OS 202 Neurological History Taking PDF

OS 202: HUMAN BODY AND MIND 1: INTEGRATION AND CONTROL SYSTEMS NEUROLOGICAL HISTORY TAKING UPCM 2029 | Christian Wilson Turalde, MD, FPNA | LU3 A.Y. 2024-2025 OUTLINE ○​ Gait...

OS 202: HUMAN BODY AND MIND 1: INTEGRATION AND CONTROL SYSTEMS NEUROLOGICAL HISTORY TAKING UPCM 2029 | Christian Wilson Turalde, MD, FPNA | LU3 A.Y. 2024-2025 OUTLINE ○​ Gait testing ​ Always check how a patient walks I.​ Introduction III.​ Components of the A.​ Purpose of Neurological Neurological History C.​ BASIC NEUROLOGICAL EXAMINATION TOOLS [2026 Trans] History Taking A.​ General Data ​ Reflex hammer B.​ Questions to Ask B.​ Chief Complaint ​ Tuning fork: 256 Hz C.​ Basic Neurological C.​ History of Present ​ Penlight Examination Tools Illness ​ Pocket vision card II.​ Guidelines for D.​ Review of Systems ​ Cotton or tissue paper Neurologic E.​ Past Medical History ​ Wooden tongue depressor History-Taking F.​ Family Medical History ​ Opaque small containers: coffee, nicotine, sugar, salt A.​ Other Things to G.​ Personal-Social History ​ Stethoscope Remember for the IV.​ Take-Home Points ​ Ophthalmoscope Neurological Exam A.​ Heuristic and Cognitive ​ Personal safety/hygiene kit due to COVID: mask, shield, gloves, B.​ Throughout the Biases alcohol Encounter B.​ Selective Cognitive C.​ Introducing Oneself to Biases in Health II.​ GUIDELINES FOR NEUROLOGIC HISTORY-TAKING the Patient Assessment ​ Adopt a friendly and relaxed interview style C.​ The Neurological ​ Use a common language that the patient prefers Assessment Path ​ Balance the use of open and closed questions V.​ References ○​ A lot of neurological complaints need the patient’s narrative ​ This requires a balance between open and closed questions LEARNING OBJECTIVES ​ Do not put words into their mouth 1.​ Outline the components of the neurological history ○​ It is in the nature of Filipinos to agree with what the other person 2.​Explain the fundamentality of history-taking in clinical medicine is stating 3.​Enumerate the important elements of common neurological ○​ It is in our Filipino culture to be affirmative, but it is important to complaints clarify[Trans 2028] 4.​Determine the inheritance patterns of some inherited neurologic ​ Explore each symptom carefully describing the extent and time diseases given a sample history and/or pedigree course as precisely as possible 5.​Proficiently report the complete neurological history of a sample ○​ Considered as the “meat” of neurologic history taking [Trans 2028] patient ○​ Complaints have 2 dimensions: [Trans 2028] ​ Temporal (i.e., through time); and I.​ INTRODUCTION ​ Severity (e.g., mild, benign, etc.) ​ Neurological history taking is the most important and most ​ Clarify what the individual actually means by their symptoms productive part of neurological assessment ○​ e.g., Pamamanhid ○​ Neurological history taking is the bread and butter of ​ Can mean different things depending on the population group diagnostic neurology, not neurological physical examination [2028 ​Numbness, tingling sensation, form of weakness Trans] ​ There is a need to clarify to the patient ○​ Provides the most information about the nature of the lesion ​ Understand how the individual's work, social life, and emotions ​ You can tell the location of the localization based on the chief are affected by their problems complaint ○​ A lot of neurological complaints disrupt activities of daily living ○​ Gives a strong indication of its location ○​ The goal is to return the patient’s health to their baseline function ○​ Helps to determine the choice of appropriate physical signs ​ In general medicine, the correct diagnosis is achieved: A.​ OTHER THINGS TO REMEMBER FOR THE NEUROLOGICAL ○​ In >80% of patients from the history alone EXAMINATION [2026 Trans] ○​ Additional 7% after traditional neurologic physical examination ​ Be presentable and professional ○​ Additional 7% upon doing full investigation (laboratory tests) ​ Wear prescribed uniform and have nameplates on at all times ○​ Resulting to a total of 94% accuracy most of the time, with a ​ Keep the patient comfortable significant confidence level ​ Ask permission if you will examine ​ Remaining 6%: idiopathic, cannot be diagnosed [2027 Trans] ​ Be respectful and sensitive to the patient’s needs and privacy ○​ Some patients do not want to be touched A.​ PURPOSE OF NEUROLOGICAL HISTORY TAKING [2026 Trans] ​ Consider your body language ​ Screening Test ​ Practice infection control techniques at all times ○​ Still ask questions and perform exams to detect any underlying ○​ During the pandemic, techniques can be modified to ensure abnormalities even if there is none expected everyone’s safety, but principles of proper approach and getting ​ Investigation Tool the history are the same ○​ Patient with a neurological complaint comes in ​ Determine presence, nature, extent of abnormality B.​ THROUGHOUT THE ENCOUNTER [2027 Trans] ​ Look for associated abnormalities ​ Maintain an attentive position ​ Neurological exam must be designed to answer a specific ○​ Lean forward 10° with straight head, back, and shoulders up question/hypothesis derived from a well done history taking ​ Maintain eye contact ○​ Patient complaining about a painful toe ○​ If difficult, you can look unto the forehead just above the nose ​ Might just be an ingrown nail (screening test) and not into the eyes ​ With history of digits numbness, might be diabetic neuropathy ​ Minimize distractions ​Reflexes are down, and weak pulsations in the feet are ○​ e.g., Taking lots of notes and use of cellphones observed upon examination ​ Give the patient time to answer in his own words, then facilitate ​ Even if some complaints don’t seem neurological, it is important to and clarify do a complete neurological examination to check for abnormalities ○​ Let the patient finish first before asking another question ○​ Do NOT interrupt. B.​ QUESTIONS TO ASK [2026 Trans] ​ If the patient is very talkative and gets lost in the topic, you can ​ Level 1: Is there a lesion? redirect them ○​ Distinguishing normal versus abnormal ​ Prepare yourself and the environment ​ Level 2: Where is the lesion? ○​ Make sure you are well-fed and rested ○​ Localize the lesion (knowledge of neuroanatomy, and ○​ Make sure the environment is not too noisy and other people are neurological examinations) not nosing around ​ Level 3: What is the lesion? ○​ Identify lesions (knowledge of pathology and neurological Additional Information from Trans 2026 diseases) ​ Initiating the Session ​ Level 4: Can anything be done with the lesion? ○​ What NOT to do: ○​ How to treat the lesion (knowledge as a clinician) ​ Providing false reassurance ​Saying “I’m here to get you cured...” Additional Information from Trans 2024 ​ Giving unwanted advice ​ Parts of Conducting a Neurological Examination ​ Using authority ○​ Mental status examination ​Do not look down at the patient as if you are superior to ○​ Examination of cranial nerves the patient ○​ Motor examination ​ Avoid using “why” questions ○​ Sensory examination ​Avoid asking “why did you get married twice”, “why were ○​ Meningeal examination you admitted to a mental institution...” ○​ Autonomic testing ​ Using professional jargon to avoid misinterpretation Trans 2 TG28: Tanael, Tansiongco, Tansiongkun, Taracatac, Tario, Tee, Tiambeng TH: Kiunisala 1 of 6  ​ Using leading or biased questions ​ Talking too much ​ Interrupting or changing the subject (because you have your agenda, let the patient talk and redirect them) C.​ INTRODUCING ONESELF TO THE PATIENT [2026 Trans] ​ Respectfully introduce and identify yourself ​ Know and use the patient’s name ○​ Ask how the patient would like to be called ​ State your purpose ​ Ensure comfort and privacy at all times ​ Show empathy, genuine interest, and do not be judgmental ○​ Remember that the patient is admitted with an illness ​ Talk to the patient in a language he/she is comfortable with ○​ e.g. Tagalog, English or Taglish ​ Use open-ended questions (Who, What, Where, When) Figure 1. Broca Rule: The X-axis determines handedness (left or right) and the Y-axis ○​ Ask the patient to describe instead of giving them yes or no determines the rate of right language dominance (%). questions ○​ Unless when clarifying the details of the history, you may also Sample Exam Question use closed-ended questions ​ True or False? Majority of left-handed individuals are right-brain ​ Allow the patient to talk, do not interrupt to ask your next question dominant. ​ Give the patient time to answer and encourage them with silence, ○​ Answer: FALSE, because most left-handed individuals are still nonverbal cues, and verbal cues left-brain dominant. ​ Focus by paraphrasing and summarizing ​ 75% left brain dominant ​ Avoid body language suggesting you are not interested in knowing ​ 25% right brain dominant what the patient has to say ​ At the end of your encounter with the patient, do not forget to B.​ CHIEF COMPLAINT thank them ​ Patient’s most troubling problem ○​ Sometimes, patients come to the clinic with multiple complaints. Additional Information from Trans 2026 ○​ Chief complaint is most likely the most severe symptom or the ​ What to Say main reason for consulting. ○​ Suggested script for self-introduction: ​ Serves to focus attention on the questions to be addressed in ​ “Mr./Ms....?” (In a questioning tone) taking the neurological history ​ “Hi, I am _______ (Full Name), a medical student.” ​ Provides the first clue to the anatomy and etiology of the ​ “I am here to do a neuro history and exam.” underlying disease ​ “Mr./Ms. ___, how would you like me to address you?” ○​ Eg. Seizure as chief complaint → not a peripheral nerve lesion → ​ If the patient has to be standing, say nothing. Otherwise, say localization in the brain “Please be seated.” ​ Sample chief complaints: headache, unilateral weakness, slurring of ​ Sample Script: speech, blurring of vision, clinical convulsion, memory lapses, ​“Good afternoon, I am _______, a first-year medical dizziness, tremors student. With your permission, I would like to get a medical history and perform a neurological examination. How Additional Information from 2028 Trans should I address you?” ​ Common neurological complaints: ○​ Be systematic ○​ Headache ○​ Avoid shortcuts ○​ Dizziness ○​ Weakness III.​ COMPONENTS OF THE NEUROLOGICAL HISTORY ○​ Numbness ○​ Memory problem A.​ GENERAL DATA ○​ Loss of consciousness ​ Start the history by asking the patient’s: ○​ Difficulty in speaking ○​ Name ○​ Tremors and involuntary movements ○​ Age ○​ Visual and hearing changes ○​ Handedness ○​ Bladder and bowel incontinence ○​ Marital status ​ Reliability of informant ○​ Occupation ○​ You may quantify the reliability of the information given to you ​ Remember that the goal is to bring the patient back to his using percentages (e.g., “Reliability of history – 80%”) baseline level (can still do what he used to do) ○​ If a patient cannot give you the history, state your informant ○​ Educational attainment ○​ You can ask the people around during your interview for ​ Important to consider since some scoring systems are verification of other additional data influenced by educational attainment ○​ Religion C.​ HISTORY OF PRESENT ILLNESS ○​ Residence/province ​ Complete history of the current medical problem that brought the ​ Some neurologic diseases are regional patient to medical attention ​Ex. X-linked Dystonia Parkinsonism in people from Panay ○​ Begins when the chief complaint was first felt ​ Sample report/documentation: ​ Includes possible risk factors or other causes of the current ○​ “AB is a 67-year-old, right-handed, married, Roman Catholic, illness retired male auto mechanic from Tondo, Manila. He is a graduate ​ Includes a detailed chronological description of all symptoms of a technical-vocational course on automotive servicing.” and prior care obtained for this problem ​ Cardinal rule in documenting history: ○​ Neurological symptoms should be described along its two ○​ If you are presenting or endorsing the case to someone who is dimensions:(2028 Trans) involved in the care of the patient (for example, endorsing to the ​ Time next shift, seeking opinion or referral), include the full name of ​ Severity​ the patient ​ Covers pertinent negative information ○​ If endorsing the case in an academic environment (not involved in ○​ What the patient did NOT present with the care of the patient, in cases of academic exercise), put the ○​ Should be deliberately written(2028 Trans) abbreviated name of the patient ​ If a particular complaint, symptom, or phenomenon was not HEMISPHERIC DOMINANCE & HANDEDNESS mentioned, NEVER assume that it is absent. ​ Broca Rule: ​ Related medical problems can be mentioned as well ○​ Right-handed individuals tend to have left-sided hemispheric ○​ Must be related to the chief complaint language dominance ​ Example: Stroke (present illness) is intimately related to ○​ Most of the time, the dominant hemisphere tends to hold the hypertension (related medical problem). language centers ○​ Those that are not directly relevant to the present illness are ○​ More than 97% of the time, most are left-brain dominant usually covered in the past medical history instead. ​ Edinburgh Handedness Index/Inventory ​ Example: Stroke patient had tuberculosis during childhood. ○​ Sometimes referred to as the Edinburgh Handedness HEADACHE Questionnaire (EHQ) ​ Elicit the PQRST Framework ○​ Can quantitatively determine how right-handed or left-handed a ○​ P - Provocation/Palliation person is depending on the responses of the person being tested ○​ Q - Quality/Quantity ○​ 20-item activities that need to be answered ○​ R - Region/Radiation ​ Questions can be like: when you throw a ball, which hand do ○​ S - Severity scale you use? ○​ T - Temporal/Time ​ Trivia: score of -40 to + 40 is ambidextrous ​ Sample: The patient reported episodes of intermittent [T], mild [S], OS 202 Neurological History Taking 2 of 6  holo-cranial [R] headache described as tight band sensation [Q], following sleepless nights [P], lasting for 2-3 hours [T], relieved by → OSCD PQRST UVW + AAA intake of acetaminophen [P]. Onset “Kailan po nagsimula?” ○​ Classic description of tension headaches ​ How did it all start? Was it all sudden or DIZZINESS gradual? ​ One of the most difficult complaints to describe in the clinic ​ Onset may be classified as acute, ​ All descriptions vary from person to person, but we can describe 4 subacute, or chronic. major identifiable categories (at our level): ​ Vertigo Setting “Ano pong ginagawa niyo nung nagsimula ○​ Physical sensation of motion of self or the environment ito?” ○​ “Rotatory sensation” ​ What were you doing when it started? ​ Near-syncope ○​ Sensation of faintness, no sense of movement Course “Nawala po ba?” ○​ Usually accompanied by sensation of blacking out by virtue of ​ Is it getting worse, better, or just the hypoperfusion of retinal arteries same? ​ Disequilibrium ○​ Disorder of imbalance of stance or gait Duration “Gaano na po ito katagal?” ○​ Dizziness of patients with cerebellar dysfunction, dorsal spinal ​ You said it started ___ years ago, does it column (proprioception) problems, and ataxia syndromes come and go? ○​ Common in patients with neurosyphlis ​ If yes, how often/frequent does it come? ​ Ill-defined light-headedness / “giddiness” For how long does it last each time? ○​ “Waste-basket” epidemiology ​ Mostly associated with mood disorders, anxiety disorders, and Place “Saan po ba masakit?” other fear syndromes ​ Can you show me exactly where it is in ​ Sample Scenario: The patient reported episodes of dizziness your body? Point where with one finger. described as near-fainting sensation accompanied by sudden blurring of vision / blacking out and feeling cold whenever he Quality ​ Describe the pain. Tell me how it feels. Is it suddenly assumes an upright position from sitting position. sharp? Stabbing? Dull? Tight? Cramps? ○​ Near-syncopal dizziness Squeezing? Burning? ○​ Common among tall persons because there is an increased lag time to redistribute perfusion Radiation ​ Direction of pain. SEIZURE ​ Does it shoot out or is it localized? Does it ​ 1st phase: Prodrome/Pre-Ictal Phase go/shoot anywhere? ○​ Early symptoms that occur days to hours prior to the seizure ○​ e.g., mood changes, lightheadedness, anxiety, sleep disturbance Severity ​ Rate the pain on a scale of 1-10, 1 being ​ 2nd phase: Ictal Phase the mildest and 10 being the worst. ○​ Time from the first clinical sign of seizure to the end of seizure ​ Does it interfere with your daily activities? activity (specific) ○​ Auras are considered early part of actual seizure event Timing “May oras ba ng araw kung kailan ito ​ Seizure itself gives anatomic location nagsisimula o lumalala?” ​ Déjà vu, Jamais vu, and odd focal sensations are some ​ Is it worse at a particular time of the day? examples of aura ​ Valsalva headache – hurts when ​ 3rd phase: Post-Ictal Phase coughing[2024 Trans] ○​ a.k.a. recovery phase ​ Nighttime headache – increases CO2 ○​ Some patients may present with transient confusion, tiredness, levels a vessel dilation → Increases and muscle aches intracranial pressure[2024 Trans] ​ Sample Scenario: The patient reported feeling anxious hours before a seizure. Early in the episode, he would describe pins-and-needles U (You) ​ Daily activities of the patient sensation over his left forearm. This would be followed by rhythmic ​ Does it change with your daily activities jerking of his left wrist and forearm for ~2 minutes. His like posture, exertion, rest, sleeping, consciousness remain intact during the event. No untoward eating, hunger? symptoms were reported after the clinical event. V (Deja Vu) “Nangyari na po ba ito dati?” Additional Information[2026 Trans] ​ Has it happened before? When? How did ​ Chronology of events leading to present visit you handle it? ​ Probes the chief complaint to rule in/out possible conditions the ​ What happened to it? Which doctor? patient may have Medication? ​ Be observant and follow all leads ​ Nature of complaint: “What do you mean by...?” What ​ What has worked or not worked for the ○​ Clarify what the patient means as there can be differences in patient so far? understanding of the complaint ​ Ask what they think is causing it ○​ e.g., Hilo may mean lightheadedness, imbalance, faintness, hypoperfusion Aggravatin ​ What makes it worse? What brings it on? ​ Allow patient enough time to narrate the history g Factors ○​ Time course, pattern, radiation ○​ Extent or severity of deficit Alleviating ​ What makes it better? ○​ Precipitating or relieving factors Factors ○​ Previous treatments and treatment response ○​ Previous investigations or admissions Associated ​ Have you noticed anything else that ○​ Other neurological conditions associated with the complaint Symptoms occurs with it? ​ For first-year medical students, a screening neurological history ​ If any symptoms occur with the described taking (i.e., no hypothesis) will suffice symptom? ​ Types of questions: ​ Does it happen before, after, or during the ○​ Open: Require more thought and more than a simple headache? one-word answer ​ “How can I help you?” ​ “You said you have pain on movement, can you tell me which movements make your pain worse?” TEMPORAL SEVERITY PROFILE ○​ Closed: Can be answered by a simple “yes” or “no” or there is ​ Patterns of neurological complaints limited answer to the question ○​ 2 dimensions: Describe time profile (x-axis) and severity profile ​ “Are you still taking the aspirin your GP prescribed?” (y-axis) ​ “Is that an accurate summary of your symptoms?” ​ Discrete monophasic event ○​ Leading: Based on your own assumptions that lead the ○​ Examples: cerebrovascular disease (CVD), acute disseminated patient to the answer you want to hear encephalomyelitis (ADEM), Guillain-Barre Syndrome (GBS), ​ Biased questioning that forces answers that fit your certain CNS infections assumption ​ “You are not allergic to anything, are you?” ​ “Are your joints painful in cold weather?” ​ Mnemonic to explore the chief complaint: ○​ SOCRATES: Site, Onset, Character, Radiation, Association, Time course, Exacerbating or relieving factors, Severity ​ Mnemonic for the HPI: OS 202 Neurological History Taking 3 of 6  Figure 6. Stepwise Pattern ​ Sample HPI: 4 years prior to consultation, there was sudden-onset right-side UE weakness with slurring of speech. Admitted and treated as CVD patient and discharged after 3 days. ○​ Interim period: patient was capable of taking care of himself (doing activities of daily living or ADLs). Slight struggles with Figure 2. Discrete Monophasic Profile language and mild right-sided weakness. Fairly compliant with ​ Discrete episodes medications. ○​ Examples: migraine and other headache syndromes, certain ​ Sample HPI (cont.): 3 years prior to consultation, there was sudden epilepsies increase in severity of right-side UE weakness with severe slurring of speech. Admitted and treated as CVD patient and discharged after 5 days. ○​ Interim period: patient needed assistance to take care of himself (doing activities of daily living or ADLs). Severe struggles with language and communicated mostly with gestures (expressive aphasia). Poorly compliant with medications. ○​ Consultation: (presumed) neurologist was approached as symptoms were unmistakably neurological by this point, and quite severe D.​ REVIEW OF SYSTEMS ​ This involves the specific eliciting of any complaints over all body systems​ ○​ Information must be specifically elicited because minor complaints are unlikely to be foremost in patients’ and carers’ attention Figure 3. Discrete Episodic Profile ○​ Very important because related symptoms or complications may ​ Fluctuating levels of severity be missed if only noting the History of Present Illness ○​ Examples: multiple sclerosis relapsing-remitting subtype, ​ Takes the form of a checklist: myasthenia gravis ○​ Other symptoms in the same system as the Chief Complaint (other neurological symptoms): ​ Hallucinations ​ Seizures and other impairments of consciousness ​ Orthostatic faintness (faintness when standing after not standing for some time) ​ Headaches ​ Special senses (vision, balance, hearing, olfaction, gustation) ​ Speech and language function ​ Swallowing ​ Limb coordination ​ Slowness of movement ​ Involuntary movement or vocalizations ​ Strength and sensation ​ Pain ​ Gait and balance ​ Sphincter, bowel (and sexual) function ○​ Other systems, from head to toe (superior to inferior): Figure 4. Fluctuating Severity Profile ​ General ​ Progressive Diseases ​Fever ○​ Rapid and slow ​Unintentional weight changes ​ Examples: Alzheimer’s Disease, dementia, Parkinson’s disease ​Generalized malaise (feeling bad) and related disorders, amyotrophic lateral sclerosis and ​Change in appetite subtypes, other neurodegenerative diseases ​ Head and neck ​BOV ​Tinnitus/Hearing Loss ​ Respiratory ​Cough/colds ​Pleuritic chest pain ​ Cardiac ​Easy fatigability ​Chest tightness ​Orthopnea ​Edema ​Paroxysmal nocturnal dyspnea ​ Gastrointestinal ​Abdominal pain ​Diarrhea/Constipation Figure 5. Progressive Diseases Profile ​Melena (dark stools due to blood) ○​ Progressive step-wise diseases ​Hematochezia (bloody red stools) ​ Example: multi-infarct dementia ​ Endocrine ​Palpitations ​Hot/Cold intolerance ​Polyuria (excessive urination) ​Polydipsia (excessive thirst) ​ Musculoskeletal and Dermatological ​Joint pains ​Joint swelling ​Skin lesions ​ Urinary ​Hematuria (blood in urine) ​Dysuria (painful/difficult urination) OS 202 Neurological History Taking 4 of 6  ​Frequent urination ○​ Partially-Shaded Shape: Known Carrier of diseased allele ​Dribbling (involuntary urination right after finishing voluntary ○​ Question Mark in Shape: Possibly affected person urination) ○​ Square Brackets around Shape: Adopted ​ Example: A patient with a severe headache may not mention ○​ Horizontal Lines directly connecting two shapes: indicator for tingling in the toes or slight difficulty breathing because these are mating. Offspring of the mating are indicated by vertical lines relatively minor complaints versus the chief complaint emerging from this horizontal line ​ Especially important in neurology where pain can be a dominating ​ Types of Inheritance chief complaint, but lesion(s) may also have other manifestations ○​ Autosomal Dominant ​ Heterozygous and homozygous diseased genotypes express Additional Information[2026 Trans] diseased phenotype ​ Probes on other systems other than the system involved in the ​ In the pedigree, the disease never skips generations and chief complaint affects males and females equally ​ Questions grouped by organ system including: ​ Board-common examples: Von Hippel-Landau disease, →​General / Constitutional neurofibromatosis, tuberous sclerosis, Huntington disease, DYT →​Skin, breast 5, DYT 6, DYT 7, Hyperkalemic Periodic Paralysis, Hypokalemic →​Eyes, ears, nose, mouth, throat Periodic Paralysis, Charcot-Marie-Tooth Disease 1A,1B,2A,2B, →​Cardiovascular Familial Hemiplegic Migraine 1,2 →​Respiratory →​Gastrointestinal →​Genitourinary ▪​ Ask about erectile dysfunction in men →​Musculoskeletal →​Neurologic / Psychiatric →​Allergic / Immunologic, lymphatic, endocrine ​ Systemic inquiry is of utmost importance →​e.g., loss of weight and appetite may suggest malignancy which may be a paraneoplastic syndrome, gain in weight may have precipitated diabetes E.​ PAST MEDICAL HISTORY Figure 7. Autosomal Dominant Inheritance ​ Includes prior medical and surgical problems and history of ○​ Autosomal Recessive trauma or major injuries not directly related to the HPI ​ Only homozygous diseased genotypes express diseased ○​ Includes the list of all medications currently being taken by the phenotypes patient (including herbal or over-the-counter drugs), as well as ​ In the pedigree, the disease tends to skip generations and any known food or drug allergies affect males and females equally ​ Example: ​ Board-common examples: Wilson disease, Friedrich’s ataxia, ○​ (-) Diabetes Mellitus Type 2, thyroid & other endocrine problems Spinal Muscular Atrophy 1,2,3, Charcot-Marie-Tooth 2,3,4 ○​ (-) Pulmonary Tuberculosis, Bronchial Asthma, COPD ○​ (-) prior major surgeries, history of trauma ○​ (-) allergies ​ Can use the statement “Patient denies any intake of other medications/supplements/pharmaceutical preparations” Additional Information[2026 Trans] ​ Essentially background information related to the patient’s health and well-being ​ Some neurological problems can present years after a causative event ​ A brief past medical history often includes these elements: →​Medical/Psychiatric Illnesses Figure 8. Autosomal Recessive Inheritance ▪​ e.g., diabetes, hypertension, depression, etc. ○​ X-Linked Recessive →​Surgeries/Injuries/Hospitalizations ​ The diseased allele is in the X chromosome, with all males with ▪​ e.g., appendectomy, car accident, etc. the allele expressing the disease and females with two copies →​Allergies and Reactions to Drugs of the diseased allele expressing the disease ▪​ Ask what happened ​ In the pedigree, the disease tends to manifest mostly in sons →​Current Medications with carrier mothers, tending to be expressed more in males ▪​ Include “over-the-counter” drugs and supplements and skipping generations −​ Ask what is it taken for ​ Board-common examples: X-Linked Dystonia Parkinsonism ▪​ Some patients will not tell you they are taking herbal (XDP) which is endemic to the Philippines, with maternal origin medications, but it is important that you elicit this in Panay group of islands; Menkes disease information from them ​ Inquire about other past and present medical problems as these may give clues to the diagnosis →​A person in atrial fibrillation may be producing multiple tiny emboli →​There may be vascular problems or recurrent miscarriages to suggest antiphospholipid syndrome →​There may be diabetes ​ Ask about pregnancy, delivery, and neonatal health →​Health of mother during pregnancy →​Substances taken by mother during pregnancy →​Type, length, and complications during birth →​Developmental milestones of the child Figure 9. X-Linked Recessive Inheritance ▪​ e.g. crawling, walking, talking ○​ Mitochondrial ​ Ask about infections, convulsions, or injuries in infancy, ​ The disease is inherited through the mitochondria of the egg childhood, or adult life supplier/mother, not through the genes. The father cannot →​Particularly ask about head or spinal injury, meningitis, or pass this type of disease to his offspring encephalitis ​ In the pedigree, the disease always manifests in sons of affected mothers and doesn’t manifest in offspring of healthy F.​ FAMILY MEDICAL HISTORY females and affected males ​ All familial diseases that are present in the patient’s family ​ Board-common examples: Mitochondrial Myopathy, members, alive and dead Encephalopathy, Lactic Acidosis and Stroke-Like Episodes ​ May be presented using a pedigree, with the patient as the index (MELAS) person ​ Example: ○​ (+) hypertension & hypertensive heart disease, both sides ○​ (-) diabetes mellitus type 2, other endocrine disorders ○​ (-) neoplasm, bronchial asthma ○​ (-) depression and other psychiatric illnesses ​ Important symbols in a pedigree: ○​ Circle: Assigned Female at birth ○​ Square: Assigned Male at birth ○​ Diamond: Uncertain sex ○​ Slash through Shape: Dead ○​ Arrow pointing at Shape: indicator for Index Person ○​ Shaded Shape: Affected person OS 202 Neurological History Taking 5 of 6  ○​ e.g. perceptions of risk to the patient is strongly influenced by whether the possible outcome is expressed in terms of the possibility that the patient might die or might live ​ Premature closure ○​ Tendency to accept a diagnosis before full verification ○​ “When the diagnosis is made, the thinking stops” ​ Search satisfying ○​ Tendency to call off a search once something is found ​ Unpacking Principle ○​ Failure to elicit all relevant information which may result in missing significant diagnostic possibilities C.​ THE NEUROLOGIC DIAGNOSTIC PATH Figure 10. Mitochondrial Inheritance Sample Problem[2028 Trans] Determine the inheritance pattern: Figure 13. Neurological diagnostic path ​ Follow the general path above when diagnosing neurological diseases ○​ First, listen to the patient’s chief complaint ○​ From there figure out possible anatomical localizations and what may have caused them ○​ Ask more about their history to further learn about their case Figure 11. Sample Problem 1 ○​ Perform the necessary neurological exams to confirm anatomical ​ Autosomal Dominant location →​The disease manifested even if one of the parents does not ○​ List the possible diseases that could cause them and review have the disease specific features of the patient →​No X-linked pattern ○​ Rank the order of likelihood of the list you made and then give the differential diagnoses V.​ REFERENCES Turalde, C.W. (2025). Neurological History Taking. UPCM 2024 Trans. Neurological History Taking. UPCM 2026 Trans. Neurological History Taking. UPCM 2027 Trans. (November 14, 2022). Neurological History Taking. UPCM 2028 Trans. (Januart 29, 2024). Neurological History Taking. Figure 12. Sample Problem 2 ​ X-linked recessive →​Recessive ▪​ There is a skip generation →​X-linked ▪​ Transmitted only in the maternal line G.​ PERSONAL-SOCIAL HISTORY ​ Include assessment patient’s educational background, and domestic and work conditions ​ Include vices like smoking, alcohol, drugs, and sexual behavior ​ Include assessment of exposure to toxins and contaminants ​ Sample: ○​ Previous smoker (20 pack-years) ​ 1 Pack years = 1 pack a day for a year ○​ Occasional alcoholic beverage drinker (1 bottle of beer/day; stopped 1 year prior) ○​ Tried cannabinoids when he was in college; has had one heterosexual partner ○​ Resides in an urban apartment shared with 4 other members of the family ○​ (-) notable exposure to environmental toxins IV.​ TAKE-HOME POINTS A.​ HEURISTICS AND COGNITIVE BIASES ​ “Uncommon presentations of common diseases are more frequent than common presentations of uncommon diseases.” ○​ An uncommon symptom of a cold is more likely to be a cold than a rare disease. ​ “When you hear hoofbeats, think horses not zebras” ○​ Occam’s Razor, the simplest solution is usually the correct one B.​ SELECTIVE COGNITIVE BIASES IN HEALTH ASSESSMENT ​ Anchoring ○​ Tendency to tunnel vision early pertinent symptoms and failing to adjust your impression as new information comes to light ​ Confirmation bias ○​ Tendency to look for evidence that would support your diagnosis rather than staying neutral with evidence. ​ Framing effect ○​ Tendency to be influenced by how a problem is presented OS 202 Neurological History Taking 6 of 6