History – taking
in NEUROLOGY
23 January 2018
Charisma T. Evangelista, MD, FPNA
San Beda College of Medicine
Neurosciences
History-taking
The history is the cornerstone of
medical diagnosis
A systematic case history and physical
examination should lead the clinician
to a diagnosis in 80 - 90% of the time.
A good history may save the patient
from having to undergo unnecessary
investigations and inappropriate
treatment.
Should set a clinician’s thought
processes in motion.
History-taking
Its most important aspect is attentive
listening.
Ask open-ended questions.
Essential are diplomacy, kindness,
patience, reserve and a manner that
conveys interest, understanding and
sympathy.
It is an opportunity to establish a
favorable physician-patient
relationship.
Mode of questioning may vary.
Make sure patient is comfortable and at
ease.
Clinical History
General Data
Chief Complaint
History of Present Illness
Review of Systems
Past Medical History
Family Medical History
Personal / Social History
Birth / Maternal History
Nutritional, Immunization,
Developmental History
General Data
Name
Age
Gender
Nationality
Place of residence
Handedness
Occupation
Civil Status
Date of admission
The Chief Complaint
The reason why the patient is seeking
consult.
Start with an open-ended question.
The Chief Complaint
22/F, Headache
65/M, Left-sided weakness
42/F, Tingling sensation of palms and
soles
33/M, Low-back pain
65/F, Memory loss
25/M, head trauma
The Chief Complaint
“namamanhid ang braso ko”
“nahihilo ako”
“na-stroke ako”
“namamaga ang batok ko, tapos parang
luluwa ang mata ko, sumasakit ulo ko...
Basta, di ko na alam ang nangyayari sa
akin”
History of Present
Illness
The details or the story behind the
chief complaint
In some cases, clinicians start with
pertinent past medical history or
chronic medical illnesses at the outset –
to identify major co-morbidities which
might have a direct or indirect bearing
on the present illness
This may help put the present illness in
context and to prompt early
consideration about whether the
neurologic problem is a complication of
some underlying condition or whether
it is an independent process.
History of Present Illness :
HEADACHE
Think PQRST
P: Palliative, Provoking, Precipitating
factors
Q: Quality
R: Region – Site and radiation of pain
S: Severity (may use VAS scale), or may ask
how headaches have affected functionality
of patient
T: Timing - Frequency and duration of
headaches, onset, mode of onset (warning
symptoms,aura)
Associated symptom/s
Previous treatment/s
History of Present Illness :
WEAKNESS
Date of first spell and number of
attacks
Frequency of attacks/ fluctuating?
Duration of attacks, evolution of
symptoms
Specific body parts and functions
involved
Other associated neurologic deficits
– with speech, vision, swallowing
Previous functional capacity
Present functional status
History of Present Illness :
PARESTHESIA
Onset of symptom
Constant or intermittent
Neck pain?
History of diabetes, cancer
Medications taken
Exposure to chemicals, pollutants
(occupational, environmental,
medical)
Other associated symptoms –
involvement of arm, face, leg?
Problems with speech or vision
History of Present Illness : BACK
PAIN
Onset of symptom
Character of pain
Radiation
History of trauma
Bowel / bladder disturbances
Sexual function
Effect on gait, other neurologic
symptoms
History of Present Illness : MEMORY
LOSS
Onset of symptom, duration
Progression of symptoms
Associated neurologic deficits
Medication history
Recent head trauma
Systemic diseases
Sexual history
Family history
History of Present Illness : HEAD
TRAUMA
Date of injury
Time of injury
Mechanism of injury
Other physical injuries
Review of Systems
Designed in part to detect health
problems of which the patient may not
complain, but which nevertheless
require attention
Must be organized and complete
Guided by differential diagnosis
Include a “neurologic” review of
symptoms
A Neurological System Review:
Symptoms Worth Inquiring About
in Patients Presenting with
Neurological Complaints*
A history of seizure or unexplained loss
of consciousness
Vertigo or dizziness
Loss of vision
Diplopia
Difficulty hearing
Tinnitus
Difficulty with speech or swallowing
Weakness, difficulty moving, abnormal
movements
Numbness, tingling
Tremor
Problems with gait, balance, or
coordination
Difficulty with sphincter control or
sexual function
Difficulty with thinking or memory
Problems sleeping or excessive
sleepiness
Depressive symptoms
Past Medical History
Important because some neurologic
symptoms may be related to systemic
diseases
Past illnesses
Previous surgeries
Medications taken
Allergies
Family Medical History
An inquiry into the possibility of
heredofamilial disorders and focuses on
the patient’s lineage
Particularly relevant in some diseases.
Patient’s ethnic background?
Personal and Social
History
Includes the patient’s marital status,
educational level, occupation, and
personal habits (alcohol, cigarette
smoking, drug use)
Diet
Sexual behavior, sexual orientation
Clinical History
General Data
Chief Complaint
History of Present Illness
Review of Systems
Past Medical History
Family Medical History
Personal / Social History
Birth / Maternal History
Nutritional, Immunization,
Developmental History
Physical
Examination
Neurologic
Examination
Diagnosis in Neurology
The diagnostic catechism:
Is there a lesion or disease?
If so, where is the lesion or the
disease?
What is the lesion or the disease (the
provisional diagnosis)?
What laboratory tests (if any) will
confirm or reject the provisional
diagnosis or establish a final
diagnosis?
What is the optimum and preventive
management? – Neurosciences III
Is there a lesion or
disease?
Is the lesion or disease in the structure
or biochemistry of the patient?
Is it at the level of the gene,
chromosome, or cell?
Does it affect the nervous system?
Where is the lesion or
disease?
If it affects the nervous system, is it:
In the PNS or CNS?
If in the CNS, is it intra- or extra-
axial?
If intra-axial, it is focal, multifocal, or
diffuse? Supra- or infra-tentorial? Left
or right? If infratentorial, brainstem or
spinal cord?
If extra-axial, is it meningeal, or in the
bony covering; meningeal space; is it
in a nerve root, plexus, peripheral
nerve, neuromuscular junction, or
muscle?
Gives the ANATOMIC
LOCALIZATION
Can be given by the history also.
What is the lesion?
Think “VITAMIN C/D”
V – Vascular – occlusion, hemorrhage,
vasculitis
I – Infectious – bacterial, viral
T – Traumatic, Toxic – gross trauma,
radiation, drugs
A – Autoimmune – SLE,
dermatomyositis, RA
M – Metabolic
I – Inflammatory
N – Neoplastic, Nutritional –
granulomas, leukemia
C/ D – Congenital, Degenerative,
Developmental, Demyelinating –
PD, Multiple sclerosis
What is the lesion?
Usually gleaned from the history.
The ETIOLOGIC DIAGNOSIS.
Lab tests/ Ancillary examinations in
Neurology
Imaging of the spinal cord, brain –
CT scan or MRI, +/- contrast/
gadolinium
Angiography
Electroencephalogram (EEG)
Electrocardiogram (EKG or ECG)
Electromyography, Nerve
conduction velocity studies
(EMG-NCV)
Blink NCV
Repetitive Nerve Stimulation
(RNS)
Lab tests/ Ancillary examinations in
Neurology
Prolonged Exercise Test
Edrophonium challenge test
Cerebrospinal fluid analysis
PET scan
Thyroid function tests, Blood
chemistry, Liver function tests,
ABG, urinalysis
Chest x-ray
Carotid-vertebral duplex scan,
transcranial doppler
2-D Echocardiography
A few pointers...
Read on the most common neurologic
disorders and be knowledgeable about
the common courses of diseases
Review neuroanatomy
Patience is a virtue
Practice makes perfect
The End
