Second edition

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Diagnostic assessment
1.1 Diagnostic interview 3
1.2 Mental status examination 5
1.3 Neurologic examination 10
1.4 Neuroimaging 17
1.1 DIAGNOSTIC INTERVIEW
Lord Brain (1964) noted that ‘in the diagnosis of nervous
diseases the history of the patient’s illness is often of greater
importance than the discovery of his abnormal physical
signs’, a sentiment echoed by Russell DeJong (1979) who
asserted that ‘a good clinical history often holds the key to
diagnosis’.
Obtaining the history, however, as noted by DeJong
(1979), ‘is no simple task [and] may require greater skill
and experience than are necessary to carry out a detailed
examination’. The acquisition of this skill is, for most, no
easy matter, requiring, above all, practice and supervision.
Certain points, however, may be made regarding the setting
of the interview, establishing rapport, eliciting the
chief complaint, the division of the interview itself into
non-directive and directive portions, concluding the interview,
and the subsequent acquisition of collateral history
from family or acquaintances. Even these general points,
however, allow exceptions depending on the clinical situation,
and the physician must be flexible and prepared to
exercise initiative.
Setting
The interview should ideally be conducted in a quiet and
private setting, set apart from distractions and anything
that might inhibit patients as they relate the history.
Importantly, that means that family and friends should be
excused during the interview, as patients may feel reluctant
to reveal certain facts in their presence. If the interview
takes place at the bedside, the physician should be seated;
standing implies that time is short, and some patients,
picking up on this cue, may skip over potentially valuable
parts of the history in order not to waste the physician’s
time. In this regard, it is also important that the physician
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1.5 Electroencephalography 21
1.6 Lumbar puncture 31
References 34
sets aside a sufficient amount of time to take the history,
which may range from less than half an hour in uncomplicated
cases related by cooperative patients to well over an
hour when the history is long and complex or the patient is
unable to cooperate fully. There is debate as to whether the
physician should take notes during the interview: some feel
it is distracting, both to the patient and the physician,
whereas others recommend it in order to ensure accuracy,
especially when the interview is lengthy. I agree with Victor
(Victor and Ropper 2001) who feels that the practice is ‘particularly
recommended’. The idea is not to make a transcript
but simply to jot down key points and dates, and to do so in
a way that allows the physician to maintain his or her attention
on what the patient is saying.
Establishing rapport
DeJong (1979) noted that ‘interest, understanding, and
sympathy’ are essential to the successful conduct of the
interview: patients who experience a sense of rapport with
their physicians are more likely to be truthful and forthcoming;
hence establishing rapport is of great importance.
First impressions carry great weight here: after introducing
themselves, physicians should clearly relate their role in
the case and then, as suggested by DeJong (1979), display
‘kindness, patience, reserve, and a manner which conveys
interest’ throughout the interview. Provided with such a
forum, most patients will, with only minor help, provide the
history required to generate the appropriate differential
diagnosis.
Eliciting the chief complaint
‘It is well’, noted Lord Brain (1964), ‘to begin by asking the
patient of what he complains’. The chief complaint is the
epitome of the patient’s illness: lacking such a focus,