History Taking & Physical Examination for A Neurology Case (Stroke)

History Taking & Physical Examination for A Neurology Case (Stroke)Created OnJune 1, 2020Last Updated OnJune 1, 2020byadmin You are here: Main Clinical Examination History Taking & Physical Examination for A Neurology Case (Stroke) < All Topics Table of Contents Chief Complaint: Mr/Ms (name), a (age) year old man/lady from (residential address), with underlying any chronic disease/comorbites (Hypertension, Diabetes mellitus, Dyslipidemia) for (how long) was brought to/presented to the hospital with a chief complaint of main presenting symptom with duration (eg. headache, left/right sided weakness/facial asymmetry since 1 day ago) History of Presenting Illness: Mr/Ms. was apparently well until duration prior to admission (1 day prior to admission) when he/she experienced acute/gradual onset of the presenting symptom (details of past medical history maybe included if the current complaint directly relates to an ongoing chronic disease). The presenting symptom is located at (ask patient to point to the site of the headache, eg over the occipital region). The presenting symptom was precipitated by causes or precipitating factors. It was continuous/intermittent in nature. It was aggravated by aggravating factors, and relieved by relieving factors. It was associated with other symptoms such as unilateral limb weakness, numbness, facial asymmetry, slurring of speech, difficulty in swallowing, choking. The presenting symptom had progressively worsened/improved. This was the first time that the patient suffering from the condition/The patient had suffered from the same condition before. Patient rated the (headache) as (pain score – ?/10) * If stroke is suspected, it is important to ask about handedness (Right/Left hand dominant) * Remember to rule out other cause of headache such as: Meningitis/Encephalitis: Fever, photophobia, neck stiffness Space occupying lesions: Nausea, vomiting, significant weight loss, appetite loss Migraine: Pulsating headache, Photophobia Cluster headache: Eye pain Glaucoma: Visual disturbance Haemorrhage: Ask for any trauma *If there’s seizure, ask for triggers of seizure such as flashing lights, metabolic disturbances (hypo/hyperglycemia(last meal taken), electrolyte imbalance, uraemia, liver disease), infection (meningitis/encephalitis), drugs (tricyclics, cocaine). After (symptom) he/she was transported via (transport) by (duration) to (Hospital) *If seizure note post-ictal state symptoms ( drowsiness, confusion, transient focal paralysis) *If trauma case, note the mechanism of injury and site of injury and note down SOCRATES *If unable to clerk patient due to loss of consciousness, clerk a witness Systemic Review: General – fever/recurrent infections, recent weight change, activity level, ability to keep up with peers, snoring and sleep apnea Head – injuries and headache Eyes – discharge, redness, puffiness, vision-related problems Ears – discharge, tinnitus, vertigo, reduced hearing Nose – congestion, epistaxis Mouth – sore throat, dysphagia. dental problems Respiratory – breathlessness, cough, wheeze, hoarseness, hemoptysis, chest pain Cardiovascular – breathlessness, palpitation, syncope, oedema, exercise tolerance Gastrointestinal – vomiting, dysphagia, abdominal pain, frequency of bowel movements, jaundice Urinary – dysuria, frequency, urgency, nocturia, haematuria, menarche Neurological – altered consciousness, weakness, numbness, fainting, incoordination, tremors, seizures Musculoskeletal – deformities, pain, swelling, warmth, muscle cramps, gait changes Skin – rashes, itching Allergy – urticaria, hay fever, asthma, eczema **If the systemic review is unremarkable, just mention: the systemic review is not significant or unremarkable. Past Medical and Surgical History: Patient has underlying comorbids (eg. Hypertension, Diabetes mellitus, Dyslipidemia) for duration (5 years). He was diagnosed in (which clinic/hospital) as he experienced (any symptoms at time of diagnosis) or found out during a health checkup. He/she is currently taking what medications/treatment, and was compliant/not compliant to it. Any change of medication? Side effects? He/she follows up the condition at which clinic and the frequency. He/she does/does not suffer from any complications of the disease. Patient was previously admitted to the hospital / no previous admission to hospital. Admitted when, symptoms at that time, diagnosed with ?, treatment given at that time, admitted for how long, completely recovered?. Drug History and Allergy: Patient has been taking/ took name of the medication/dietary supplements with dose, route, duration for indication, obtained from which health faculty. He/she is/was compliant/not compliant to the medications/dietary supplements. He/she is allergic to name of medications or food substances as he developed allergic reactions such as reactions that took place as he/she took the medications or He/she has no known allergies. He/she is not consuming any complementary or homeopathic medicine. (If yes, indications and type of medications should be asked and presented) *Allergy to any food and medication, severity of allergic reaction, management rendered for allergic reaction, current emergency medication for allergy Family History: Patient’s mother is age years old while his/her father is age years old. Both his/her parents are well and healthy or suffering from medical illnesses. He/she has number of siblings whose ages ranging from youngest to oldest years old. They are well and healthy or suffering from medical illnesses. *Relevant inherited diseases including comorbid disease, cardiovascular disease, peripheral vascular disease, epilepsy, malignancy etc. *Describe any mortality due to familial disease, and quality of living of the relatives afflicted by the disease Social History: Patient is currently working as a (occupation). He is single/married for (duration of marriage) with (how many children, age ranges from youngest to eldest). They stay together in (type of house, residential address). He/she is/not a smoker for how long, how many sticks per day (calculate pack years). If quit, when did they quit? He/she does/does not drink alcohol or abuse any recreational drug. He/she claimed to have/no financial difficulty and has a good relationship with his/her family. *Note if there are any caretakers for the patient if required. *Note the current care plan for ongoing medical conditions e.g. stroke *Note the ease of access of facilities for the...

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