This document provides guidance on performing a neurological history and physical examination. It emphasizes that history taking is one of the most important skills, as it can help identify and localize neurological pathology. The key aspects of history taking outlined are introducing oneself to the patient, obtaining consent, listening to the patient, and documenting the assessment clearly. The document then describes the components of a complete history, including chief complaint, history of present illness, past medical history, medications, and systems review. It also provides details on performing a neurological examination and using tools like the Mini-Mental State Examination to evaluate cognition.

1. Neurological History and Physical
Examination
Mari lazariashvili, MD, PhD Student
Teaching University “GEOMEDI”
2023

2. What is history taking?
• History taking is one of the most important skills a health care
professional has, Careful history-taking can be used to identify
and localise a patient's neurological pathology, without
assessment of health needs becomes very difficult.
• It is a process by which information is gained by a physician by
asking specific questions to the patient with the aim of obtaining
information useful in formulating a diagnosis and providing
medical care to the patient.

3. History Taking
• 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.
• Ensure consent has been gained.

4. Key principles of patient assessment
• Ensure the patient is as comfortable as
possible.
• Listen to what the patient says.
• Summarise each stage of the history taking
process.
• It is estimated that 80% of diagnosis are
based on history taking alone.
• Finaly ensure again that your documentation
(of the assessment) is clear, accurate and
legible.

6. Taking the History
• Always record personal details:
• name
• age
• address
• sex
• ethnicity
• occupation
• religion
• marital status
• Record date of examination

7. History Taking
• Diagnosis in medicine is based on
• Clinical history
• Physical Examination
• Investigations

8. “ Always listen to the patient they might be
telling you the diagnosis “
“ Medicine is learned at the bedside and
not into the classroom “
(sir William Osler 1849-1919)

9. Complete History Taking
• Chief complaint (This is what the patient tells you is wrong,
for example: chest pain)
• History of presenting complaint (Gain as much
information you can about the specific complaint)
• Past/Previous medical history – (childhood/adult
illness, immunizations, other medical problems (if any)).
• Drug history and allergies (Find out what medications
the patient is taking, including dosage and how often they are
taking them, for example: once-a-day, twice-a-day, etc. At this
point it is a good idea to find out if the patient has any allergies)

10. Chief Complaint
• The main reason for which the patient is trying to seek medical
help by visiting the physician.
• Usually a single symptoms, occasionally more than one
complaints eg: fever, headache, pain, etc
• The patient describe the problem in their own words.
• It should be recorded in patients own words.
• The complain should be recorded with their onset duration

11. Chief Complaint
• How to ask for chief complaint?
• What brings your here?
• How can I help you?
• What seems to be the problem?
• If there is more than one complaint, it should be
written according to chronological order.
• Chief complaint Example:
• Fever-2 weeks,
• Productive cough-1 week,
• Vomiting -2 days,
• Fatigue-1day,

12. History of Presenting Complaint
• History of the present illness.
• Elaborate on the chief complaint in detail.
• Ask relevant associated symptoms.
• Gain as much information you can about the specific
complaint.
• Lead the conversation by asking questions.
• Always start with an open ended question and take the
time to listen to the patient’s ‘story’.
• Once the patient has completed their narrative then closed
questions can be asked to clarify .
• Leading question are to be avoided.

13. History of presenting complaint
• In details of present problem with- time of onset/
mode of evolution/ any investigation; treatment
&outcome/any associated symptoms.
• Avoid medical terminology and make use of a
descriptive language that is familiar to patients
• Sequential presentation
• Always relay story in days before admission
• Narrate in details

14. Past/Previous medical history
• Any history of similar complaint in the past.
• Other medical problems the patient has or had.
• Any chronic disease present like hypertension, diabetes etc
• Past hospitalizations and past surgeries.
• Medications if any taken in the past (dosage and duration)
• Allergies
• Pediatric: Birth history, Developmental Milestones,
Immunizations.
• Gyane/Obstetric history if female.

15. • Social history - This is the opportunity to find out a bit more
about the patient’s background.
• Remember to ask about smoking and alcohol. You should also
ask the patient if they use any illegal substances, for example:
cannabis, cocaine, etc.
• Also find out who lives with the patient. You may find that they
are the carer 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)
• Family history - 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, for example:
polycystic kidney disease…

16. Sistems review
• These are the main systems you should cover:
• CVS
• Respiratory
• GI
• Neurology
• Genitourinary/renal
• Musculoskeletal
• Psychiatry

17. Neurological History Taking
• Mental Status — To include at minimum:
• Level of consciousness, orientation to person, place and
time
• Language fluency and content, comprehension,
repetition, naming
• Recent and remote memory
• Attention & concentration
• Fund of knowledge

18. Neurological History Taking
• Cranial Nerves II-XII

19. Neurological History Taking
• Motor — Check all four extremities:
• Includes strength, drift in the upper extremities
fine motor movement in the hands, muscle tone, and
bulk (noting any atrophy or fasciculations).

20. Neurological History Taking
• Reflexes — Check all four extremities:
• Deep Tendon and Pathological Reflexes such as plantar
responses (Babinski sign); frontal lobe release signs.

21. Neurological History Taking
• Sensory — Check all four extremities:
• Include pinprick (or temperature), touch, vibration,
position.
• May also be useful to assess for Romberg Sign.

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

24. Physical Examination Instruments
• Percussion Hammer – used to test
neurologic reflexes.
• The head of the instrument is used to test
reflexes by striking the tendons of the
ankle, knee, wrist and elbow.

25. Physical Examination Instruments
• Ophthalmoscope – used to examine the interior structures of
the eye.
• The ophthalmoscope has a light, magnifying lens and opening for
the physician to view the eye.

26. Mini-Mental State Examination (MMSE)
• The Mini-Mental State Examination (MMSE)
first developed by Folstein in 1975.
• It is the most widely used standardized
instrument for cognitive impairment in the
world.
• It is used in all cultures and translated in
many languages.
• MMSE is a 30 point screening tool.
• Administration of the test takes between 5
and 10 minutes.

28. The Montreal Cognitive Assessment
(MoCA)
• The Montreal Cognitive Assessment (MoCA) is a widely used
screening assessment for detecting cognitive impairment.
• It was created in 1996 by Ziad Nasreddine in Montreal, Quebec.
• The MoCA test is a one-page 30-point test administered in
approximately 10 minutes.
• MoCA scores range between 0 and 30.

30. • https://www.youtube.c
om/watch?v=5ob5uJMg
ZOs

31. Thank you for your attention!