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11/13/24, 8\:12 PM Guide | Stroke & TIA history

Stroke & TIA history

Table of contents

Introduction

The ability to take a history from a patient presenting with a transient ischaemic attack (TIA) or ischaemic stroke (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 di
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.
Con
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 o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
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Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t y o u m e a n b y a f u n n y t u r n ?"
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 di
comprehension of speech (receptive dysphasia).
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
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 di

History of presenting complaint

Due to the nature of TIAs and strokes, it can be useful to
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 collateral history is often very valuable in the context of suspected stroke or TIA, particularly when the patient is unable to
communicate e
Onset
The time at which the patient's symptoms developed is very important as this helps to both di
stroke as well as informing management options (e.g. thrombolysis window).
Establish the onset time of the patient's symptoms\:
" W h e n d i d y o u
" H o w l o n g h a v e t h e s y m p t o m ( s ) b e e n p r e s e n t ?"
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 di
Severity
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
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.
Course
Explore how the patient's symptoms have evolved since their onset\:
" H a v e t h e s y m p t o m s i m p r o v e d s i n c e t h e y
" W h e n w e r e y o u r s y m p t o m s a t t h e i r w o r s t ?"
" A r e t h e s y m p t o m s c o m i n g a n d g o i n g ?"
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Precipitating factors
Try to identify if there was an obvious trigger for the symptoms\:
" W h a t w e r e y o u d o i n g a t t h e t i m e t h a t t h e s y m p t o m s d e v e l o p e d ?"
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.
Associated features
Ask about other associated symptoms including\:
Headache, nausea, vomiting, neck sti
artery syndrome), subarachnoid haemorrhage and bacterial meningitis.
Unilateral headache\: suggestive of migraine which can present with neurological symptoms that mimic stroke (e.g.
hemiplegic migraine).
Fevers\: may indicate infective aetiology such as septic emboli in infective endocarditis.
Nausea, vomiting and dizziness\: associated with posterior circulation strokes.
Palpitations\: associated with atrial
Previous episodes
Ask if the patient has experienced similar symptoms previously\:
" H a v e y o u e v e r e x p e r i e n c e d a n y t h i n g l i k e t h i s b e f o r e ?"
" H o w m a n y t i m e s h a v e y o u e x p e r i e n c e d t h e s e s y m p t o m s ?"
" H o w l o n g d i d t h e y t a k e t o r e s o l v e p r e v i o u s l y ?"
" W h e n w a s t h e l a s t e p i s o d e ?"
Patients presenting with a stroke may have experienced TIAs in the preceding days, weeks or months.
Dominant hand
Ask the patient what their dominant hand is\:
" W h a t' s y o u r d o m i n a n t h a n d ?"
It is useful to know this prior to performing clinical examination.

Stroke and TIA symptoms

Once you have completed exploring the history of presenting complaint, you need to move on to more focused questioning
relating to the symptoms associated with stroke and TIA.
We have included a focused list of the key symptoms to ask about when taking a stroke/TIA history, followed by some further
information on each, should you want to know a little more.
Key TIA/stroke symptoms
Key symptoms that may be associated with strokes and TIAs include\:
Weakness
Sensory disturbance
Visual disturbance
Speech disturbance
Ataxia
Dysphagia
Reduced level of consciousness
Pain
Weakness
Ask the patient if they have noticed any weakness\:
" H a v e y o u n o t i c e d a n y n e w w e a k n e s s ?"
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Gather more details about the weakness\:
Distribution of the weakness (e.g. right arm, leg and face)
Severity of the weakness (e.g. subtle, struggling with holding a cup, completely
Onset and duration of the weakness
Course of the weakness (i.e. improving,
Sensory disturbance
Ask the patient if they have noticed any changes in sensation\:
" H a v e y o u n o t i c e d a n y c h a n g e s i n t h e s e n s a t i o n o f y o u r a r m s , Gather more details about the sensory disturbance\:
l e g s o r f a c e ?"
Distribution of the sensory disturbance
Severity of the sensory disturbance (e.g. completely numb, tingling, feeling slightly di
Onset and duration of the sensory disturbance
Visual disturbance
Ask the patient if they have noticed any changes to their vision\:
" H a v e y o u n o t i c e d a n y r e c e n t c h a n g e s t o y o u r v i s i o n ?"
Gather more details about the visual disturbance\:
Type of visual disturbance (e.g. vertigo, hemianopia, quadrantanopia, amaurosis fugax)
Severity of the visual disturbance (e.g. blurred vision, complete loss of vision)
Onset and duration of the visual disturbance
Ataxia
Ask the patient if they have noticed any problems with their balance or coordination\:
" H a v e y o u n o t i c e d a n y d i
Gather more details about the ataxia including\:
Impact on the patient's ability to walk and use their limbs to carry out tasks.
Presence of associated symptoms suggestive of a posterior circulation stroke (e.g. vertigo, nausea).
Speech disturbance
Ask the patient if they have noticed any changes to their speech\:
" H a v e y o u n o t i c e d a n y c h a n g e s t o y o u r s p e e c h , o t h e r s ?"
s u c h a s s l u r r i n g , p r o b l e m s ge t t i n g y o u r w o r d s o u t o r i s s u e s u n d e r s t a n d i n g
Clarify the type of speech disturbance\:
Expressive dysphasia\:
" I k n e w w h a t I w a n t e d t o s a y , b u t I c o u l d n' t g e t i t o u t"
Receptive dysphasia\:
" I w a s n' t a b l e t o u n d e r s t a n d a n y o n e , t h e y w e r e s p e a k i n g g i b b e r i s h"
Dysarthria\:
" M y s p e e c h w a s r e a l l y s l u r r e d , i t s o u n d e d l i k e I w a s d r u n k"
Dysphagia
Ask the patient if they have noticed any dysphagia\:
" H a v e y o u e x p e r i e n c e d a n y d i
Gather more details about the dysphagia including\:
Solid foods\:
" A r e y o u a b l e t o m a n a g e s o l i d f o o d s ?" " D o e s i t f e e l l i k e t h e y g e t s t u c k i n y o u r gu l l e t ?"
Liquids\:
" D o y o u s t r u g g l e t o d r i n k l i q u i d s ?" " D o y o u
Dysphagia is common in stroke and if not recognised early it can lead to aspiration pneumonia and choking episodes.
Reduced level of consciousness
If a collateral history is possible ask about the patient's reduced level of consciousness\:
" W h e n d i d t h e p a t i e n t b e g i n t o b e c o m e m o r e d r o w s y ?"
Gather more details about the reduced level of consciousness including\:
History of head trauma
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Associated symptoms such as headache, nausea, vomiting and jerking movements.
Pain
Ask the patient if they have any pain\:
" D o y o u h a v e a n y p a i n a t t h e m o m e n t ?"
Explore the pain further using the SOCRATES acronym\:
Site\:
" W h e r e i s t h e p a i n ?"
Onset\:
"W h e n d i d t h e p a i n
Character\:
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?"
Radiation\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Associations\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?"
Time course\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Exacerbating and relieving factors\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e o r b e t t e r ?"
Severity\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
Stroke/TIA risk factors
When taking a stroke/TIA history it's essential that you identify stroke and TIA risk factors (e.g. past medical history, family
history, social history).
Important stroke/TIA risk factors include\:
Ischaemic heart disease
Hypertension
Atrial
Hypercholesterolaemia
Diabetes
Previous stroke or TIA
Smoking
Excessive alcohol intake
Hypercoagulable disease (e.g. sickle cell anaemia, polycythemia vera)
Prosthetic heart valves
Carotid stenosis
Poor ventricular function
Migraine with aura
Combined oral contraceptive pill
Family history of stroke in

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
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.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
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" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

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

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 di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry 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\:
Systemic\: fevers (e.g. septic emboli), weight change (e.g. dysphagia)
Cardiovascular\: palpitations (e.g. arrhythmia), chest pain (acute coronary syndrome), shortness of breath (e.g. heart failure)
Respiratory\: dyspnoea, cough (e.g. aspiration pneumonia)
Gastrointestinal\: dysphagia (e.g. stroke)
Genitourinary\: oliguria (e.g. dehydration)
Musculoskeletal\: trauma (secondary to fall), contractures (secondary to stroke)
Dermatological\: pressure sores (secondary to immobility)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
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Make sure to ask about the medical conditions mentioned in the stroke/TIA risk factors section.
If the patient does have a medical condition, you should gather more details to assess how well controlled 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 hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. cardiac valve surgery, carotid endarterectomy)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Ask if the patient has previously been diagnosed with a stroke or TIA\:
Clarify when these episodes occurred and what neurological de
Clarify which investigations were performed and what treatment(s) the patient received.
Ask about residual neurological de
Allergies
anaphylaxis).
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

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications commonly prescribed to patients with stroke or TIA include\:
Antiplatelets (e.g. aspirin, clopidogrel)
Anticoagulants (e.g. warfarin, apixaban, rivaroxaban, dabigatran)
Antihypertensives (e.g. lisinopril, amlodipine)
Statins (e.g. atorvastatin)
Medications which increase the risk of ischaemic stroke include\:
Combined oral contraceptive pill
Oral hormone replacement therapy

Family history

Ask the patient if there is any family history of stroke or TIA\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a h i s t o r y o f s t r o k e s o r T I A s ?"
Clarify at what age the stroke or TIA occurred (disease developing at a younger age is more likely to be associated with genetic
factors)\:
" A t w h a t a g e d i d y o u r f a t h e r s u
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 r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?"
" D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?"
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Social history

Explore the patient's social history to both understand their social context 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)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Recreational drug use
Ask the patient if they use recreational drugs 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).
Diet
Ask if the patient what their diet looks like on an average day. Take note of unhealthy foods which are known to contribute to
cardiovascular/cerebrovascular disease (e.g. high salt intake, high saturated fat intake).
Exercise
Ask if the patient regularly exercises (including frequency and exercise type).
Occupation
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 o
particularly if working at heights or with heavy machinery.
Driving
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 de

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
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Source\: geekymedics.com
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