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Approach to the Neurologic Patient On Call: History Taking, Differential Diagnosis, and Anatomic Localization


It is in the early morning hours. You get a call from a resident in the emergency room (ER). A 48-year-old teacher has headache, neck pain, and urinary incontinence, and, as of this morning, is no longer able to hold a pen in his right hand. How do you proceed? What do you tell the ER resident? What tests should be ordered? How urgent is this situation?

Neurology, perhaps more than any other field in medicine, demands familiarity with a wide spectrum of anatomic details and diagnostic studies. Electrophysiologic, serologic, genetic, pathologic, and a host of imaging techniques have enabled diagnoses to be made with a higher degree of accuracy and certainty than ever before. Yet all diagnostic puzzles, simple or complex, begin with the presentation of a symptom by a patient to a doctor.

It is often said that 90% of the neurologic diagnosis comes from the patient’s history. Indeed, it is the exception when a diagnosis is stumbled on after a “shotgun” approach of ordering diagnostic studies unguided by the patient’s initial complaints. In the type of encounter for which this book was written, namely a rapid response to an acute complaint, the single most important factor in the encounter is the initial interview with the patient. This book aims to guide you through a logical, focused, and effective approach to diagnosis and management of your patient’s acute problem. This fourth edition has updated chapters in all aspects of emergency neurologic care, including the latest pharmacologic and diagnostic options. After a discussion of general principles of managing patients on call, this chapter covers some key points about neurologic history taking along with principles of differential diagnosis and anatomic localization. The neurologic physical examination is outlined in Chapter 2 . The basics of the most important initial diagnostic studies are covered in Chapter 3 .

Principles of Managing Patients When On Call

  • 1.

    Obtain adequate information from the initial phone contact.

    • Establish the nature of the complaint, understand its acuteness and its severity, and learn what has been done so far. (Have vital signs been checked? Has any labwork been sent?)

  • 2.

    Establish a working differential diagnosis before you see the patient.

    • Some preparatory thought will produce a more efficient and directed interview and examination of the patient. Prioritize your diagnoses by placing the most potentially dangerous diagnoses at the top of the list, followed by the most likely diagnoses.

  • 3.

    Be focused in your bedside assessment.

    • Unlike the comprehensive examination that you perform when admitting a patient to the hospital or when seeing a patient for the first time in the clinic, your history taking and examination of the patient when you are on call needs to be focused and efficient.

  • 4.

    Know when to call for additional consultation.

    • Examples would be an ophthalmologic consultation for branch retinal artery occlusion versus anterior ischemic optic neuropathy, or a neurosurgical consultation to place an intracranial pressure monitor.

  • 5.

    Be accurate and concise in your documentation of the encounter.

    • Although it will be your responsibility to solve the clinical problem as completely as possible, many times you will be unable to make a diagnosis or complete a treatment during the time you are involved with the patient. You must document the patient’s history and physical examination as precisely as possible. Make sure you date and time your note. If there was a delay in arriving at the bedside because of another emergency, then document this. Include relevant laboratory data in your note. Your evaluation and formulation of the problem should be well integrated and transparent. The recommendations for treatment should be stated clearly and should be concordant with what was written in the orders. If discussions with family members took place, then the content and outcome of the discussions should be documented.

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