What should be included in a comprehensive neurological History of Present Illness (HPI)?

Comprehensive Neurological History of Present Illness (HPI)

A comprehensive neurological HPI should include detailed characterization of symptoms, temporal factors, severity assessment, contextual features, impact on daily function, and relevant risk factors to establish an accurate baseline for diagnosis and treatment planning. 1, 2

Essential Components

Chief Complaint and Symptom Characterization

• Document the nature of primary neurological symptoms with specific descriptions rather than vague terms (e.g., "right-sided weakness with 3/5 strength in upper extremity" rather than just "weakness") 1, 2
• Record subjective symptoms including cognitive and behavioral symptoms, gait problems, tremor, balance issues, swallowing difficulties, incontinence, and pseudobulbar affect 1
• Document the presence or absence of related symptoms that may help establish a neurological pattern or syndrome 2

Temporal Factors

• Establish the precise time of symptom onset - for stroke patients, document the "last known well time" as this is the single most important determinant of treatment options 1
• Document the frequency, duration, and progression or changes in symptoms over time 2
• For episodic symptoms (like seizures or transient neurological deficits), record the sequence and pattern of events 1

Severity Assessment

• Quantify the intensity of symptoms using appropriate scales (e.g., NIH Stroke Scale for stroke patients, Glasgow Coma Scale for altered consciousness) 1
• Document functional limitations resulting from symptoms 1, 2

Contextual Features

• Explore relationships between symptoms and potential triggers, exacerbating factors, and alleviating factors 1, 2
• Document any circumstances surrounding symptom onset (e.g., activity at time of onset, environmental factors) 1

Impact Assessment

• Evaluate how symptoms affect activities of daily living, functional status, interpersonal relationships, and quality of life 1, 2
• Document any need for assistance or adaptive equipment 1

Risk Factor Assessment

Vascular Risk Factors

• Document history of hypertension, hyperlipidemia, diabetes mellitus, smoking status, alcohol use, and physical activity level 1
• Record history of cardiovascular disease including myocardial infarction, arrhythmia/atrial fibrillation, congestive heart failure, and peripheral arterial disease 1
• Document history of cerebrovascular disease including prior strokes (hemorrhagic or ischemic), transient ischemic attacks, and carotid interventions 1

Other Relevant Medical History

• Document history of migraine, sleep disorders, hypercoagulable states, chronic infections, autoimmune diseases, and depression 1
• Record history of surgeries, particularly noting any cognitive difficulties that arose after surgery 1
• Document complete medication list including over-the-counter preparations 1

Family History

• Document history of stroke, vascular disease, dementia, and other neurological diseases in first-degree relatives 1
• Record age of onset for relevant family conditions 1

Special Considerations for Specific Neurological Presentations

For Cognitive/Behavioral Symptoms

• Obtain information from both patient and reliable informant (care partner) to ensure accuracy 1, 2
• Document changes in memory, speed of thinking, behavior, mood, and daily function 1
• Assess impact on interpersonal relationships, personal and public safety, and need for care partner support 1

For Stroke Symptoms

• Document handedness to estimate hemispheric dominance 1
• Record exact dates and times of symptom onset, presentation to medical care, and treatment initiation 1
• For hemorrhagic events, document the degree of intracranial hemorrhage and associated neurological deterioration 1

For Seizures

• Document detailed description of seizure activity, including any aura, loss of consciousness, automatisms, postictal state, and recovery time 1
• Record any history of prior seizures and their characteristics 1

Physical Examination Elements to Include in HPI

• Document vital signs including blood pressure (consider orthostatic measurements), heart rate, height, weight, and waist circumference 1
• Include findings from the NIH Stroke Scale, timed gait assessment, motor examination, reflex testing, and Babinski sign evaluation 1
• Document mental status examination findings, particularly components aimed at capturing vascular contributions to cognitive impairment 1

Common Pitfalls to Avoid

• Overlooking the functional impact of symptoms can lead to missed diagnoses; always document effect on daily activities 1, 2
• Neglecting to obtain the "last known well time" in potential stroke patients can limit treatment options 1
• Missing relevant risk factors can lead to inaccurate diagnosis and management 1, 2
• Failing to integrate information from both patient and informant for cognitive/behavioral symptoms 1

Documentation Best Practices

• Include specific examples of how symptoms manifest in the patient's life 2
• Document relevant negative findings that help rule out differential diagnoses 2
• Conclude with a clear summary of the primary neurological concerns and their impact on the patient 2
• Use standardized assessment tools when appropriate (e.g., NIH Stroke Scale, Glasgow Coma Scale) 1