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?
- What frequency?
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?
- Is the weakness getting worse or better?
- Onset and duration of sensory disturbance?
- Location of the sensory disturbance?
- Severity of sensory disturbance? (e.g. completely numb, tingling, feeling slightly different)
- Onset and duration of visual disturbance?
- Type of visual disturbance? (e.g. vertigo/heminopia/quadrantopia/amaurosis fugax)
- Does the patient feel their balance is poor?
- Are they bumping into walls and door frames? (also consider visual field loss)
- Does the patient think any of their limbs feels more clumsy?
- Is the patient experiencing vertigo? (room spinning around them)
- Clarify type of speech disturbance:
- Expressive dysphasia “I knew what I wanted to say, but I couldn’t get it out”
- Receptive dysphasia “I wasn’t able to understand anyone, they were speaking jibberish”
- Dysarthria “My speech was really slurred, it sounded like I was drunk”
Swallowing problems (dysphagia)
- Has the patient has noticed any problems swallowing fluids or food? (e.g. coughing/choking)
- Dysphagia is common in stroke and if not recognised can lead to aspiration pneumonia and choking
- Has the patient experienced headache during this episode?
- Did the headache start before or after the onset of other symptoms?
- Clarify the type of headache:
- Thunderclap – subarachnoid haemorrhage
- Unilateral – consider migraine (hemiplegic migraine is a stroke mimic)
- Generalised headache worse when lying down – consider raised intracranial pressure (e.g. haemorrhagic stroke)
- In the context of stroke consider either raised intracranial pressure (e.g. haemorrhagic stroke) or posterior circulation ischaemic stroke (POCS)
Reduced level of consciousness
- Consider raised intracranial pressure (e.g. haemorrhagic stroke or malignant middle cerebral artery syndrome)
- Consider seizures which can occur in the context of haemorrhagic strokes and ischaemic strokes
If pain is a symptom, clarify the details of the pain using SOCRATES
- Site: Where is the pain?
- Onset: When did it start? / Sudden or gradual?
- Character: Sharp / dull ache / burning
- Radiation: Does the pain move anywhere else?
- Associations: Are there any other symptoms associated with the pain?
- Time course: Worsening / improving / fluctuating / time of day dependent
- Exacerbating/Relieving factors: Anything make the pain better or worse?
- Severity: On a scale of 0-10, how severe is the pain?
Major stroke risk factors
- Ischaemic heart disease
- Atrial fibrillation
- Previous stroke or TIA
- Excessive alcohol intake
- Family history of stroke in first-degree relatives
Ideas, Concerns and Expectations
Ideas: What are the patient’s thoughts regarding their symptoms?
Concerns: Explore any worries the patient may have regarding their symptoms
Expectations: Gain an understanding of what the patient is hoping to achieve from the consultation
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
- What you plan to cover next – “Now I’d like to discuss your past medical history, a bit about health conditions in your family, your day to day life, and your medications”
Past medical history
Stroke risk factors:
- Ischaemic heart disease
- Atrial fibrillation
- Previous stroke or TIA
- Excessive alcohol intake
- Hypercoagulable disease (e.g. sickle cell anaemia, polycythemia vera)
- Prosthetic heart valves
- Carotid stenosis
- Poor ventricular function
- Migraine with aura
Previous stroke or TIA:
- 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
- Carotid surgery
- 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.
- Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
- Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
- GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Abdominal pain / Bowel habit / Weight loss
- Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
- CNS – Anxiety/ Stress/ Headaches/ Weakness / Numbness/ Pain/ Tingling / Loss of consciousness/Confusion
- Musculoskeletal – Bone and joint pain / Muscular pain
- Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
Thank the patient
Summarise the history
Document your findings
Move on to examination and investigations