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History

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A complete history of the nature, onset, extent, and duration of the chief complaint and associated complaints must be taken. This should include previous diseases, personal and family history, occupational data, and social history. A complete listing of medications is essential. It may be desirable—or necessary—to interview relatives and friends.

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Detailed information is particularly important in regard to the following:

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Headache

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Note the duration, time of onset, location, frequency, severity, progression, precipitating circumstances, associated symptoms, and response to medications. A worsening headache, or “the worst headache of my life,” is especially concerning.

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Seizures and Episodic Loss of Consciousness

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Record the character of the individual episode, age at onset, frequency, duration, mental status during and after episodes, associated signs and symptoms, aura, and type and effectiveness of previous treatment.

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Visual Disturbances

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The frequency, progression or remissions, scotomas, acuity changes, diplopia, field changes, and associated phenomena should be noted.

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Motor Function

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Has the patient become weak? Has the patient lost coordination? Are distal muscles (eg, those of the hand or foot) affected more than proximal ones (eg, those of the upper arm or leg)? Are there abnormal muscle movements? Have muscles wasted?

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Sensory Function

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Has the patient noticed numbness or tingling? Over which part of the body? What is the location of the sensory loss? Can the patient tell where his or her legs are located? Is there a history of painless burns?

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Cranial Nerve Function

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Is there double vision? Note any facial drooping, slurred speech, difficulty swallowing, problems with balance, tinnitus (a ringing or buzzing sound in one or both ears), or impaired hearing.

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Pain

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Include in the assessment the onset, location, progression, frequency, characteristics, effect of physical measures, associated complaints, and type and effectiveness of previous treatment.

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It is very important to obtain a clear picture of the time course of the disorder. Was onset of symptoms sudden or gradual? If gradual, over what time scale (hour, days, months)? Are symptoms always present, or are they intermittent? What precipitates symptoms, and what relieves them?

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The Physical Examination

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Even before beginning the formal physical examination, important information may be gleaned by observing the patient while the history is given. Is the patient well groomed or unkempt? Is the patient aware of and appropriately concerned about the illness? Does the patient attend equally well to stimuli on the left and right sides; that is, does the patient relate equally well to the physician when asked questions from the left and then the right? The examiner can learn much simply by interacting with the patient and observing closely.

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A general ...

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