By Eelco F. M. WijdicksFirst Online:
28 April 2020Abstract
A clinical history leads to an examination, tests and a diagnosis. This time-honored sequence in medicine remains valid in critical illness, but in the heat of the moment there is a quickly appearing inevitable sketchiness. Intensivists should never be too unquestioning, too comfortable with incomplete information, or too unwilling to start over if information is muddled or contradictory. No scale in neurology looks at history. There is no tool or requirement to provide a standard system of communication. I review the essentials of history taking in a neurocritically ill patient. Examples of the value of a good medical history are shown but also the familiar biases when asking questions. There are obstacles, errors of commission and omission, and the importance of recognition of a clinical trajectory.
An established component of neurocritical medical evaluation is, of course, taking a history (known also as anamnesis). This is a formidable task in critical illness and especially taxing when patients are confused, aphasic, or, worse, sedated and intubated. The information-seeking healthcare provider relies on accompanying persons (ideally, close family members), but these often must travel separately, arriving significantly after the patient. Recounting the circumstances of the ictus and clinical trajectory mostly falls to others; the narrative may understandably be somewhat emotive. We can expect to miss important points; they accumulate quickly in the heat of the moment.
Few textbooks address clinical history taking in critically ill patients and none, I believe, comprehensively. However, intensivists should not be too comfortable with incomplete information or too unwilling to start from square one if information is muddled or contradictory.
Several clinical situations are unique to neurointensive care: the comatose patient found down, rapidly progressive weakness, respiratory failure without obvious pulmonary or cardiac triggers, and, of course, mysterious, progressive encephalopathy with abnormal cerebrospinal fluid (CSF) and hard-to-pinpoint magnetic resonance imaging (MRI) abnormalities. Often, in retrospect, a clinical diagnosis becomes obvious with a better history. We all are reminded of the CSF we should have requested to diagnose meningitis if we had known of the looming infection and fever. There is the MRI of the spine we should have ordered to diagnose an epidural abscess, which we might have considered if we had queried the patient about his unremitting back pain before he lapsed into unresponsive septic shock. Acute double vision may be painful and indicates an immediate need for vascular studies and contrast-enhanced MRI. We expect cerebral vasospasm after a ruptured aneurysm, but it may come earlier than expected if we are unaware that the presenting headache was already a rebleed. Unexplained respiratory failure becomes clearly neurologic if we elicit a prior history of progressive dysphagia, muscle mass loss and twitching (motor neuron disease), diplopia, and weakness increasing with exercise or repetitive use but with day-to-day variation, yet typically strong after a good night’s rest (myasthenia gravis),
This paper addresses the obstacles, competencies, and recognition of a clinical trajectory. Examples of the value of a good medical history are shown but also the familiar biases, prejudices, and potential lost focus when asking questions. We can decry the loss of clinical skills—and it is true—but let us start with what comes first. Even the most skilled clinical neurointensivist must work from a solid history.Read full article.