Introduction
Greet the patient and explain why you are there and what you are about to do.
Chief Complaint
- Ask the patient: “What brings you to the clinic today? Can you describe your main concern or symptoms?”
- Listen carefully to the patient’s response and note down their chief complaint.
History of Present Illness (HPI)
Explore the details of the patient’s symptoms:
- Onset: When did the symptoms start?
- Duration: How long have they been experiencing these symptoms
- Progression: Have the symptoms changed over time?
- Aggravating or Alleviating Factors: What makes the symptoms worse or better
- Associated Symptoms: Are there any other symptoms accompanying the main complaint?
Past Medical History (PMH)
- Ask about any relevant medical conditions, surgeries, hospitalizations, or chronic illnesses. Pay attention on the medical condition which are considered risk factors for neurological diseases.
- Inquire about allergies, medications, and immunizations.
Medications
List the patient’s current medications and their dosages. Ask for any recently discontinued medications.
Social History
Ask about the patient’s occupation, living situation, hobbies, and any substance use (e.g., alcohol, tobacco, recreational drugs).
Family History
Inquire about any neurological conditions or relevant diseases in the patient’s family.
Review of Systems (ROS)
Systematically ask about symptoms related to various body systems:
- General: Fatigue, weight changes, fever
- Neurological: Headaches, dizziness, weakness, numbness, tingling, changes in senses, stiffness, tremor, pain
- Musculoskeletal: Joint pain, muscle weakness
- Cardiovascular: Chest pain, palpitations
- Gastrointestinal: Nausea, vomiting, bowel changes
- Respiratory: Shortness of breath, cough
- Psychiatric: Anxiety, depression, sleep disturbances
Neurological Examination
Perform a focused neurological examination:
- Mental Status: Assess orientation, memory, attention, and language.
- Cranial Nerves: Evaluate each cranial nerve function.
- Motor System: Check muscle strength, tone, and coordination.
- Sensory System: Test sensation (light touch, pinprick, vibration).
- Reflexes: Assess deep tendon reflexes (e.g., knee jerk, biceps reflex).
- Coordination: Observe gait, finger-nose-finger test, heel-to-shin test.
STOP! As a medical student after performing the investigation given above, you will be able to make a differential diagnosis, workout and treatment plan BUT DO NOT DISCUSS your plan with the patient and do not comment on the diagnosis or treatment they will share with you. Instead check your understanding and ideas with a specialist. Use this opportunity to prepare yourself for the time when you will be the treating physician.
Differential Diagnosis
Generate a list of potential diagnoses based on the patient’s symptoms and examination findings.
Additional Investigations
Consider any necessary tests (e.g., blood work, EEG, EMG, echography, imaging, lumbar puncture) to further evaluate the patient.
Plan Develop a management plan:
- Treatment: Consider symptomatic relief, disease-specific therapies options.
- Referrals: If needed, refer to a specialist (e.g., neurosurgeon, ophtalmologist, otorhinolaryngologist, rheumatologist, endocrinologist).
- Follow-up.
Remember to **maintain empathy**, actively listen to the patient, and adapt the interview based on their responses. 
Verified by Dr. Petya Stefanova
