Sie sind auf Seite 1von 22

History – taking

23 January 2018
Charisma T. Evangelista, MD, FPNA
San Beda College of Medicine
 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
 Should set a clinician’s thought
processes in motion.

 Its most important aspect is attentive
 Ask open-ended questions.
 Essential are diplomacy, kindness,
patience, reserve and a manner that
conveys interest, understanding and
 It is an opportunity to establish a
favorable physician-patient
 Mode of questioning may vary.
 Make sure patient is comfortable and at
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

 Start with an open-ended question.

The Chief Complaint

 22/F, Headache
 65/M, Left-sided weakness
 42/F, Tingling sensation of palms and
 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

History of Present
 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 :
 Think PQRST
 P: Palliative, Provoking, Precipitating
 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

 Associated symptom/s
 Previous treatment/s

History of Present Illness :

 Date of first spell and number of
 Frequency of attacks/ fluctuating?
 Duration of attacks, evolution of
 Specific body parts and functions
 Other associated neurologic deficits
– with speech, vision, swallowing
 Previous functional capacity
 Present functional status

History of Present Illness :

 Onset of symptom
 Constant or intermittent
 Neck pain?
 History of diabetes, cancer
 Medications taken
 Exposure to chemicals, pollutants
(occupational, environmental,
 Other associated symptoms –
involvement of arm, face, leg?
Problems with speech or vision

History of Present Illness : BACK

 Onset of symptom
 Character of pain
 Radiation
 History of trauma
 Bowel / bladder disturbances
 Sexual function
 Effect on gait, other neurologic

History of Present Illness : MEMORY

 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

 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

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

 Numbness, tingling
 Tremor
 Problems with gait, balance, or
 Difficulty with sphincter control or
sexual function
 Difficulty with thinking or memory
 Problems sleeping or excessive
 Depressive symptoms
Past Medical History
 Important because some neurologic
symptoms may be related to systemic

 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
 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


Diagnosis in Neurology
The diagnostic catechism:
 Is there a lesion or disease?
 If so, where is the lesion or the
 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
 What is the optimum and preventive
management? – Neurosciences III

Is there a lesion or
 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

 If it affects the nervous system, is it:
 In the PNS or CNS?
 If in the CNS, is it intra- or extra-
 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
 Gives the ANATOMIC
 Can be given by the history also.

What is the lesion?

 Think “VITAMIN C/D”
 V – Vascular – occlusion, hemorrhage,
 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.


Lab tests/ Ancillary examinations in

 Imaging of the spinal cord, brain –
CT scan or MRI, +/- contrast/
 Angiography
 Electroencephalogram (EEG)
 Electrocardiogram (EKG or ECG)
 Electromyography, Nerve
conduction velocity studies
 Blink NCV
 Repetitive Nerve Stimulation
Lab tests/ Ancillary examinations in
 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