• Name:
• Age/Sex:
• Informant:
- Name: _______
⸻
Chief Complaints
• Chief complaints in chronological order with duration.
History of Presenting Illness (HOPI)
Headache
• Present / Absent
• Duration: ______________________________
• Onset: Sudden / Gradual
• Course: Progressive / Non-progressive
• Site: Frontal/ Temporal/ Occipital/ Parietal/ Holocranial/ Retro-orbital/ Other:____
• Character: Throbbing/ Dull aching/ Bursting/ Stabbing/ Band-like/ Other:___
• Severity: _____/10
• Aggravating Factors: Coughing/ Sneezing/ Bending forward/ Bright light/ Loud sounds/ Exertion/ Stress
• Relieving Factors: Rest/ Sleep/ Analgesics/ Vomiting
• Associated Symptoms: Nausea/ Vomiting/ Photophobia/ Phonophobia/ Fever/ Visual disturbances/ Seizures/ Altered consciousness
⸻
Loss of Consciousness (LOC)
• Present / Absent
• Duration since:
• Number of episodes:
• Duration of each episode:
• Recovery: Spontaneous/ Required intervention
Associated Features
• Tongue bite
• Urinary incontinence
• Abnormal limb movements
• Postictal confusion
• Palpitations
• Chest pain
• Trauma
⸻
Seizures
• Present / Absent
• Duration since :
• Type: Generalized/ Focal
• Character: Tonic-clonic/ Absence/ Myoclonic/ Other: _____
• Duration of episodes:
• Aura: Visual/ Auditory/ Olfactory/ Sensory
• Tongue bite
• Urinary incontinence
• Frothing from mouth
• Post-ictal confusion
• Previous episodes
• Compliance with antiepileptic drugs
⸻
Weakness of Limbs
• Present / Absent
• Duration: ______________________________
• Distribution: Right upper limb/ Left upper limb/ Right lower limb/ Left lower limb/ Both upper limbs/ Both lower limbs/ All four limbs
• Onset: Sudden/ Gradual
• Course: Progressive(Ascending/descending)/ Non-progressive
• Pattern: Proximal/ Distal
• Associated Features
- Difficulty walking
- Difficulty climbing stairs
- Difficulty combing hair
- Difficulty holding objects
- Facial deviation
- Speech difficulty
- Sensory symptoms
⸻
Sensory Symptoms
• Present / Absent
• Nature: Numbness/ Tingling/ Burning sensation/ Pins-and-needles sensation/ Loss of sensation
• Distribution: One limb/ One side of body/ Glove-and-stocking distribution/ Dermatomal distribution
⸻
Speech Disturbance
• Present / Absent
• Slurring of speech
• Inability to speak
• Difficulty understanding speech
• Difficulty naming objects
⸻
Cranial Nerve Symptoms
• Facial deviation
• Double vision (Diplopia)
• Blurring of vision
• Loss of vision
• Hearing loss
• Difficulty swallowing
• Nasal regurgitation
• Hoarseness of voice
• Facial numbness
• Loss of smell
• Loss of taste
⸻
Gait and Balance
• Difficulty walking: Present / Absent
• Frequent falls: Present / Absent
• Swaying while walking: Present / Absent
• Inability to stand: Present / Absent
History of
• Tremors
• Stiffness
• Slowing of movements
• Involuntary movements
⸻
Memory and Higher Mental Functions
• Forgetfulness
• Personality changes
• Altered behaviour
• Confusion
• Hallucinations
• Poor concentration
• Impaired judgment
⸻
Visual Symptoms
• Blurring of vision
• Double vision
• Transient vision loss
• Visual field defects
• Photophobia
⸻
Bladder and Bowel Involvement
• Urinary retention
• Urinary incontinence
• Constipation
• Fecal incontinence
• Erectile dysfunction
⸻
Constitutional Symptoms
• Fever
• Weight loss
• Anorexia
• Fatigue
• Night sweats
• Altered sensorium
⸻
History Suggestive of Stroke
• Sudden onset weakness
• Facial deviation
• Slurred speech
• Difficulty swallowing
• Sudden vision loss
• Altered consciousness
• Hypertension
• Diabetes mellitus
• Atrial fibrillation
• Previous stroke/TIA
⸻
History Suggestive of Epilepsy
• Recurrent seizures
• Aura
• Tongue bite
• Urinary incontinence
• Postictal confusion
• Family history of epilepsy
• Drug compliance
⸻
History Suggestive of Parkinson Disease
• Resting tremor
• Bradykinesia
• Rigidity
• Shuffling gait
• Mask-like facies
• Postural instability
⸻
History Suggestive of Meningitis
• Fever
• Severe headache
• Neck stiffness
• Vomiting
• Photophobia
• Altered consciousness
• Seizures
⸻
History Suggestive of Raised Intracranial Pressure
• Early morning headache
• Projectile vomiting
• Blurring of vision
• Diplopia
• Altered sensorium
• Seizures
⸻
Past History
Previous history of:
• Stroke/TIA
• Epilepsy
• Hypertension
• Diabetes mellitus
• Tuberculosis
• Meningitis
• Head injury
• Brain tumor
• Migraine
• Parkinson disease
• Multiple sclerosis
• Other neurological illness:
⸻
Previous Interventions/Hospitalizations
• Previous hospital admissions
• ICU admission
• Neurosurgery
• Blood transfusion
• Rehabilitation therapy
⸻
Drug History
History of use of:
• Antiepileptic drugs
• Antiplatelets
• Anticoagulants
• Antihypertensives
• Steroids
• Anti-Parkinsonian medications
• Other medications: ______________
• Drug allergy: Present / Absent
⸻
Treatment History
Previous investigations:
• CT Brain
• MRI Brain
• EEG
• Lumbar puncture
• Nerve conduction study (NCS)
• Electromyography (EMG)
• Carotid Doppler
• Other investigations: ______________
Previous treatment:
• Thrombolysis
• Thrombectomy
• Neurosurgery
• Rehabilitation therapy
• Other treatment: ______________
⸻
Personal History
• Appetite: Normal / Reduced
• Diet: Vegetarian / Mixed
• Sleep: Adequate / Disturbed
• Bowel habits: Normal / Abnormal
• Bladder habits: Normal / Abnormal
⸻
Addiction History
• Smoking: Present / Absent
• Alcohol intake: Present / Absent
• Tobacco chewing: Present / Absent
• Substance abuse: Present / Absent
Details (Smoking: Pack year/Smoking index, Alcohol details, etc)
Family History
History / No history of:
• Stroke
• Epilepsy
• Migraine
• Parkinson disease
• Dementia
• Neuromuscular disorders
• Hereditary neurological diseases
• Pedigree suggestive of inherited neurological disorder: Yes / No
Mr./Mrs. ______, a __-year-old Male/Female, resident of ______, education status ______, working as a ______, presented to OPD/Emergency with complaints of __________ for the past _____ days/months/years.
The patient was apparently asymptomatic until _____ ago when he/she developed headache, which was sudden/gradual in onset and progressive/non-progressive in nature. The headache was localized to the frontal, temporal, occipital, parietal, holocranial, or retro-orbital region and was throbbing, dull aching, bursting, stabbing, or band-like in character. Severity was ___/10.
The headache was aggravated by coughing, sneezing, bending forward, bright light, loud sounds, exertion, or stress and relieved by rest, sleep, analgesics, or vomiting. It was associated with nausea, vomiting, photophobia, phonophobia, fever, visual disturbances, seizures, or altered consciousness.
- Sudden "thunderclap" headache → Subarachnoid hemorrhage
- Early morning headache with vomiting → Raised intracranial pressure (ICP)
- Throbbing unilateral headache with photophobia → Migraine
- Band-like headache → Tension headache
- Headache with fever and neck stiffness → Meningitis
The patient experienced/did not experience loss of consciousness since _____ days / ___ days ago. If present, it was sudden/gradual in onset, lasting _____ minutes, complete/partial, with spontaneous recovery or requiring intervention. Associated features included tongue bite, urinary incontinence, abnormal limb movements, postictal confusion, palpitations, chest pain, or trauma.
- Transient LOC with rapid recovery → Syncope
- LOC with tongue bite and postictal confusion → Generalized seizure
- Progressive drowsiness → Raised ICP, encephalopathy
The patient developed/did not develop seizures since _____. Episodes were generalized/focal, tonic-clonic/absence/myoclonic, lasting _____ minutes. History/No history of aura (visual, auditory, olfactory, sensory), tongue bite, urinary incontinence, frothing from mouth, and postictal confusion. Frequency of attacks was _____. Compliance with antiepileptic drugs and previous episodes were assessed.
- Focal seizure progressing to generalized seizure → Structural brain lesion
- Recurrent generalized seizures → Epilepsy
- New-onset seizure in elderly → Stroke, brain tumor
The patient developed weakness of bilateral/unilateral ___ limb since _____. It was sudden/gradual in onset, progressive/non-progressive, involving the right/left upper limb, lower limb, both upper limbs, both lower limbs, or all four limbs. Weakness was proximal/distal, associated with difficulty walking, climbing stairs, combing hair, holding objects, facial deviation, speech difficulty, or sensory symptoms.
- Sudden hemiparesis → Stroke
- Ascending weakness → Guillain–Barré syndrome
- Progressive symmetrical proximal weakness → Myopathy
- Quadriparesis → Cervical cord lesion
The patient complained/did not complain of numbness, tingling, burning sensation, pins-and-needles sensation, or loss of sensation. Symptoms involved one limb, one side of the body, glove-and-stocking distribution, or dermatomal distribution.
- Glove and stocking sensory loss → Peripheral neuropathy
- Dermatomal sensory loss → Radiculopathy
- Hemisensory loss → Stroke
The patient developed/did not develop slurring of speech, inability to speak, difficulty understanding speech, or difficulty naming objects.
- Stroke
- Aphasia
- Dysarthria
- Space-occupying lesion
History/No history of facial deviation, double vision (diplopia), blurring/loss of vision, hearing loss, difficulty swallowing, nasal regurgitation, hoarseness of voice, facial numbness, loss of smell, or loss of taste.
- Facial deviation with limb weakness → Stroke
- Diplopia with ptosis → Myasthenia gravis
- Difficulty swallowing → Bulbar palsy
The patient complained/did not complain of difficulty walking, imbalance, frequent falls, swaying while walking, or inability to stand. History of tremors, stiffness, slowing of movements, or involuntary movements was elicited.
- Shuffling gait → Parkinson disease
- Ataxic gait → Cerebellar lesion
- Spastic gait → Upper motor neuron lesion
- High-stepping gait → Peripheral neuropathy
The patient developed/did not develop forgetfulness, personality changes, altered behaviour, confusion, hallucinations, poor concentration, or impaired judgment.
- Dementia
- Delirium
- Frontal lobe lesion
- Encephalopathy
No history/History of blurring of vision, double vision, transient vision loss, visual field defects, and photophobia.
- Transient monocular blindness → Transient ischemic attack
- Bitemporal hemianopia → Pituitary tumor
- Homonymous hemianopia → Stroke
History/No history of urinary retention, urinary incontinence, constipation, fecal incontinence, or erectile dysfunction.
- Spinal cord lesion
- Cauda equina syndrome
- Multiple sclerosis
Fever, weight loss, anorexia, fatigue, night sweats, and altered sensorium were present/absent.
- Fever with headache and neck stiffness → Meningitis
- Weight loss with focal neurological deficit → Brain tumor
- Altered sensorium with fever → Encephalitis
- Sudden onset weakness
- Facial deviation
- Slurred speech
- Difficulty swallowing
- Sudden vision loss
- Altered consciousness
- Hypertension
- Diabetes
- Atrial fibrillation
- Previous stroke/TIA
- Recurrent seizures
- Aura
- Tongue bite
- Urinary incontinence
- Postictal confusion
- Family history
- Drug compliance
- Resting tremor
- Bradykinesia
- Rigidity
- Shuffling gait
- Mask-like facies
- Soft voice
- Postural instability
- Fever
- Severe headache
- Neck stiffness
- Vomiting
- Photophobia
- Altered consciousness
- Seizures
- Early morning headache
- Projectile vomiting
- Blurring of vision
- Diplopia
- Altered sensorium
- Seizures
Past History:No previous history/ history of stroke/TIA, epilepsy, hypertension, diabetes, tuberculosis, meningitis, head injury, brain tumor, migraine, Parkinson disease, or multiple sclerosis. No History of previous hospitalizations, neurosurgery, ICU admission, or blood transfusion.
Drug History:History/ No history of use of antiepileptic drugs, antiplatelets, anticoagulants, antihypertensives, steroids, or anti-Parkinsonian medications. No history of any drug allergy.
Treatment History: Previous CT/MRI brain, EEG, lumbar puncture, nerve conduction study, EMG, carotid Doppler, neurosurgery, thrombolysis, thrombectomy, or rehabilitation.
Personal History:His/her Appetite is normal/reduced. He/She is Vegetarian/Consumes mixed diet. Sleep is adequate/disturbed. History/No history of smoking, alcohol intake, tobacco chewing, or substance abuse.
Family History:No family history of Stroke, epilepsy, migraine, Parkinson disease, dementia, neuromuscular disorders, or hereditary neurological diseases.
Mr./Ms. ______, a __-year-old individual, presented with mild headache for ___ days without history of seizures, limb weakness, sensory deficits, speech disturbance, altered consciousness, visual symptoms, or significant neurological illness, suggestive of a benign primary headache disorder.
Mr./Ms. ______, a __-year-old hypertensive/diabetic individual, presented with sudden onset right/left-sided weakness, facial deviation, slurring of speech, and difficulty walking without preceding trauma, suggestive of an acute cerebrovascular accident (ischemic stroke).
Mr./Ms. ______, a __-year-old individual, presented with recurrent generalized tonic-clonic seizures associated with tongue bite, urinary incontinence, and postictal confusion, suggestive of epilepsy.
Mr./Ms. ______, a __-year-old individual, presented with high-grade fever, severe headache, repeated vomiting, neck stiffness, photophobia, and altered sensorium, suggestive of acute meningitis.
Mr./Ms. ______, a __-year-old individual, presented with progressively worsening early morning headache, projectile vomiting, blurring of vision, seizures, and focal neurological deficits, suggestive of raised intracranial pressure secondary to an intracranial space-occupying lesion.
Mr./Ms. ______, a __-year-old individual, presented with gradually progressive resting tremor, bradykinesia, rigidity, shuffling gait, and postural instability, suggestive of Parkinson disease.
Mr./Ms. ______, a __-year-old individual, presented with rapidly progressive ascending symmetrical weakness of both lower limbs progressing to the upper limbs following a recent febrile illness, with absent bladder involvement initially, suggestive of Guillain–Barré syndrome.
