Rob Naismith, MD
The history is the most important part of your work-up. By the end of the history, you should have a clear picture of the person, their problem, and the likely etiologies. The history is also how we learn about disease and how it affects people. Reading a textbook can never replace personally hearing the story and examining multiple people with a certain disease. View each experience as a chance to learn more about a disease process, and to make personal observations that will be memorable.
A proper history takes time, typically at least 15-20 minutes, longer for more complex and acutely ill patients. Always sit-down when speaking to patients, and ensure their comfort and privacy. Always provide a proper introduction for the patient and each family member, while giving a brief overview of how things work in the hospital, and what to expect over the next 45+ minutes.
Ask open-ended questions and do not interrupt. Begin by eliciting their chief complaints. Some introductory questions might include, “How can I help you?”, “What would you like to discuss?”, or “What is troubling you the most?” If they begin to mention numerous symptoms, let them. Note the symptoms so you can return to each of these to get the necessary details. If you interrupt after the first, you may not get back to the rest.
Ask clarifying questions where appropriate, because your vocabulary may differ from the patient. While we understand vertigo and dizziness to mean different things, patients may not have that distinction. When you are not sure what ‘dizzy’, ‘fatigue’, ‘weak’, or ‘zoning-out’ means, ask in an open manner, “You mentioned you felt dizzy. Please describe that more so I could better understand.” Try to minimize multiple choice answers, because the real answer may be none-of-the-above. As an example of what not to ask, “When you say dizzy, do you mean the room is moving or that you felt light-headed?” Having the patient attempt to describe the symptom in their own words will give you new insights and bring you closer to what happened.
If they go on a tangent, use a redirecting question. The redirecting question lets the patient know that they said something important, and more information is required. For example, “A moment ago you mentioned that you couldn’t move. Please tell me more about the circumstances and what you experienced.” Some patients are very adept at telling a logical story with minimal interruption; other patients are nervous or unsure what is important, so they begin to discuss things that are not relevant to their symptoms or experience.
What if the patient appears unenthusiastic about providing the history, and says, “It’s all in my chart.” or “I just told all this to someone, do I have to do it again?” Put yourself in their shoes, which may mean feeling tired, anxious, and helpless. Think of how you can acknowledge their frustration while stressing the importance of reviewing the history once again. Let them know that you want to hear what happened directly from them. You might say, “I can only imagine how frustrating it must be to not feel well, and to have to repeat yourself to so many people. I really want to hear about your problems directly from you, so I can best understand what is happening.”
While asking direct questions may appear to save time, the thoroughness and quality of the data will not be sufficient to consider all diagnostic possibilities. Direct questions often reflect your bias towards a particular disease, and at this stage of gathering the data, you must keep an open mind. Direct questions severely restrict the patient’s ability to elaborate or correct. When you shift to a yes-or-no question format, the interview will be compromised because the patient now believes you know exactly what is important. Occasionally, you do need to ask a specific yes/no question, or pin-down a vague symptom, but then you need to work to get the conversation flowing again.
Occasionally, some patients simply do not elaborate upon their answers. You can give verbal and non-verbal signals to keep talking, “Please tell me more.”, “That’s very interesting.”, “And then what happened?” Your posture, eye contact, and head nodding can all be used to get the person to speak more prolifically.
How you ask something is also crucial. Make sure the question is non-leading, so do not ask, “You didn’t have any dizziness, did you?” Even the directed questions should be framed in a non-leading way. Sometimes we have to provide a choice to make sure we know what the patient means, but this shouldn’t happen too often. Including your interpretation of the word may help when things are vague, so instead of asking, ”Did you have vertigo or just dizziness?”, say, “Did it feel like the room was moving or spinning, much like on an amusement park ride, or did you feel woozy or light-headed, like you just heard some really bad news or felt faint.”
You should seek additional informants when indicated. These might include family, the nurse at the nursing facility, the manager at work who witnessed the seizure, etc. Patients with impaired consciousness or attention, those with seizures, and those with dementia always need an additional informant. The history is incomplete until you track down all available sources.
Your job is to recreate a chronological line of all their symptoms starting from the very beginning. If someone has had MS for 10 years, and they are coming in with an exacerbation over the past 2 weeks, then their history really begins 10 years ago. Delve into each symptom to obtain all the details. These include things such as the ‘PQRST’ questions – provocative factors, quality, relieving factors, severity, and time line. Include historical details when informative, such as what they were doing at the time. You want to ask how things resolved. If they fell, were they able to get up by themselves, did they have to lay there for 2 hours until someone came in, or did they have to crawl over to the phone to call someone. Quantify whenever possible – how many times did they fall last year, how many times did they fall this year. Include hard measures of disability – 3 years ago they started using a walker, last year they started to use a wheelchair, this year they cannot transfer out of the wheelchair without assistance. Inquire on how the symptoms have led to changes in work, relationships, taking care of the home, and in hobbies and travel.
In addition to the PQRST, think about localization and the differential. Inquire about co-localizing symptoms, “You mentioned your right arm suddenly felt weak. Did you notice any slurred speech, or did anyone mention that your face was also weak? Did you have any trouble speaking or understanding?” Symptoms in the differential might include, “Did you lose consciousness during the event? Did you have any shaking or tremor?” A superior oral presentation will be peppered with positive and negative localizing and differential symptoms.
One needs to be very cautious about interpreting the perceived benefits of prescribed treatments, because disease can fluctuate and medicines have placebo effects. Likewise, be cautious about other doctors’ opinions about the diagnosis. We want to take a fresh and independent approach to the patient’s complaints. Do not assume the existing diagnosis to be the correct one. Perhaps the diagnosis was made years ago, but new symptoms suggest a different disorder.
You also need to have a sense of the patients social and support structure. If someone is a single mother of 3, doesn’t have a high school education, is 3 months behind on paying her utilities, and is not on good terms with her family, then this is important. If someone lives on the 5th floor of an apartment without an elevator, then this is important.
Lastly, a good history will provide clues as to what you will find during the exam. If they are complaining of stiffness and weakness in the legs, then you would expect brisk reflexes and weakness. If they are complaining of numbness of the hand, ask them whether it is the whole hand or just part of it. If they are having double vision, ask if it is worse looking in a certain direction, and how are the 2 objects oriented. Being able to make a ‘telephone diagnosis’ takes some skill in asking the right questions that will allow the patient to accurately report what you will find objectively.
By the end of the history, you should have a clear picture of their symptoms and how they have unfolded over time. You should also have some hypotheses about what you will find on exam and a start to your differential. You should also have some inside knowledge about who is this person, how has their disease affected them, and what is their social support and living situation.
The neurological exam is one of the best aspects of neurology. Many patients have physical findings with tremendous utility for understanding how a disease functionally affects a person, for localizing, and for prioritizing the differential. Almost everyone with a neurological disease (except seizures and headaches) will have some abnormalities on their exam. Some of these are quite striking, and some can be very subtle. You cannot learn these in a book or a single lecture, so we learn this by seeing patients together with those who are more experienced. When you round with attendings, they will point out the subtle findings. Watch carefully how your attending does the exam.
You should do a complete neuro exam on all your patients, at least for the initial work-up. The chief or the attending might do a more focused exam, but that’s not the goal for you at this time. You need to have a firm grasp of what is normal and what is abnormal, and that takes much practice.
Mental status can be a large or short part of the exam. On every patient, you should specifically check orientation (person, place, time, situation), recall, short-term memory, attention, calculations, and long-term memory. You should take the persons educational level into context here. These can be expanded upon depending on the story and other findings. Language consists of 6 components. These include comprehension, fluency, naming, repetition, reading, and writing.
Cranial nerves should include visual acuity and funduscopic exam. You need to be able to readily see the optic nerve before the end of the rotation.
For the motor exam, you need to be able to pick-up subtle weakness. This would include having people do fine finger movements, toe tapping, walking on heels and toes, and hopping on each foot if safe to do so. When you check power, be sure that you have the mechanical advantage so that you will know if they have mild weakness.
Remember that for reflexes, you are trying to detect subtle differences, not just whether they are present or absent. The exam is much like an experiment where you are hypothesis testing. After you obtain the history, go wash your hands and use that time to create your hypotheses. Think about the localization(s), and the possible diagnoses on your differential. Do not bias the exam too much by leading the patient. You can conduct it as an objective experiment, and be convinced that the abnormality is really there. If you are not sure, repeat the test until you are convinced. Do more detailed testing when indicated by the history. For example, it may take 15 seconds to elicit the reflexes if they have no symptoms referable to that system, or it may take 2-3 minutes if you are really trying to discern a difference.
Your write-ups on neurology should be clear and concise. There is no reason to write a textbook summary as your assessment. The history should be very detailed and lengthy. This is because it is the most important part of your work-up. If the history is 1-2 short paragraphs, then this is not enough. The write-up is really an opportunity to organize all the data in an explicit manner, and then synthesize to come to a logically differential and plan. The write-up, while different that an oral presentation, should help you prepare for the oral presentation.
The social history should give an indication of the person’s living situation and social support. Even though alcohol, drug abuse, and tobacco use are really medical problems, they have been traditionally included under social history. The real social history will include educational level, job position with specific details, living situation, financial situation, important hobbies, etc.
Your assessment should contain a brief, 1-2 sentence statement which summarizes the entire work-up. Write this statement as if no one will read your write-up except the assessment. For example, “This is a 67 y/o man with cardiac disease who presents with sudden onset of slurred speech and left-sided weakness, and is found to have a left hemiparesis and neglect on exam. CT showed evidence of previous strokes, but nothing identified as acute”.
The next part of your assessment should include localization. Be only as specific as you can. For example, if there is left hemiparesis alone, then you could only say that it could be in the right hemisphere or brainstem. If someone has left hemiparesis densely involving arm and leg with a dense field cut and gaze deviation and a global aphasia, then you know that there is a stroke in the entire MCA territory on the right.
The next part of your assessment discusses the differential diagnosis. You should prioritize your differential, and not just make it into a long laundry list. What are the most possible diagnoses that are pertinent to this person’s story? That is, you need to integrate the whole story, and demonstrate that you understand what is going on here. Always include things that are common, treatable, and/or dangerous. Have a brief discussion as to why something is higher in the differential than another, or why it is less likely. This will include reviewing the diagnoses in a textbook and the medical literature. Review papers are a good place to start.
In constructing differentials, it is good to have a framework in working-through the different categories of disease. The following mnemonic is good to use:
D – Degenerative and hereditary
V – Vascular (infarct, ischemia, hemorrhage)
I – Infectious (immunocompetent, immunocompromised, bacterial, viral, fungal, parasitic)
C – Cancer (mass effect, paraneoplastic)
T – Trauma and surgical
I – Immunologic (autoimmune, allergic)
M – Metabolic (nutritional deficiency or excess, organ dysfunction, electrolyte disturbance)
Finally, put your plan and the reason for doing these things. For example, obtain MRI to see if there is evidence of acute infarcts in both hemispheres, consult PT to assist in gait training, obtain cardiac echo to evaluate for thrombus or valvular abnormality. Don’t put in plans for neurological emergencies if you aren’t going to do them. For example, don’t write to consider an LP if bacterial meningitis is a possibility, or consider EEG if non-convulsive status is a possibility. If you thought these were possibilities, you probably would have done the test before doing the write-up.
The patient is a 50-year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago.
History of present illness
Mrs. Smith states that on Sunday evening (7/14/03) about 20 minutes after sitting down to work at her computer, she developed blurred vision, which she describes as the words on the computer looking fuzzy and seeming to run into each other. When she looked up at the clock on the wall, she had a hard time making out the numbers. At the same time, she also noted a strange sensation in her right eyelid. She went to bed and upon awakening the following morning, she was unable to open her right eye. When she lifted the right eyelid with her fingers, she had double vision with the objects appearing side by side. The double vision was most prominent when she looked to the left, but was also present when she looked straight ahead, up, down, and to the right, and went away when she closed either of her eyes. She also noted that she had pain in both of her eyes that increased if she moved her eyes around, especially on looking to the left. She was seen in the Alton Memorial Hospital ER and subsequently transferred to BJH by ambulance.
Mrs. Smith also notes that for the past two to three weeks, she has been having intermittent pounding bifrontal headaches that worsen with straining, such as when coughing or having a bowel movement. The headaches are not positional and are not worse at any particular time of day. She rates the pain as 7 or 8 on a scale of 1 to 10, with 10 being the worst possible headache. The pain lessened somewhat when she took Vicodin that she had lying around. She denies associated nausea, vomiting, photophobia, loss of vision, seeing flashing lights or zigzag lines, numbness, weakness, language difficulties, and gait abnormalities. Her recent headaches differ from her “typical migraines,” which have occurred about 4-6 times per year since she was a teenager and consist of seeing shimmering white stars move horizontally across her vision for a couple minutes followed by a pounding headache behind one or the other eye, photophobia, phonophobia, and nausea and vomiting lasting several hours to two days. She has never taken anything for these headaches other than ibuprofen or Vicodin, both of which are partially effective. The last headache of that type was two months ago.
Her visual symptoms have not changed since the initial presentation. She denies previous episodes of transient or permanent visual or neurologic changes. She denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms. She is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days.
Past medical history
- Migraine headaches, as described in HPI.
- Depression. There is no history of diabetes or hypertension.
Zoloft 50 mg daily, ibuprofen 600 mg a few times per week, and Vicodin a few times per week.
The patient lives with her husband and 16-year-old daughter in a 2-story single-family house and has worked as a medical receptionist for 25 years. She denies tobacco or illicit drug use and rarely drinks a glass of wine.
Her mother had migraines and died at the age of 70 after a heart attack. Her maternal grandfather had a stroke at age 69. There is no other family history of stroke or vascular disease, but she has no information about her father’s side of the family.
Review of systems
She states that she had an upper respiratory infection with rhinorrhea, congestion, sore throat, and cough about 6 weeks ago. She denies fever, chills, malaise, weight loss, neck stiffness, chest pain, dyspnea, abdominal pain, diarrhea, constipation, urinary symptoms, joint pain, or back pain. Neurologic complaints as per HPI.
General physical examination
The patient is obese but well-appearing. Temperature is 37.6, blood pressure is 128/78, and pulse is 85. There is no tenderness over the scalp or neck and no bruits over the eyes or at the neck. There is no proptosis, lid swelling, conjunctival injection, or chemosis. Cardiac exam shows a regular rate and no murmur.
The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes.
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. She develops horizontal diplopia in all directions of gaze especially when looking to the left. There is ptosis of the right eye. Convergence is impaired.
CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.
CN VII: Face is symmetric with normal eye closure and smile.
CN VII: Hearing is normal to rubbing fingers
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact
CN XII: Tongue is midline with normal movements and no atrophy.
There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally.
|Deltoid||Biceps||Triceps||Wrist extension||Finger abduction||Hip flexion||Hip extension||Knee flexion||Knee extension||Ankle flexion||Ankle extension|
Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Plantar responses are flexor.
Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes.
Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent.
Posture is normal. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes.
(Record here all available lab data; circle any abnormal values).
CT (non-contrast) 7/17: no abnormalities. Orbits not well seen.
MRI 7/18: Multi-focal areas of increased signal on T2 and FLAIR in the deep white matter bilaterally. These range in size from 1 to 10 mm and do not enhance after administration of gadolinium. There are no signal abnormalities in the brain stem or in the corpus callosum. No abnormalities in orbits, sinuses, or venous structures.
In summary, the patient is a 50-year-old woman with longstanding headaches who has had an acute onset of pupil-sparing partial third nerve palsy on the right (involving levator palpabrae, superior rectus, and medial rectus) associated with a bifrontal headache. Because this is an isolated third nerve palsy without involvement of other cranial nerves or orbital abnormalities, the lesion is localized to the nerve itself, e.g. in the subarachnoid space. Ophthalmoplegic migraine remains a likely diagnosis given the history of migraine with aura, even though the current headache is different in character from her usual headaches and is not associated with visual aura, nausea/vomiting, or photophobia. However, other potentially serious causes of third nerve palsy must be excluded. If a third nerve palsy is due to a compressive lesion, the pupillary fibers will generally become involved within about one week of the onset of symptoms. So the fact that her pupil is normal in size and reactive to light weighs against the diagnosis of a compressive lesion such as an aneurysm or tumor, but does not eliminate the possibility.
The MRI does not show evidence of a mass lesion, but an aneurysm cannot be completely excluded without an angiogram. Another potentially serious cause of the third nerve palsy is meningitis. The patient is afebrile, has no meningeal signs, is well-appearing, and has been stable over three days, making bacterial meningitis highly unlikely, but atypical meningitis including fungal, Lyme, sarcoid or carcinomatous meningitis are possibilities. Finally, the patient may have a vascular lesion of the third nerve due to unrecognized diabetes.
The appearance of the MRI abnormalities is non-specific. The lesions are potentially explainable by migraines, but are also consistent with hypertension or a vasculopathy. The patient denies a history of hypertension, is not currently hypertensive, and has no risk factors for vascular disease, but the possibility of a genetic disorder such as CADASIL cannot be excluded given the lack of paternal history.
Problem 1. R IIIrd nerve palsy.
The patient will undergo a cerebral angiogram to evaluate for an aneurysm, particularly a posterior communicating aneurysm. Patient has been informed of risks and benefits of this procedure and it is scheduled for AM. She will be kept NPO for the procedure.
A lumbar puncture will be performed with opening pressure assessed and CSF sent for cell count and differential, protein, glucose, cultures and cytology. She will have her glucose and hemoglobin A1C drawn to evaluate for diabetes.
She will have close observation for possible neurologic worsening including neuro checks every 4 hours for first 24 hours.
She will be given an eye patch for comfort to eliminate the diplopia.
Problem 2. Headache.
She will be given a trial of naprosyn 400 mg po bid; if this is ineffective, she may require narcotic analgesia while her evaluation is being completed. If the cerebral angiogram and lumbar puncture are negative and her headache does not improve, she may be a candidate for IV dihydroergotamine treatment. Despite the infrequency of her migraines, the occurrence of a debilitating migraine with neurological deficits warrants the use of a prophylactic agent. A tricyclic antidepressant would be a good choice given her history of depression.
Problem 3. Depression.
The patient denies current symptoms and will continue Zoloft at current dose.
Problem 4. Obesity.
The patient requests referral to a dietician.
Your job for a presentation is to clearly and concisely reconstruct the timeline from the beginning, giving details about their symptoms as you go along. There are 2 types of presentations. The first is the 5 minutes work-rounds variety, and the second is the 45 minutes teaching conference variety.
You should not read from your notes during the history. You could make a brief outline on a card with a list of the medicines with doses, the vitals, and the labs, but reading the history is directly from the H&P is bad. You need to be able to look people in the eye and grab their attention. Remember, everyone is going to be tired and thinking about the other 10 things they need to do at the moment. If you give a boring presentation, then no one will pay attention. I would always try to put the story in the proper context when relevant, even for the 5 minute presentation. For example, if someone went to the county fair and rode the roller coaster, and an hour later developed vertigo, slurred speech, and inability to walk, then this gives us the context in which a vertebral dissection might have occurred. It also makes the story unique and memorable. If someone developed a headache while having sex, then this might be relevant for subarachnoid hemorrhage. If someone was in church singing in the choir and they passed out, then this is relevant. If you were to just list the symptoms without the context, then it is more boring and the patients start to sound the same.
The 5-10 minute presentation will be what is used during Team Rounds. This is a bare-bones presentation, but it is very dense with relevant material. It is really the ‘tip of the iceberg’ in terms of what you know about the patient. You cannot tell us everything, so you have to decide on what you do tell us. It consists of a chief complaint and the history. You should state pertinent positives and negatives along the way depending upon the differential diagnosis. There is no review of systems in the 5 minute presentation. If the family history is not relevant, then don’t even bother to mention it. If the social history is relevant, then include it in the history. If a past medical problem is relevant, then include it in the identifying information For example, “This is a 67 y/o RH white man who presents with acute onset of slurred speech. His history is significant for atrial fibrillation, congestive heart failure, coronary artery disease, and a previous stroke in 2005 with residual mild left hemiparesis.” We do not care whether they had their gallbladder or tonsils out, or if they have seasonal allergies unless it is relevant. We do not care if they take Prilosec unless it is relevant. Bottom line is that the attending should have a very clear picture of what is going on with this person within a few moments. There are no guessing games or cards to be kept up ones sleeves. Just go ahead and say it like it is.
When presenting to the attending on rounds, put the chief complaint up front and in medical terms. Do not use the patient’s words unless they are particularly relevant or insightful. Consider the following example, “Mr. Jones is a 72 y/o RH black man with CAD, HTN, hypercholesterolemia, GERD, and arthritis who presents because his daughter insisted he come to the hospital.” You are now 15 seconds in the presentation and the attending has no clue. By giving the medical complaint up front, the attending can start to organize your presentation. Now consider the opening statement in the paragraph above. Right from the start, the attending knows the complaint (slurred speech), along with age and gender. Is it ALS? Is it a Bell’s palsy? Is it a stroke? These are going through the attending’s mind. Next s/he hears a list of cardiovascular risk factors, and immediately stroke goes to the top of all considerations. That is how the brief presentation should work. You should present the details, almost anticipating what needs to be heard at that given time.
The exam should be abbreviated to convey what is important. Also, remember to stay organized: 1) mental status, 2) language, 3) cranial nerves, 4) motor, 5) reflexes, 6) sensory, 7) coordination and gait. We are all going on the assumption that you did a complete general and neurological exam. It would be fine to list out the vitals and then say that the general medical exam is unremarkable if that is what you found. For a stroke, you might say mental status and language are intact. Cranial nerves are relevant for left lower facial droop and dysarthria, but no field cut. Motor is relevant for a left hemiparesis 3-4/5 in severity affecting the arm greater than the leg. Reflexes are brisk on the left with an upgoing toe. Coordination on the left was appropriate for that degree of weakness. He had diminished sensation on the left, but was able to reliably perceive touch. He had both visual and sensory neglect. He needed assistance to walk due to the hemiparesis. You generally don’t want to get bogged down in listing out all the cranial nerves, all the numbers for the muscle testing, and all the numbers for reflexes. You want to include pertinent negatives here based on your differential. This is how your attending will know you are smart. If bacterial endocarditis is on the differential, then you should specifically state in the general exam that there were no conjunctival or extremity lesions and no murmur.
Because the presentation is brief, you shouldn’t have to give a summary statement of what you just said. You should give a statement about the localization, and then the differential diagnosis. The differential should be ranked to include things that are common, things that are treatable, and things that are dangerous. Next you can state your plan for evaluating the differential and for helping the patient get better.
You will need to prepare for the 5 minute presentation. Don’t think you could do it otherwise. It takes practice to condense 1-2 hours of your work-up into 5 minutes. The attending realizes you spent a lot of time with your patient, but doesn’t want to hear every last detail. You will show the attending how smart you are by how well you are able to do this. Losing focus and going on a tangent with your presentation will not impress. Some of your grade will come from this interaction. Rehearse out loud in your call room, or find another student to help practice. Make an outline on a card. All these things will help keep you focused, because we all get nervous when speaking in front of a group.
Lastly, don’t forget that your attending will like to hear the neuro exam in order. This is
- Mental status,
- Cranial nerves,
- Coordination & gait.