Plan of the case history in Neurology

1. Passport part.
1.1.Last name, first name.
1.2.Age (date of birth).
1.3.Address
1.4.Occupational status.
1.5.Date of admission.
1.6.Way of admission.
2. The "chief complaint (CC)" – the major health problem or concern, and its time course.
3. History of the present illness (HPI).
4. Past medical history (PMH) (including major illnesses, any previous surgery/operations
(sometimes distinguished as past surgical history or PSH), any current ongoing illness,
e.g. diabetes).
5. Family diseases – especially those relevant to the patient's chief complaint.
6. Social history– including living arrangements, occupation, marital status, number of
children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign
travel, and exposure to environmental pathogens through recreational activities or pets.
7. Regular and acute medications (including those prescribed by doctors, and others
obtained over-the-counter or alternative medicine).
8. Allergies – to medications, food, latex, and other environmental factors
9. Sexual history, obstetric/gynecological history, and so on, as appropriate.
10. Physical examination.
10.1. Brief overview of organs and systems (general appearance, skin, cardiovascular,
respiratory, digestive, urinary, locomotor, endocrine systems).
10.2. Neurological exam

Mental status

Level of consciousness

Orientation

Language — fluency, comprehension, repetition, naming, reading, writing

Memory and higher intellectual functions

Mood

Cranial nerves

I CN

II CN

III, IV, VI CN

V CN

VII CN
VIII CN

IX, X, XII CN

XI CN

Motor system

Bulk (muscle mass)

Tone

Strength

Tendon reflexes

Pathological reflexes

Sensory system

Pain and temperature

Proprioception

Coordination

Finger-to-nose test

Rapid alternating movements

Romberg’s Test

Station and gait

Meningeal signs

11. List of differential diagnosis.

12. Syndromological diagnosis (specific sets of symptoms and signs)
13. Topical (lesion location in nervous system)
14. Aetiological diagnosis (relates the topical diagnosis, to a specific disease pattern, disease
history and auxiliary investigations).
15. Follow-up notes.
16. Management plan.
17. Prognosis.