Professional Documents
Culture Documents
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.
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INTRODUCTIONS
Introduce yourself, identify your patient and gain
consent to speak with them.
Example:
HEADACHE
Is this headache continuous up to now or does it
come and go?
Over the past two weeks, over 2-3 times a week.
Onset:
July 1st
Present:
July 14
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CHIEF COMPLAINT
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.
Example:
D: Ano po ang nararamdaman nyo? Bakit kayo
nagpunta dito?
P: Masakit po ang ulo ko.
PAST HISTORY
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
abuse.
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
hospital.
The social history includes such things as the
patients marital status, educational level,
occupation, and personal habits.
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PATIENT QUESTIONS/FEEDBACK
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
soon.
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PEARLS
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
proceeds.
o When you see a patient, based on the chief
complaint, come up of an imaginary yellow
pad listing all your differentials: congenital,
inherited,
infection,
trauma,
vascular,
demyelinating, immunologic, metabolic, toxic,
and degenerative diseases.
2.
3.
Reference:
Adam and Victors Principles of Neurology (10th Edition,
2014)
OTHER NOTES:
The following points about taking the neurologic history deserve
further comment:
1.
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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