In my experience, with enough coaxing, the person will be able to go back to the exact moment they realized something was not right – even if it was many years before. It may be a stumble on a familiar footpath outside the local shop, a missed kick during their Wednesday game of five-a-side or a dropped fork at dinner. It was easy to laugh it off as clumsiness at the time, but many a patient will have been aware deep down, even then, that all was not well. This can go on for months and, in some cases, years. They convince themselves there is nothing wrong in between each stumble or trip. But no matter how hard they try to put it out of their mind, fear will fester in the small hours.
Conversely, others had no reason to think that this minor incident was anything but an isolated event as an extraordinary amount of time can pass before a ‘second hit’ occurs. It is then that they realize that the incident was not a one-off. Whichever way the person’s mind works, eventually something clicks and they decide they cannot ignore the problem any longer.
Taking a good neurological history can appear terribly intrusive and is a very personal thing for patients. It is engrossing to see how vulnerable even the most worldly person can become in front of a doctor – like a child in a confessional, they don’t want to say the ‘wrong’ thing lest the penance they are asked to pay is too great. Reading a patient’s body language tells you so much, and listening carefully to their answers to your questions enables you to put together the jigsaw of their lives so you have a context for their medical complaint.
My first question, a simple one, is how old they are. The responses are always instructive, and, funnily enough, people rarely just give a number. Some refer to their next birthday (‘fifty-four next April’) rather than state their actual age now. It is lovely to hear older folk refer to their age as ‘seventy-nine and a half’, accompanied by a wink – ‘the half is very important at my age!’ Answering by birth year – 1946, say – is typical among those who prefer to no longer celebrate birthdays. I’ll push: ‘Well, if you were born in 1946, how old does that make you now?’ I have to judge between nervousness and cognitive decline before pressing any further. Sometimes a patient will look to their spouse for the answer, and so my concerns about dementia will rise.
Another on the list of basic questions is whether the patient is right- or left-handed. We also have to ask if they are right-handed ‘originally’. It was a feature of schooling in Ireland and elsewhere not too many years ago that left-handed children (in Irish, you’d have been called a ciotóg) were forced to write with their right hands. If, like me, you’re right-handed, then there is about a 95 per cent chance that the left side of your brain is dominant. The left hemisphere of the brain controls the right side of the body, and in right-handed people the left brain determines most of our ability to speak. For left-handed people it is about 60/40. That is, 40 per cent of left-handers will be right-brain dominant, and 60 per cent will be left-brain dominant. This is critically important in most brain conditions but is most obvious in stroke. If I have a stroke in my left brain, I am likely to develop right arm and leg weakness and I might well have great difficulty forming sentences or even understanding what is being said. If I have a stroke in my right brain, I will have left-sided weakness, but my speech will generally be well preserved. So it is important to define right- and left-handedness at the onset of every history. If someone is struggling with their speech, then we usually know where to start looking for the fault in the brain with a view to trying to fix it.
Beyond this, I’ll go through other health issues. Even if they present with, say, a weak leg, I’ll ask about their vision, speech and ability to swallow, and then their bladder and bowel function. I do this not only to make sure I don’t miss any symptoms that may be relevant to their weak leg, but also because many patients typically don’t volunteer symptoms beyond the leg. They do so either because they think a problem swallowing, for example, is unconnected to the leg and, being considerate, don’t want to waste my time with a laundry list of minor ailments, or they’re already fearful that the symptoms are all connected, and the problem is far worse than they suspected.
The next question I tend to ask is what, if any, regular medication a person is taking. This will influence any medication I might later consider, to avoid drug interactions, but it will also flag the patient’s other illnesses. People may say that they’re not on any medications – ‘we don’t do tablets in our family’ is a frequent, proud refrain – and later mention that they regularly take aspirin, or a blood-pressure drug and a cholesterol drug. Sometimes they’ve been taking them for so long it is second nature and they don’t see them as medicine at all. Young women can be the very same when it comes to the contraceptive pill.
The list of medications can vary greatly from one person to the next, and the lists can be lengthy. The latter is the bane of both patients’ and doctors’ lives. Some people are very organized and come with colour-coded spreadsheets of their tablets past, present and – potentially – future. Others bring worn-out boxes and bottles of assorted tablets. The expectation is that the doctor will know what these little blue and brown pills are, but this is rarely the case, and an inordinate amount of time is spent going through the names of each medication, the dose and the times at which they are taken. How some people remember to take so many combinations of drugs is staggering. I admit to rarely remembering to finish a prescribed course of antibiotics – you should, mind you! – and marvel at patients who can take thirty or more tablets a day at the right time and in the right sequence without making an error. It is, to my mind, a remarkable achievement in itself.
The tablets they take that are not prescribed can be even trickier to unpick. Many people I see with chronic headaches are taking a combination of over-the-counter painkillers every day. ‘What do you take when you get a headache?’ I might ask. ‘Oh, just paracetamol,’ they reply. ‘The odd time I have to take a Nurofen … or a Difene … and, if it’s really bad, I take a Solpadeine.’ Gradually it dawns on the patient that they’re taking a painkiller every few hours, every day. This inevitably causes what’s known as medication overuse headaches: the treatment has become the disease.
Similarly, most patients don’t consider complementary therapies or vitamin tablets to be ‘medication’, but can be consuming them in vast quantities (though in numerous studies many of these – particularly homeopathic remedies – have been shown to have little or no medical impact at all). However, once again understanding what people are taking (even if it may be entirely inert), and why, can be crucial in getting the bigger picture.
When I have the right list and doses of medication, I can usually discern the general health of a patient. Blood-pressure tablets can cause all sorts of problems like dizzy spells, and anti-angina tablets can cause headaches. Some people start taking aspirin because a friend suggested it would be a good idea; others believe that their cholesterol medication will free them from future heart and stroke problems. When I see a person taking medication for their blood pressure, cholesterol and diabetes, for example, then their neurological problems could all be due to a stroke; if there is a problem in the blood vessels in their heart, then their symptoms may well be due to a similar blood-vessel problem in the head. Frequently it may be the medication causing the symptoms.
Long-term conditions like high blood pressure or diabetes are an important part of a patient’s basic medical history, but such illnesses may be so integral to people’s lives that they forget to mention them until asked. Diabetes is a common condition both in Ireland and throughout the world, and I am in awe of the people who live with it, particularly those who develop it at an early age. The young teenagers who have to inject themselves regularly with insulin and monitor their own blood sugars several times a day are incredible. Teenage years are notoriously problematic for us all, but it is truly admirable to get through them while managing a chronic condition. Diabetes, like all ongoing conditions, is of interest to neurologists for several reasons. It can affect th
e peripheral nerves and lead to neuropathic pain in the hands and feet, or persistent pins-and-needles sensations. Diabetes can also affect the eyesight, among other things, so careful monitoring of blood sugars is vitally important.
I also still ask whether someone has ever suffered from tuberculosis (TB), which is still prevalent in some parts of the world. Thanks to Dr Noel Browne and his successors, who helped bring an almost epidemic condition under control in Ireland in the 1950s and 1960s, TB is becoming increasingly irrelevant in the Irish population. I’m sure he would smile to hear younger people ask me, ‘What’s TB?’
One of the most interesting and, in many instances, informative components of a patient’s stories is their social history, but it requires delicacy. As students we were taught to ask whether someone is married, has children, smokes, or drinks alcohol. These days a more nuanced approach is required. I will still ask a patient if they are married; if they say no, I’ll ask whether they have a partner or any children. This can be very helpful in working out what social and financial stresses a person is under without having to ask directly, though some guesswork may be needed. A young woman living with two or three children without other support might well be suffering from stress, for example, leading to chronic sleeplessness and headaches. An older man living alone whose children have emigrated may be lonely, looking for reassurance that his mild memory lapses do not signify incipient dementia and the need for a nursing home.
At times asking personal questions produces heart-breaking answers – how to respond when a patient, already concerned for their health, tells me that they had three children and now have two? To ask what happened seems intrusive, not to ask seems uncaring, but tragedy can be a root cause of an apparent medical problem. The death of a child haunts parents and siblings for ever, and it is a wonder to me how they manage to carry on. But carry on they do, and it can be an unpleasant part of my job to heap further distress on these people when giving them a diagnosis of, say Parkinson’s, when they think life has already thrown all that it can at them.
Occasionally the conversation takes a direction that provides an awkward insight into people’s home lives. How many underlying tensions does attending a doctor lay bare within families, I often wonder. When an Irish husband says he likes a glass of wine with dinner, his wife may laugh: ‘More like a bottle!’ And so the row begins. How a relationship is going is ceaselessly absorbing during a neurology consultation, and completely relevant. A couple’s level of affection or lack thereof quickly becomes palpable as they hold hands or otherwise reach out to each other as I divulge good or bad news or, alternatively, make no contact whatsoever with their loved one. It’s all in how people sit beside each other (legs crossed, arms folded, staring ahead), or how one dominates the conversation even though the other one is the patient – the man who will talk over his wife and try to engage in a laddish conversation while relating his own medical insights, or the wife who will report that the husband sitting beside her complaining of a shake was always nervous and never had any get up and go. This can be deeply uncomfortable and I end up pondering what they talk about in the car on the way home.
Some couples have clearly stopped communicating years earlier, and when I ask the Liverpool football fan who has not missed a match on TV for years who the star player of the team is at the moment, he might laugh it off to avoid answering, but when he doesn’t know the answer and his wife says, ‘But that’s what you talk about all the time!’ you can then see the implications dawning and panic setting in. Because she switches off at home it’s only in this formal setting, talking to a doctor, that she has registered how much ground he has lost.
It never ceases to intrigue me how two people can live together, day in day out, and not notice their other half fading away before their eyes. In many cases it will turn out that an emigrant son or daughter returning at Christmas has been the catalyst for a visit to the GP and hence to a neurologist. When adult children haven’t seen a parent in a while they more readily spot changes that have crept up gradually and remained invisible to the other parent. Having been an anxious emigrant for many years myself when my father was ill, I tend to feel for the worriers sitting in the coffee shops and bars of Dublin Airport on 2 January, wondering what will become of their parents (and, perhaps, what will become of themselves when they grow older, so far away from their family).
Work, of course, brings with it a great deal of stress for many, and their sleeping patterns can bear this out. None of us can function adequately with chronic sleep deprivation, and I often see people with headaches and concentration difficulties as a result.
Young lawyers make stimulating case studies in the neurology clinic. They can seem very confident to begin with. They are used to being in control so conceivably feel uncomfortable when the roles are reversed. Many appear to think doctors are somewhat fearful of dealing with lawyers (in truth we may well be). One young man, when I asked what he did, replied, ‘I keep you guys out of jail’ – that consultation went well. Some will ask to record the conversation we have, which takes the passive out of passive-aggressive. Others will ask to see the notes I have just written while taking their medical history. It seems they are concentrating more on the mechanics of the consultation than the point of it.
There is nothing to hide and I have no problem with people requesting the notes or even recording the conversation. And, yet, I have to admit to feeling that this leads to a level of defensiveness that breaks the unspoken bond of trust you hope you would have when working as a doctor. In the end, anyone can request to review his or her medical notes so it is hardly the third secret of Fatima. The nature and tone of the requests may affect the tenor of the conversations and the mutual sense of trust between doctor and patient. I realize that my lingering reservation is probably a generational thing. It’s also verging on irrational as nothing in their files should surprise or upset patients. Like many institutions, in previous times medicine was hierarchical and had a reflexive culture of secrecy. Even when I was training, patients’ files were considered to be for medics’ eyes only. Sometimes medics would make observations about patients’ demeanour or social circumstances – notes they felt would give colleagues insights into a patient’s likely progress or challenges they might face in following a course of treatment. Nowadays, of course, such subjective views do not go into files (which is not to say they are not formed: we are only human, after all), so no patient should be startled to read anything in their file.
Not surprisingly, dealing with colleagues can also be tricky, and when neurology is not their chosen speciality there is a thin line between appearing condescending and making too many assumptions about what your colleague does or does not know about the mechanics of the brain.
After asking whether there is a family history of any ailments, I would ask everyone whether they smoke, drink or do drugs. These questions are not to be judgemental: I’m not about to give patients a lecture about the evils of substance use or misuse. I need to know purely because smoking, drinking or drug-use may have pertinent neurological implications.
The drugs question always raises a smile among the older generation, but I have been caught out on a few occasions by a middle-aged, middle-class, golf-club-attending heroin user, so I ask everyone. For smoking, the answer is rarely straightforward.
‘I used to smoke but gave it up.’
‘Good for you,’ I say. ‘When did you give them up?’
‘Last week,’ goes the embarrassed reply.
When a life-long smoker gives up seemingly out of the blue it may be quite telling. Ask enough questions, past the ‘Oh, I was sick of them’, or ‘Cigarettes are getting too expensive’, and you’ll find a friend or a parent who has died recently from a smoking-related illness. Or a coughing fit one morning that scared the life out of them. Stopping smoking suddenly is one way that frightened patients try to wrest back control of their health. In neurology, the insidious nature of certain conditions can be ignored to the point whe
re people can’t recall when they first became aware that something was wrong, but if it coincided with giving up smoking you can be sure that, at least subliminally, they were preparing themselves for something bad, usually cancer.
Anyone who has drunk too much of an evening will appreciate that one’s memory the next day can be flawed. Drinking to excess in the longer term can lead to chronic memory problems, to the extent that heavy drinkers may even appear to have early dementia. It’s easy to get a bit unsteady on your feet after a few too many drinks, but in the long term the balance centre of the brain (the cerebellum) will start to degenerate, possibly leading to a permanent state of unsteadiness. As a result, how much and how often a person drinks is of some importance in the neurological history.
There are subtler questions, too; I may ask if a person likes to read and, if so, what they’re reading at the moment. ‘Oh, he reads all the time,’ the spouse will say, but the patient with memory problems won’t be able to recall the book they’re currently reading. (Some lie and say that they like to re-read books, and proceed to regale me with excerpts from Wuthering Heights, which they actually last read in school thirty years before.)
It may seem cruel to put already sick patients under the microscope like this but a neurology consultation has to get to the root of a problem. A neurologist needs a panoramic view of a patient’s circumstances, not just of the weak or shaky hand. We need the big picture of their daily lives, and any changes they’ve detected. Of course, doctors can read too much into a given situation, but after the checklist is complete – social history, family history, medication, drug allergies, chronic diseases, previous medical history – we finally get to the actual reason why a person came to see me.
Just One More Question Page 4
