Physical Address
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Taking a History
Chief Complaint
The chief complaint is the reason for the encounter. The encounter always has a defined purpose, even if the visit is for a medical screening of an individual with no known medical complaints or issues. This should be documented prominently in the encounter note so that the purpose of the visit is clear.
History of Present Illness
In taking a history, the neurologist asks the patient to give an account of the symptoms, how they began, and how they evolved over time. This is the History of Present Illness (HPI). The neurologist should always identify sources of information: Did the information come from direct interview of the patient or from secondhand reports? History taking often requires the neurologist to redirect the patient. For example, some patients use vague terms to describe their symptoms, and the examiner must be sure that they understand what the patient means. For example, patients may use the word “weakness” when they mean sensory disturbance. A host of symptoms can be encoded in the term “dizzy”; for example, some patients mean a spinning sensation of the room or of themselves, which is called vertigo, whereas others mean lightheadedness or a sensation of impending syncope. The precise sequence and timing of how the symptoms developed give key clues to the diagnosis. Another example of misleading history is when patients relate what diagnoses other clinicians have made, rather than what symptoms they experienced.
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