Take a history of neurological disease during a general physical examination

This is an automatically translated article.

The article was professionally consulted by Specialist Doctor II Ho Viet Le Diem - General Internal Medicine - Department of Examination & Internal Medicine - Vinmec Central Park International General Hospital.
Taking a complete and detailed neurological history is an essential starting point during a general physical exam. This is the foundation for ensuring that the mental health needs of people with a history of mental illness or those with underlying medical conditions are addressed.

1. Administrative information

The doctor should ask the patient for their name or the name they prefer to be called, to which the patient can answer without assistance. If the patient is a child or teen, the doctor may ask more about education.
In addition, the information to ask the patient about their marital status, occupation, religious beliefs and living situation is also essential, both to help the doctor get to know the patient and help them see open-heart more.

2. Reason for visiting

This is the most important problem or reason for a patient to see a neurologist. Some common reasons such as insomnia, anxiety, depression, fatigue... or negative intentions such as suicide.
Usually, this is recorded as the patient's own word and the doctor will note it in quotation marks. From this very reason, the doctor will establish the approach for each case. At the same time, this is also the prerequisite to solve the patient's treatment goals.

3. Neurological history in the patient

This is the main part of the visit, exploiting the whole story related to the reason for visiting. Patients should be encouraged to write according to their thoughts. The doctor should listen and avoid interruptions. However, when the patient feels that he has presented enough, the doctor should ask again what is unclear or incoherent before presenting it in the medical record. The doctor can read it back to the patient so that he or she can add details that have not yet been remembered. Specifically, the elderly often come to the doctor because of forgetfulness, confusion, sometimes accompanied by weakness in limbs; while in young people it is because of insomnia, anxiety, stress.
In most neurologic patient stories, the physician needs to uncover why the patient is seeking medical help at this time. This helps distinguish acute and chronic symptoms of neurologic changes, each with a different approach and treatment. Regardless of the condition, however, the clinician should remain neutral, not exhibiting appropriate positive and negative sentiment because these can be important aspects in determining the diagnosis and treatment. treatment in complex cases. Furthermore, recording important life events in the patient's history not only helps to identify the influence of the environment on their neurological disease, but also helps to establish a relationship with the patient.

4. Medical history

This section will list medical problems, both past and present, and all medical and surgical conditions. If the patient is seen only because of signs of neurological disease, the physician should also ask at least some related screening questions such as whether the patient has regular physical examination. Where possible, doctors should collect all of their patients' medical records instead of just relying on their statements.
In addition, even the smallest detail of a patient's medical history, from childhood, can play an important role in this neurological visit, such as falls. , head trauma, convulsions and loss of consciousness. All of these can cause physical damage to the nervous system and are related to current problems

5. Medication under treatment

List the patient's current medications, prescription and nonprescription, including dosage, duration taken, and whether the patient is compliant. If possible, the doctor should directly observe the drug that the patient is actually taking.
In addition, the doctor should also ask about past medications and look for signs of drug noncompliance or abuse. If this is the case, the patient should be encouraged to freely state the reason.

6. Past history of neurological disease

The physician should list all of the patient's past neurologic examinations and treatments, including outpatient, inpatient, and therapeutic treatment.
Of these, the psychotropic drugs the patient has taken in the past is an important predictor of what results they received. In addition, patients should also let their doctor know which medications have helped them feel most comfortable and satisfied in the past, and which medications have not been appropriate. From there, the doctor can plan the most suitable treatment regimen for neurological diseases, reducing adverse effects for the patient.

7. Family history

Doctors also dig up information about mental illness or similar medical problems for family members.
If at least one family member of the patient has been diagnosed with a similar mental illness, the physician should suspect an inherited neuropathy. Furthermore, if any drug is found to be effective for the patient's next of kin, it may become appropriate to treat the existing patient with the same drug.

8. Social history

Patients should be recorded with adequate social characteristics such as marital and life status. In addition, when asking about employment status, the doctor should pay attention to the patient's working capacity as well as the frequency of absences at work. In the event that the patient is not employed, ask if the patient is currently seeking employment; At the same time, the reason for losing the previous job also needs to be known.
For educational attainment, the physician should record the highest level achieved by the patient. If the child is a young child, the child should be told if he or she needs special education or has a learning disability or any other problem such as a hearing loss or speech problem. These issues are important in assessing patients with psychiatric and caregiving criteria because patients can be unwittingly at risk if they are not addressed.
In addition, the physician should also note characteristics of the patient's habits, including past and present use of tobacco, alcohol and drugs. This is important because many patients can become dependent on these substances.

9. Perinatal history and adolescent development

This is important for pediatric patients with neurological disease. The doctor needs to document any perinatal history, whether the baby was born prematurely, had a low birth weight, or had complications related to the birth. At the same time, the doctor needs to assess whether the development is appropriate for the age, in particular, it is necessary to ask the parents or caregivers at what age the child can speak the first word or take the first steps to make an assessment. suitable determination.

10. Exploring history of neurological disease during general health check-up at Vinmec

As the material life and level of knowledge are constantly improving, regular health check-ups are essential for everyone to have the opportunity to live longer and live healthier.
By proactively going for a general health check-up right before there are any abnormal signs, through visiting, examining and performing screening tests, doctors can help identify the early warning signs. Especially for mental illnesses, when detected at an early stage, treatment can be more effective, successful, and proactive in preventing unfortunate events.
Vinmec International General Hospital system deploys general health checkup packages and performs paraclinical tests suitable for each subject. Customers will be directly taken by the doctor to take personal and family medical history, measure blood pressure, body mass index, physical examination, perform screening tests as well as advice in each situation.
With a team of professional, highly qualified and experienced doctors, modern facilities, advanced testing machinery system, the periodic health check-up at Vinmec deserves to be an address. Reliable, world-class quality medical care for everyone and every family.
Doctor Ho Viet Le Diem has more than 10 years working in the Department of Resuscitation - Cardiac Surgery at Cho Ruong Hospital with the position of cardiologist and Open Heart Resuscitation. And has more than 03 years as a General Internal Medicine doctor at Family Medical Practice in Ho Chi Minh City. Currently, Dr. Diem is working at the Internal Medicine Department - Vinmec Central Park International General Hospital.

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