- •Overview
- •Preface
- •Translator’s Note
- •Contents
- •1. Fundamentals
- •Microscopic Anatomy of the Nervous System
- •Elements of Neurophysiology
- •Elements of Neurogenetics
- •General Genetics
- •Neurogenetics
- •Genetic Counseling
- •2. The Clinical Interview in Neurology
- •General Principles of History Taking
- •Special Aspects of History Taking
- •3. The Neurological Examination
- •Basic Principles of the Neurological Examination
- •Stance and Gait
- •Examination of the Head and Cranial Nerves
- •Head and Cervical Spine
- •Cranial Nerves
- •Examination of the Upper Limbs
- •Motor Function and Coordination
- •Muscle Tone and Strength
- •Reflexes
- •Sensation
- •Examination of the Trunk
- •Examination of the Lower Limbs
- •Coordination and Strength
- •Reflexes
- •Sensation
- •Examination of the Autonomic Nervous System
- •Neurologically Relevant Aspects of the General Physical Examination
- •Neuropsychological and Psychiatric Examination
- •Psychopathological Findings
- •Neuropsychological Examination
- •Special Considerations in the Neurological Examination of Infants and Young Children
- •Reflexes
- •4. Ancillary Tests in Neurology
- •Fundamentals
- •Imaging Studies
- •Conventional Skeletal Radiographs
- •Computed Tomography (CT)
- •Magnetic Resonance Imaging (MRI)
- •Angiography with Radiological Contrast Media
- •Myelography and Radiculography
- •Electrophysiological Studies
- •Fundamentals
- •Electroencephalography (EEG)
- •Evoked potentials
- •Electromyography
- •Electroneurography
- •Other Electrophysiological Studies
- •Ultrasonography
- •Other Ancillary Studies
- •Cerebrospinal Fluid Studies
- •Tissue Biopsies
- •Perimetry
- •5. Topical Diagnosis and Differential Diagnosis of Neurological Syndromes
- •Fundamentals
- •Muscle Weakness and Other Motor Disturbances
- •Sensory Disturbances
- •Anatomical Substrate of Sensation
- •Disturbances of Consciousness
- •Dysfunction of Specific Areas of the Brain
- •Thalamic Syndromes
- •Brainstem Syndromes
- •Cerebellar Syndromes
- •6. Diseases of the Brain and Meninges
- •Congenital and Perinatally Acquired Diseases of the Brain
- •Fundamentals
- •Special Clinical Forms
- •Traumatic Brain injury
- •Fundamentals
- •Traumatic Hematomas
- •Complications of Traumatic Brain Injury
- •Intracranial Pressure and Brain Tumors
- •Intracranial Pressure
- •Brain Tumors
- •Cerebral Ischemia
- •Nontraumatic Intracranial Hemorrhage
- •Infectious Diseases of the Brain and Meninges
- •Infections Mainly Involving the Meninges
- •Infections Mainly Involving the Brain
- •Intracranial Abscesses
- •Congenital Metabolic Disorders
- •Acquired Metabolic Disorders
- •Diseases of the Basal Ganglia
- •Fundamentals
- •Diseases Causing Hyperkinesia
- •Other Types of Involuntary Movement
- •Cerebellar Diseases
- •Dementing Diseases
- •The Dementia Syndrome
- •Vascular Dementia
- •7. Diseases of the Spinal Cord
- •Anatomical Fundamentals
- •The Main Spinal Cord Syndromes and Their Anatomical Localization
- •Spinal Cord Trauma
- •Spinal Cord Compression
- •Spinal Cord Tumors
- •Myelopathy Due to Cervical Spondylosis
- •Circulatory Disorders of the Spinal Cord
- •Blood Supply of the Spinal Cord
- •Arterial Hypoperfusion
- •Impaired Venous Drainage
- •Infectious and Inflammatory Diseases of the Spinal Cord
- •Syringomyelia and Syringobulbia
- •Diseases Mainly Affecting the Long Tracts of the Spinal Cord
- •Diseases of the Anterior Horns
- •8. Multiple Sclerosis and Other Myelinopathies
- •Fundamentals
- •Myelin
- •Multiple Sclerosis
- •Other Demyelinating Diseases of Unknown Pathogenesis
- •9. Epilepsy and Its Differential Diagnosis
- •Types of Epilepsy
- •Classification of the Epilepsies
- •Generalized Seizures
- •Partial (Focal) Seizures
- •Status Epilepticus
- •Episodic Neurological Disturbances of Nonepileptic Origin
- •Episodic Disturbances with Transient Loss of Consciousness and Falling
- •Episodic Loss of Consciousness without Falling
- •Episodic Movement Disorders without Loss of Consciousness
- •10. Polyradiculopathy and Polyneuropathy
- •Fundamentals
- •Polyradiculitis
- •Cranial Polyradiculitis
- •Polyradiculitis of the Cauda Equina
- •Polyneuropathy
- •Fundamentals
- •11. Diseases of the Cranial Nerves
- •Fundamentals
- •Disturbances of Smell (Olfactory Nerve)
- •Neurological Disturbances of Vision (Optic Nerve)
- •Visual Field Defects
- •Impairment of Visual Acuity
- •Pathological Findings of the Optic Disc
- •Disturbances of Ocular and Pupillary Motility
- •Fundamentals of Eye Movements
- •Oculomotor Disturbances
- •Supranuclear Oculomotor Disturbances
- •Lesions of the Nerves to the Eye Muscles and Their Brainstem Nuclei
- •Ptosis
- •Pupillary Disturbances
- •Lesions of the Trigeminal Nerve
- •Lesions of the Facial Nerve
- •Disturbances of Hearing and Balance; Vertigo
- •Neurological Disturbances of Hearing
- •Disequilibrium and Vertigo
- •The Lower Cranial Nerves
- •Accessory Nerve Palsy
- •Hypoglossal Nerve Palsy
- •Multiple Cranial Nerve Deficits
- •12. Diseases of the Spinal Nerve Roots and Peripheral Nerves
- •Fundamentals
- •Spinal Radicular Syndromes
- •Peripheral Nerve Lesions
- •Fundamentals
- •Diseases of the Brachial Plexus
- •Diseases of the Nerves of the Trunk
- •13. Painful Syndromes
- •Fundamentals
- •Painful Syndromes of the Head And Neck
- •IHS Classification of Headache
- •Approach to the Patient with Headache
- •Migraine
- •Cluster Headache
- •Tension-type Headache
- •Rare Varieties of Primary headache
- •Symptomatic Headache
- •Painful Syndromes of the Face
- •Dangerous Types of Headache
- •“Genuine” Neuralgias in the Face
- •Painful Shoulder−Arm Syndromes (SAS)
- •Neurogenic Arm Pain
- •Vasogenic Arm Pain
- •“Arm Pain of Overuse”
- •Other Types of Arm Pain
- •Pain in the Trunk and Back
- •Thoracic and Abdominal Wall Pain
- •Back Pain
- •Groin Pain
- •Leg Pain
- •Pseudoradicular Pain
- •14. Diseases of Muscle (Myopathies)
- •Structure and Function of Muscle
- •General Symptomatology, Evaluation, and Classification of Muscle Diseases
- •Muscular Dystrophies
- •Autosomal Muscular Dystrophies
- •Myotonic Syndromes and Periodic Paralysis Syndromes
- •Rarer Types of Muscular Dystrophy
- •Diseases Mainly Causing Myotonia
- •Metabolic Myopathies
- •Acute Rhabdomyolysis
- •Mitochondrial Encephalomyopathies
- •Myositis
- •Other Diseases Affecting Muscle
- •Myopathies Due to Systemic Disease
- •Congenital Myopathies
- •Disturbances of Neuromuscular Transmission−Myasthenic Syndromes
- •15. Diseases of the Autonomic Nervous System
- •Anatomy
- •Normal and Pathological Function of the Autonomic Nervous System
- •Sweating
- •Bladder, Bowel, and Sexual Function
- •Generalized Autonomic Dysfunction
- •Index
8
2The Clinical Interview in Neurology
General Principles of History Taking . . . 8
Special Aspects of History Taking . . . 9
General Principles of History Taking
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 serves to establish a doctor− patient relationship built on trust, and it is a prerequisite for the success of any treatment that will follow. The history should always be taken with utmost care.
The type of neurological disturbance from which a patient is suffering can usually be determined from a carefully obtained clinical history even before the physical examination or any further tests are performed. In many patients, the history alone permits the assignment of a precise diagnosis, but only if the physician has been listening closely to the patient.
! “A blind neurologist is better than a deaf neurologist.”
Skillful history taking is the distinguishing mark of a good clinician.
General prerequisites for good history taking. In any branch of clinical medicine, not just in neurology, a good history can be obtained only if the patient has confidence in the physician. Introduce yourself to the patient and take the history in a place offering 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 someone else is present during the interview, e. g., a medical student, introduce this person and make sure the patient really has no objection to his or her presence. Persons other than the physician taking the history should behave discreetly and keep themselves somewhat in the background. The history should be detailed and complete and should be taken by, or under the supervision of, an experienced clinician, as far as possible.
General principles of the clinical interview. While interviewing the patient, observe these principles: in the beginning 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 historical data by specific inquiry, but only after the patient has finished describing the problem in his or her own words. The patient’s story may be rambling or vague; even so, you should take care not to seem impatient or
irritated. Once your turn comes, however, you must amplify and refine this initial information by persistent or even stubborn questioning, until at last you have obtained 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.
Your demeanor toward the patient. Every patient has the right to be treated courteously and tactfully and to receive the physician’s full attention during an appropriately set period. You should perform a meticulous physical examination only after you have listened carefully to the patient’s story and filled it out with further, detailed questioning. The patient has the right to a full explanation of your findings and of what they imply about his or her illness. You should 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 euphemism.
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. You should communicate mainly with the patient. You might 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 nearest 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.
The history and physical examination are two independent and equally important components of clinical diagnostic assessment. They must complement each other and should, to some extent, be performed in parallel. The 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 should then reveal other, perhaps unexpected findings, the clinician can amplify the history by asking further, specific questions. Ideally, the clinician will be able to make the diagnosis from the history and physical examination alone.
Mumenthaler / Mattle, Fundamentals of Neurology © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license.
Special Aspects of History Taking |
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Special Aspects of History Taking
The “classic” history has certain standard components and is meant to provide a complete picture of the patient, including his or her present complaints, past medical history, personality, and life situation.
The present illness. When taking a clinical history, always first give the patient a chance to describe his or her current complaints and the reason for the consultation. Only afterward should you begin interrogating the patient systematically to make the history complete, in accordance with the principles presented above. Systematic history taking is performed in standard fashion in all branches of clinical medicine; a basic outline is provided in Table 2.1. In each specialty, however, there are further important issues that tend to arise regularly and these should be asked about specifically. The important questions to ask in the neurological history are summarized in Table 2.2.
Past medical history, family history, and social history. Once you have a clear and complete picture of the
patient’s current complaints, you can begin to ask about earlier symptoms and illnesses, starting with general questions and then proceeding into greater detail. Always ask about problems that might bear a relation to the present illness: a patient suffering from ischemic stroke, for instance, should be asked about hypertension, heart disease, and smoking. Inquire into the health of the patient’s blood relatives, particularly with regard to neurological and other hereditary diseases. Finally, ask about the patient’s familial and social setting: marriage or other partnership, children, occupation, and any potential problems or conflicts in these areas. Ascertain how the patient’s current (or earlier) medical problems affect him or her in everyday life, both at home and in the workplace. Broach these matters as unobtrusively as possible, however, because overzealous questioning might make the patient wrongly think that you believe his or her problems to be primarily psychogenic. Of course, if a thorough diagnostic evaluation reveals that a psychogenic mechanism is the likely cause, then this, too, should be discussed openly with the patient.
Table 2.1 Outline of the general clinical history
1The patient’s spontaneous description of his or her current complaints —more precise information can be elicited by direct questioning
2Systematic analysis of the current complaints
(see Table 2.2)
3Prior illnesses (past medical and surgical history)
information spontaneously provided by the patient
specific questioning by the physician, particularly about earlier conditions of potential relevance to the current complaints
gestational and birth history, when indicated
4Life Habits
alcohol and tobacco
medications
illicit drugs
potentially toxic environmental influences
5Neurovegetative functions
sleep, digestion, urination, sexual dysfunction
6Personality and social situation
the patient’s personal and social setting: education, occupation, familial/social/financial position, and any current problems or conflicts (information of this type enables the physician to assess all of the factors affecting the patient’s ability to deal with his or her medical problems successfully)
the patient’s behavior, manner of speaking, gestures, facial expressions, emotional responses, and reactions to questions, etc., give the examiner an overall impression of the patient’s personality
7Family history
Table 2.2 History of the present illness
Major symptom(s)
The patient’s spontaneous description, refined by specific questioning
How long have the symptoms been present? Where are they located?
How did they begin? (suddenly, gradually, or after a specific inducing event?)
How have they developed over time? (constant, increasing, decreasing, fluctuating?)
What influences the symptoms? (ameliorating/aggravating influences, medications?)
Effects
How severe are the symptoms in terms of their effect on everyday life at home and at work, and on the patient’s emotional well-being? Is treatment required?
Current accompanying symptoms
Here it is particularly important to supplement the patient’s spontaneous complaints with specific questioning. An experienced clinician knows what questions to ask even if the patient has provided very little information.
Relevant past medical history
Did the patient already have earlier symptoms or conditions that might be relevant to the current complaints? (e. g., earlier transient ischemic attacks in a patient suffering from acute stroke?)
Does the patient have any predisposing factors for conditions that might account for the current complaints? (e. g., cigarette smoking leading to a Pancoast tumor of the apex of the lung?)
Relevant family history
This may lend support to a conjectural diagnosis: e. g., similar symptoms in blood relatives of the patient’s parents, if a recessively inherited condition is suspected, or hemicranial headaches in the mother of a patient with suspected migraine
2
The Clinical Interview in Neurology
Mumenthaler / Mattle, Fundamentals of Neurology © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license.
10 2 The Clinical Interview in Neurology
A carefully elicited clinical history ought to enable the experienced clinician to formulate a tentative diagnosis even before proceeding to the physical examination. With the tentative diagnosis in mind, he or she can then devote particular attention to certain aspects of the ex-
amination. Of course, the clinician must not allow his or her findings to be so colored by prior expectations that they are no longer reliable. The tentative diagnosis should inform the physical examination, not convert it into a pointless exercise.
Mumenthaler / Mattle, Fundamentals of Neurology © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license.