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Table of Contents
The ability to take a history from a patient presenting with a transientischaemicattack (TIA) or ischaemicstroke (referred to as stroke for the rest of the guide) is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a TIA or stroke history in an OSCE setting.
TIAs and ischaemic strokes are both caused by an interruption of blood supply to an area of the brain. The primary difference between a TIA and an ischaemic stroke is the duration of symptoms. The symptoms of a TIA fully resolve within 24 hours (typically within 30 minutes) whereas those of an ischaemic stroke do not.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
“Can you explain what you mean by a funny turn?”
In the context of a stroke or TIA, it’s important to pay attention to how the patient is communicating with you to identify neurological signs such as:
Dysarthria: a motor speech disorder resulting in poor articulation.
Dysphasia: a language disorder resulting in difficulties in the generation of speech (expressive dysphasia) or difficulties in the comprehension of speech (receptive dysphasia).
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Due to the nature of TIAs and strokes, it can be useful to first ask some simplequestions, 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
if the patient is able to understand you
if you are able to understand the patient
A collateralhistory is often very valuable in the context of suspected stroke or TIA, particularly when the patient is unable to communicate effectively.
The time at which the patient’s symptoms developed is very important as this helps to both differentiate between a TIA and stroke as well as informing management options (e.g. thrombolysis window).
Establish the onsettime of the patient’s symptoms:
“When did you first notice the symptom(s)?”
“How long have the symptom(s) been present?”
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. Make sure to ask the patient if they got up in the night for any reason (e.g. toilet) and if they noticed symptoms at that time, as this may make the difference between whether they are within the thrombolysis window or not.
Explore the severity of the patient’s symptoms:
Weakness: subtle (e.g. clumsy hand), moderate or complete paralysis.
Sensory disturbance: paraesthesia or complete loss of sensation.
Visual disturbance: roughly quantify how much of the visual field is affected.
Expressive dysphasia: clarify if the patient was able to speak at all.
Receptive dysphasia: clarify if the patient is able to understand any communication.
Dysarthria: ask if the patient’s speech was mildly slurred or incomprehensible.
Explore how the patient’s symptoms have evolved since their onset:
“Have the symptoms improved since they first began?”
“When were your symptoms at their worst?”
“Are the symptoms coming and going?”
Try to identify if there was an obvious trigger for the symptoms:
“What were you doing at the time that the symptoms developed?”
In cases of carotid artery dissection (a rare cause of ischaemic stroke), there may be a history of neck trauma. In most cases, however, there is no obvious precipitant.
Family history of stroke in first-degree relatives
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Musculoskeletal: trauma (secondary to fall), contractures (secondary to stroke)
Dermatological: pressure sores (secondary to immobility)
Past medical history
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
Make sure to ask about the medical conditions mentioned in the stroke/TIAriskfactors section.
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. cardiac valve surgery, carotid endarterectomy):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Ask if the patient has previously been diagnosed with a stroke or TIA:
Clarify when these episodes occurred and what neurological deficits the patient developed.
Clarify which investigations were performed and what treatment(s) the patient received.
Ask about residual neurological deficits to allow differentiation between acute and chronic deficits.
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medicationname, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any sideeffects from their medication:
“Have you noticed any side effects from the medication you currently take?”
Medications commonly prescribed to patients with stroke or TIA include:
Medications which increase the risk of ischaemic stroke include:
Combined oral contraceptive pill
Oral hormone replacement therapy
Ask the patient if there is any familyhistory of stroke or TIA:
“Do any of your parents or siblings have a history of strokes or TIAs?”
Clarify at what age the stroke or TIA occurred (disease developing at a younger age is more likely to be associated with genetic factors):
“At what age did your father suffer his first stroke?”
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:
“I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
“Do you remember what medical condition was felt to have caused his death?”
Explore the patient’s socialhistory to both understand their socialcontext and identify potential cardiovascular/cerebrovascular risk factors.
General social context
Explore the patient’s general social context including:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
if they have any carer input (e.g. twice daily carer visits)
Record the patient’s smokinghistory, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk profile:
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Recreational drug use
Ask the patient if they use recreationaldrugs and if so determine the type of drugs used and their frequency of use. Recreational drugs can precipitate strokes in rare cases (e.g. cerebral vasospasm).
Ask if the patient what their diet looks like on an averageday. Take note of unhealthyfoods which are known to contribute to cardiovascular/cerebrovascular disease (e.g. high salt intake, high saturated fat intake).
Ask if the patient regularly exercises (including frequency and exercise type).
Ask about the patient’s current occupation:
Assess the patient’s level of activity in their occupation (sedentary jobs are associated with increased cardiovascular risk).
If the patient is experiencing TIAs it is important to advise them to take time off work until they have been fully investigated, particularly if working at heights or with heavy machinery.
If the patient drives and has presented with TIAs or stroke it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues. A TIA or stroke may result in temporary or permanent restrictions on the patient’s ability to continue driving (this will depend on the clinical features of the episode and residual neurological deficits).
Closing the consultation
Summarise the keypoints back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.