Professional Documents
Culture Documents
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
“nahihilo ako”
“na-stroke ako”
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
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
Diet
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?
The End