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Dr. Romeo Y. Enriquez | July 14, 2015 | NEUROLOGY



o Introductions
o Chief Complaint
o History of Present Illness (Body of the
o Past History
Past Medical History (PMH)
Drug History (DH)
Family History (FH)
Social History
o Review of Systems
o Summary
o Patient Questions/Feedback
Clinical Pearls

Sometimes you have small clues that will lead you to an

underlying diagnosis. Achieve rapport with your patient or
significant others (NEVER ABBREVIATE).

The moment the patient enters the room, you greet them
Good morning sir, good afternoon sir then introduce
yourself. I am Dr. Enriquez, I am the neurologist, Dr.
Balajadia asked me to see you.

Challenge among medical clerks: What am I going to ask

next? Are my questions appropriate for these particular
kinds of patients?
The most important tools in history taking:
Knowledge of Neuroanatomy
Physical Examination
Approach to the Diagnosis
o Where is the lesion?
o What kind of lesion?
After the history, ascertain things that were not part of the
discussion (Review of Systems, Family History, etc.)
To gather as much clues and evidence to arrive at
a logical diagnosis
o If there are no evidences then it is not
considered a part of the history, instead, it
is only hearsay and it does not mean
anything. Anything that is hearsay will lead
away from the diagnosis.
To validate information gathered
o By doing a physical examination (hard
o Watch out for inconsistencies (lying
To correlate the evidence obtained with the
pathophysiologic mechanisms
o Look for certain signs and symptoms
o While interviewing patient, localize or try
physiological abnormality (small clues that
would lead to diagnosis)
To achieve rapport with patient or significant

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Introduce yourself, identify your patient and gain
consent to speak with them.

Should you wish to take notes as you proceed, ask

the patients permission to do so.
For experienced physicians, when they interview a
patient, expecially in patients rooms, there is no
room for them to make notes as they interview, so
they only rely on the proper structure of what they
are trying to get. When they get out of the room,
they have to write the notes because they might
In the office, you dont have to compose the
narrative immediately or even in the emergency
room, you just doodle.

Is this headache continuous up to now or does it
come and go?
Over the past two weeks, over 2-3 times a week.

Headache (if CONTINUOUS):

Headache (if INTERMITTENT):

Vomited Vomited

July 1st

July 14

Even if it takes ten years, you have an idea when the

different signs and symptoms progress. We do not make
the note taking interfere with the continuity of the

Be respectful as much as possible and do not

Talk Down on patients or relatives. (Use Sir,
Maam, or Po) regardless of age or social,
economic status.
As soon as the patient enters, the history taking starts
there. You evaluate the gait, general appearance, posture,
mood, feelings, affect. Even if you are interviewing,

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evaluate the patient (physical exam) while taking the

The history is the cornerstone of medical diagnosis;
neurologic diagnosis is no exception. In many instances, the
physician can learn more from what the patient says and how he
says it than from any other avenue of inquiry. A skillfully taken
history will frequently indicate the probable diagnosis, even
before physical, neurologic, and neurodiagnostic examinations
are carried out. The most important aspect of history taking is
attentive listening.
(From DeJongs The Neurologic Examination, 6th Edition, 2013).

What is the reason for seeing the doctor?
What made the family bring the patient to the
emergency room?
Use the exact words the patient used.
You may use vernacular if necessary.
The rest of the initial questions in the history shall
be based on the chief complaint.
D: Ano po ang nararamdaman nyo? Bakit kayo
nagpunta dito?
P: Masakit po ang ulo ko.


Gain as much information you can about the
specific complaint.
Sticking with pain as an example you should ask:
o Site: Where exactly is the pain?
o Onset: When did it start, was it
constant/intermittent, gradual/ sudden?
o Character: What is the pain like e.g. sharp,
burning, and tight?
o Radiation: Does it radiate/move anywhere?
o Associations: Is there anything else
associated with the pain e.g. sweating,
o Time course: Does it follow any time pattern,
how long did it last?
o Exacerbating/relieving factors: Does anything
make it better or worse?
o Severity: How severe is the pain, consider
using the 1-10 scale?
The SOCRATES acronym can be used for any
type of pain history.

If there is multitude of symptoms, you can work on one

paragraph per symptom plus associated signs or
You can also do one paragraph per major symptom by
Comprehensive history may also be written chronologically
which is usually done among clinicopathologic

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1. Past Medical History (PMH)
Gather information about a patients other medical
problems (if any).
The past history is important because neurologic
symptoms may be related to systemic diseases.
Relevant information includes a statement about
general health; history of current, chronic and past
illnesses; hospitalizations; operations; accidents
or injuries, particularly head trauma; infectious
diseases; venereal diseases; congenital defects;
diet; and sleeping patterns.
2. Drug History (DH)
Find out what medications the patient is taking,
including dosage and how often they are taking
them e.g. once-a-day, twice-a-day, etc. At this
point it is a good idea to find out if the patient has
any allergies.
Ex. Are you taking any maintenance medications?
Since when?
3. Family History (FH)
Gather some information about the patients family
history, e.g. diabetes or cardiac history. Find out if
there are any genetic conditions within the family
e.g. polycystic kidney disease.
You may also do a genogram.
The family history (FH) is essentially an inquiry into
the possibility of heredofamilial disorders and
focuses on the patients lineage.
In addition to the usual questions about cancer,
diabetes, hypertension, and cardiovascular
disease, the FH is particularly relevant in patients
with migraine, epilepsy, cerebrovascular disease,
movement disorders, myopathy, and cerebellar
disease, to list a few.
In some patients, it is pertinent to inquire about an
FH of alcoholism or other types of substance
Family size is also important.
4. Social History
This is the opportunity to find out a bit more about
the patients background.
Remember to ask about smoking and alcohol.
Depending on the PC it may also be pertinent to
find out whether the patient drives, e.g. following
an MI patient cannot drive for one month.
You should also ask the patient if they use any
illegal substances, e.g. cannabis, cocaine, etc.
Also find out who lives with the patient.
o You may find that they are the caregiver for an
elderly parent or a child and your duty would
be to ensure that they are not neglected
should your patient be admitted/remain in
The social history includes such things as the
patients marital status, educational level,
occupation, and personal habits.

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The marital history should include the number of

marriages, duration of present marriage, and
health of the partner and children.
These are the main systems you should cover:
o Respiratory
o GI
o Neurology
o Genitourinary/renal
o Musculoskeletal
o Psychiatry
In primary care medicine, the review of systems
(ROS) is designed in part to detect health
problems of which the patient may not complain,
but which nevertheless require attention.
In specialty practice, the ROS is done more to
detect symptoms involving other systems of which
the patient may not spontaneously complain but
that provide clues to the diagnosis of the
presenting complaint.
Complete your history by reviewing what the
patient has told you.
Repeat back the important points so that the
patient can correct you if there are any
misunderstandings or errors.
o Repeat back what they say so that there is no
o If you are in a hurry and you take the history
very fast, chances are, when you review the
history, you have the wrong diagnosis.
o Even if you speak the same language, a
statement may have different meanings.
You should also address what the patient thinks is
wrong with them and what they are
expecting/hoping for from the consultation.
o There are some situations when a patient has
many things to say. Ask the patient
directly/bluntly: WHAT HELP ARE YOU
EXPECTING FROM ME? Some patients
require psychological help, counselling, or
need for a witness to testify for them in court
or to certify that they are sick.
A good acronym for this is ICE - Ideas, Concerns
and Expectations.
o Take time to EXPLAIN to the patient what is
wrong with them.
o Use words that a patient will understand.
o It is also best to use ILLUSTRATIONS.
o When you explain, correlate the explanation of
the pathophysiology with the normal anatomy.
o Provide the patient with a sound rationale of
the DIAGNOSTICS needed and the
TREATMENT applicable.
o For example:
If a patient went to the clinic because
of severe headache, and you suspect

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a medulloblastoma of the cerebellum,

explain that the patient has a tumor of
the middle of the cerebellum, point out
through a diagram the location of the
Explain that the basis is that the
patient cannot walk unless the
patients feet are apart and that he
cannot maintain balance.
Explain to the patient that a CT Scan
is needed to confirm the diagnosis.
Since the patient is already
accompanied by vomiting, tell the
patient that confinement is advised.
Provision of medicines to reduce
pressure in the brain is also needed.
Assure the patient that once he is
stabilized, you will discuss with him
therapeutic options (What can be
For example:
Migraine lang yan! ANALGESICS The
patient is in coma.
We often take for granted the signs and
symptoms of family memebrs
For example:
Wala yan, migraine lang yan! It turns out
to be a ruptured aneurysm.
At the end of the interview, THANK the patient
for their time.
In the clinic, inform the patient of their next

When taking the history, all questions are meant to

STRENGTHEN the diagnosis. The history may also
help in identifying differential diagnoses and rule them

During or after taking their history, the patient may
have questions that they want to ask you.
It is very important that you dont give them any
false information. As such, unless you are
absolutely sure of the answer it is best to say that
you will ask your seniors about this or that you will
go away and get them more information (e.g.
leaflets) about what they are asking.
When you are happy that you have all of the
information you require, and the patient has asked
any questions that they may have, you must thank
them for their time and say that one of the doctors
looking after them will be coming to see them

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When taking the history, all questions are meant
to strengthen your working diagnosis
o In asking the pain scale rating of the patient,
assume that the patient knows what each
rating means and do not underestimate the
patients subjective pain rating.
Subsequent questions are also meant to rule out
other diagnostic procedures
o Kill your diagnosis Differential Diagnoses
o List down all possible other diagnosis and rule
out each as the interview and assessment
o When you see a patient, based on the chief
complaint, come up of an imaginary yellow
pad listing all your differentials: congenital,
demyelinating, immunologic, metabolic, toxic,
and degenerative diseases.

For example, a patient comes in with a headache, localize

and assess further. Ask the patient since when was the
headache and if the patient reports that it had been for 3
days already, rule out the category of Degenerative
Diseases; then continue evaluating, say, it turns out the
headache was related to chronic hyperglycemia, therefore,
it is a Metabolic Disorder.

As a medical student, the working diagnosis

may be: This patient has a lesion on the
vermix of the cerebellum or a cerebellar
tumor presenting the Localized problem,
based on the assessment and mentioning the
Anatomic Area

You should have a working anatomical and

etiologic diagnosis before performing the
neurological examination
o Develop clinical assessment by strengthening
History Taking and Physical Examination.
In 85% of patients: history alone will lead
to a diagnosis
10% of patients will require a neurologic
examination for clues
5% of cases requires ancillary procedures
95% requires CT Scan alone for
objective assessment
5% necessitates other imaging



He should be urged to give a description of the

symptom-being asked, for example, to choose
a word that best describes his pain and to
describe precisely what he means by a
particular term such as dizziness, imbalance,
or vertigo.
o The patient who is given to highly
circumstantial and rambling accounts can be
kept on the subject of his illness by directive
questions that draw out essential points.
The setting in which the illness occurred, its mode
of onset and evolution, and its course are of
paramount importance.
o One must attempt to learn precisely how each
symptom began and progressed.
o The nature of the disease process can be
decided from these data alone, such as in
o If such information cannot be supplied by the
patient or his family, it may be necessary to
judge the course of the illness by what the
patient was able to do at different times or by
changes in the clinical findings between
successive examinations.
In general, one tends to be careless in estimating
the mental capacities of patients. Attempts are
sometimes made to take histories from patients who
are cognitively impaired or so confused that they
have no idea why they are in a doctor's office or a
o Asking the patient to give his own interpretation
of the possible meaning of symptoms may
sometimes expose unnatural concern, anxiety,
suspiciousness, or even delusional thinking.
o Young physicians and students also have a
natural tendency to "normalize" the patient,
often collaborating with a hopeful family in the
misperception that no real problem exists.
o This attempt at sympathy does not serve the
patient and may delay the diagnosis of a
potentially treatable disease.

Adam and Victors Principles of Neurology (10th Edition,

The following points about taking the neurologic history deserve
further comment:
Special care must be taken to avoid suggesting to
the patient the symptoms that one seeks.
o Errors and inconsistencies are as often the
fault of the physician as of the patient.
o The patient should be discouraged from
framing his symptom(s) in terms of a diagnosis
that he may have heard.

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