Chapter 1: The History

Author's Commentary

The age and chief complaint of the patient establish the localization of the disease process and limit the differential diagnoses to entities that occur within the patient’s age range.

The chronological sequence of disease process events (acute, subacute, or chronic) is frequently specific for each disease entity. There is value in negative information. It defines the fine points of the clinical history, as most of the history outlines the general category of the disease.

Exclude irrelevancies: patients frequently have a compulsion to recite all of their hospitalizations, physician visits, and their missed diagnoses. Also, they often come armed with downloaded papers that may or may not be relevant to their illness. Take all of this information to your side of the desk tactfully, engage the patient with direct eye contact, and proceed with the history.

Excerpts From Chapter 1

Neurology remains the specialty in medicine that still requires a good history and examination to diagnose a puzzle. It is ultimately logical, and the approach leads the physician to localize the lesion to a part of the neuraxis and then develop a differential diagnosis based on this localization.

The imaging tools are now superb but must be applied correctly, and their limitations understood. There is no imaging device that can diagnose a migraine headache. A purist might argue that a spreading depression of Leão might accomplish this with positron emission tomography (PET), but unfortunately, other pathologies can cause the same physiology. Magnetic resonance imaging (MRI) does not evaluate bones well because a signal cannot be generated from a calcium lattice (no free H+). A negative MRI of the spine in a patient with clear L5–S1 symptomatology, a weak extensor hallucis longus muscle, and a depressed ankle jerk has overwhelming evidence of L5, S1 pathology. An older patient has bone disease of the spine rather than disk disease. This is not understood by most, who hold the MRI as the gold standard for a diagnosis of spinal problems. Complicated spine problems require a myelogram with contrast to evaluate the relationship of the nerve root to the facet, pedicle, and exit foramina.

These studies may be negative, but the patient still complains of severe L5 –S1 pain. Recent information suggests that inflammatory cytokines released at an area of injury may directly stimulate C and A-delta pain fibers. If all imaging studies are negative as well as the electromyogram (EMG), but the history and the neurologic examination is positive, the examiner believes the patient and does the best that can be done to relieve the pain.

A productive way to look at modern neurology is that history gives the diagnosis, the neurologic examination proves it, and modern imaging and laboratory tests guide the treatment and predict the prognosis.