Being able to take a thorough history of a transient ischaemic attack (TIA) or stroke is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough history. Check out the stroke and TIA history taking mark scheme here.
TIAs and strokes both occur when the blood supply to the brain is interrupted. The difference occurs in the definition of the timing: A stroke produces symptoms that last for at least 24 hours, whereas symptoms produced by a TIA are transient (less than 24 hours), usually resolving fully within 30 minutes.
Opening the consultation
Introduce yourself – name/role
Confirm patient details – name/DOB
Explain the need to take a history
Ensure the patient is comfortable
A collateral history is often very valuable in the context of suspected stroke or TIA, particularly when the patient is unable to communicate effectively.
It’s important to use open questioning to elicit the patient’s presenting complaint “So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required. “Ok, so tell me more about that” “Can you explain what you mean by ‘funny turn?”
In the context of stroke/TIA it’s also important to pay attention to how the patient is communicating:
Do they have good articulation?
Is there evidence of dysphasia?
Is there evidence of dysarthria?
History of presenting complaint
Due to the nature of TIAs and strokes, it may be useful to first ask some orientation questions, such as the patient’s age, the month and what they believe your job role to be. This can enable you to quickly establish if the patient is orientated and help gauge how reliable the history is likely to be.
Onset of symptom(s):
When did the symptom start? (date and time)
Was the onset acute or gradual?
It is essential to get an accurate onset time of symptoms:
This can help differentiate between TIA and stroke as discussed above
If the patient is having an ischaemic stroke then this information is key in deciding if they are within the therapeutic window for thrombolysis
If a patient has woken up with symptoms (but had none before going to sleep) the onset time is assumed to be when they went to sleep
Duration of symptom(s): minutes/hours/days/weeks/months/years
Weakness: Try to clarify how weak (e.g. subtle, moderate, complete paralysis)
Sensory disturbance: Was the arm completely numb or did it just feel different to normal?
Visual disturbance: How much of the vision was affected? Was vision blurred or completely lost?
Expressive dysphasia: Was the patient able to speak at all?
Receptive dysphasia: Was the patient able to understand any communication?
Dysarthria: Was the patient’s speech mildly slurred or incomprehensible?
Course: Is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous: Is the symptom always present or does it come and go?
Precipitating factors: Was there any obvious triggers for the symptom?
Relieving factors: Does anything appear to improve the symptom?
Associated features: Are there other symptoms that appear associated? (e.g. headache/nausea/vomiting/neck stiffness)
Has the patient experienced this symptom previously?
How many previous episodes?
Ask the patient what their dominant hand is (useful to know before clinical examination)
Ask about any recent head or neck trauma (important if considering intracranial bleeding or carotid dissection)
Key stroke and TIA symptoms
Onset and duration of weakness?
Location of the weakness? (e.g. lower limb, upper limb, face)
Severity of the weakness? (e.g. subtle, struggling with holding a cup, completely flaccid)
Mobility: Is the patient still able to independently mobilise?
Check when the episodes occurred and what deficits the patient developed (e.g. sensory disturbance, weakness, visual disturbance)
Clarify what investigations they underwent and what treatment they received
Ask about residual deficits (e.g. after stroke) as it is useful to know the patient’s baseline function to accurately interpret current clinical findings
Previous similar episodes – clarify frequency of episodes and symptoms experienced
Other neurological conditions – useful to be aware of as the patient may have pre-existing neurological deficits as a result (e.g. multiple sclerosis)
Recent trauma to the head or neck – useful when considering intracranial bleeding and carotid dissection
Other medical conditions– clarify what other medical conditions the patient has, as they may be relevant when considering treatment options for stroke or TIA
Cardiac surgery (e.g. valve replacement)
Antiplatelets or anticoagulant medication:
Other regular medications:
Cholesterol-lowering agents (e.g. statins)
Combined oral contraceptive pill
ALLERGIES – document these clearly
Stroke or TIA in first-degree relatives?
Cardiovascular disease in first-degree relatives?
Clarify the age at which these conditions affected the patient’s family member
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type/volume/strength of alcohol
Recreational drug use – e.g. cocaine/amphetamines
Exercise – baseline level of the patient’s day to day activity
Type of accommodation – adaptations/stairs
Who lives with the patient?
Is the patient supported at home?
Activities of daily living:
Is the patient independent and able to fully care for themselves?
Can they manage self-hygiene/housework/food shopping?
Does the patient have any carer input? (clarify the level of care)
Does the patient use any mobility aids? (e.g. stick/wheelchair/frame)
Occupation – important to be aware of as the stroke or TIA may have implications on their ability to work safely (e.g. if they drive for work/works at height)
If the patient drives then a TIA or stroke may result in temporary or permanent restrictions on their ability to continue driving (this will depend on the clinical features of the episode and residual deficits)
Clarify the type of vehicle the patient drives, as heavy goods vehicles (HGVs) have different requirements
A thorough history will also include a systemic enquiry. This can be helpful when considering other possible causes for the patient’s presentation (e.g. infections, inner ear problems, psychomotor problems, hypoglycaemia, seizures and cardiac syncope). It can also pick up on other problems the patient might be experiencing. Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.