Assessment: The Neurologic
Examination
HEALTH HISTORY
An
important aspect of the neurologic assessment is the history of the present
illness. The initial interview provides an excellent opportunity to
systematically explore the patient’s current con-dition and related events
while simultaneously observing overall appearance, mental status, posture,
movement and affect. De-pending on the patient’s condition, the nurse may need
to rely on yes-or-no answers to questions, on a review of the medical record,
or input from the family or a combination of these.
Neurologic
disease may be stable or progressive, with both in-termittent symptom-free
periods as well as times with fluctua-tions in symptoms. The health history
therefore includes details about the onset, character, severity, location,
duration, and fre-quency of symptoms and signs; associated complaints;
precipi-tating, aggravating, and relieving factors; progression, remission, and
exacerbation; and the presence or absence of similar symp-toms among family
members. The nurse may also use the inter-view to inquire about any family
history of genetic diseases.
Included in the health history is a review of the
medical history, including a system-by-system evaluation. The nurse should be
aware of any history of trauma or falls that may have involved the head or
spinal cord. Questions regarding the use of alcohol, med-ications, and
recreational drugs are also included. The history-taking portion of the
neurologic examination is critical and, in many cases of neurologic disease,
leads to an accurate diagnosis.
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