Screening for mild cognitive impairment:

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Neurological History
Taking the patient’s history is traditionally the first step in virtually every clinical encounter. A thorough neurologic history allows the clinician to define the patient’s problem and, along with the result of physical examination, assists in formulating an etiologic and/or pathologic diagnosis in most cases. [1, 2]

Solid knowledge of the basic principles of the various disease processes is essential for obtaining a good history. As Goethe stated, “The eyes see what the mind knows.” To this end, the reader is referred to the literature about the natural history of diseases. The purpose of this article is to highlight the process of the examination rather than to provide details about the clinical and pathologic features of specific diseases.

The history of the presenting illness or chief complaint should include the following information: [3]

Symptom onset (eg, acute, subacute, chronic, insidious)

Duration

Course of the condition (eg, static, progressive, or relapsing and remitting)

Associated symptoms, such as pain, headache, nausea, vomiting, vertigo, numbness, weakness, and seizures

Pain should be further defined in terms of the following:

Location (Ask the patient to point with one finger, if possible.)

Radiation (Pay attention to any dermatomal relationship.)

Quality (stabbing, stinging, lightninglike, pounding, etc)

Severity or quantity (Estimate functional limitation.)

Precipitating factors (stress, periods, allergens, sleep deprivation, etc)

Relieving factors (sleep, stress management, etc)

Diurnal or seasonal variation

Important miscellaneous factors of the history include the following:

Results of previous attempts to diagnose the condition

Any previous therapeutic intervention and the response to those treatments

A complete history often defines the clinical problem and allows the examiner to proceed with a complete but focused neurologic examination.

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Neurologic Examination
The neurologic examination is one of the most unique exercises in all of clinical medicine. Whereas the history is the most important element in defining the clinical problem, neurologic examination is performed to localize a lesion in the central nervous system (CNS) or peripheral nervous system (PNS). The statement has been made, “History tells you what it is, and the examination tells you where it is.” The history and examination allow the neurologist to arrive at the etiology and pathology of the condition, which are essential for treatment planning. [4, 5]

Unlike many other fields of medicine in which diseases are visible (eg, dermatology, ophthalmology) or palpable (eg, surgery), neurology is characterized by conditions that may be detected only by applying specific examination techniques and logical deduction, except when telltale cutaneous markers or other stigmata suggest the diagnosis. Considerable insight and intuition are required to interpret the symptoms and signs observed during neurologic examination. These features make the neurologic history and physical examination both challenging and rewarding. Neurologic examination can be particularly helpful for critically ill patients because many patients admitted to the intensive care unit (ICU) have pre-existing or acquired neurological disorders which significantly affect their short-term and long-term outcomes. [6]

A properly performed neurologic examination may take 90 minutes or even longer for the novice. Experienced neurologists take substantially less time and can frequently grasp the essential features of a clinical condition quickly. What might appear to be a complex problem of localization for the referring physician may turn out to have a simple explanation, and the neurologic consultation may help to avoid extensive testing.

Neurologic examination in the era of imaging
With the advent of CT scanning in the early 1970s, the future clinical role of the neurologist was questioned. During one of his visits to the United States, Dr. McDonald Critchley was asked what he thought would be the future of neurology in the era of CT. His answer was most enlightening: “CT scanning will take away the shadows of neurology, but the music will still remain.” These prophetic words still ring true despite the advent of MRI, positron emission tomography (PET), and functional neuroimaging of all types.

It has been said that “neurology owes more to its disorders than those disorders owe to neurology.” This is because much knowledge has come from previous observations of neurologic conditions, because the eponyms for the diagnoses were sometimes long, and because so little was previously offered in the terms of cures such that the specialty was ridiculed as one that was “long on diagnosis and short on treatment.” Fortunately, technologic advances have changed that perception.

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