. A good rule of thumb is to
listen initially for at least 5 minutes without interrupting the patient. The patient often
volunteers the most important information at the start of the history. During this time, the
examiner can also assess mental status including speech, language, fund of knowledge,
and affect, and observe the patient for facial asymmetry, abnormalities of ocular movement,
a paucity of spontaneous movements as seen with movement disorders.
• Steer the patient away from discussions of previous diagnostic tests and of the
opinions of previous caregivers. Abnormalities on laboratory studies may be incidental to
the patient’s primary problem or may simply represent a normal variant.
• Take a careful medical history, medication history, psychiatric history, family history,
and social and occupational history. Many neurologic illnesses are complications of
underlying medical disorders or due to adverse effects of drugs. For example, parkinsonism
is a frequent complication of metoclopramide and most neuroleptic agents. A large number
of neurologic disorders are hereditary, and a positive family history may establish the
diagnosis in many instances. Occupation plays a major role in various neurologic disorders
such as carpal tunnel syndrome (computer keyboard operators), and peripheral neuropathy
(exposure to lead or other metals).
• Interview surrogate historians. Patients with dementia or altered mental status are
usually unable to provide exact details of the history, and a family member may provide key
details needed to make an accurate diagnosis. This is especially true for patients with
dementia and certain right hemispheric lesions with various agnosias (unawareness of
disease) that may interfere with their ability to provide a cogent history. Surrogate historians
also provide missing historical details for patients with episodic loss of consciousness, such
as syncope, epilepsy, and narcolepsy.
• Summarize the history for the patient. Summarizing the history is an effective way to
insure that all details were covered in sufficient detail to make a tentative diagnosis.
Summarizing will also allow the physician to fill in historical gaps that may not have been
apparent when the history was initially taken. In addition, the patient or surrogate may
correct any historical misinformation at this time.
• End by asking the patient what he thinks is wrong with him. This allows the physician
to evaluate the patient’s insight into his condition. Some patients have a specific diagnosis
in mind that brings them to seek medical attention. Multiple sclerosis, amyotrophic lateral
sclerosis, Alzheimer’s disease and brain tumors are diseases that patients often suspect
may be the cause of their neurologic symptoms.
The neurologic history has several components, including the history of present illness, review
of systems, past medical history, medication history, family history and social history.
The History of the Present Illness consists of an accurate, chronological description of the
patient's presenting illness.