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History taking Stroke and TIA

History of presenting complaint

Due to the nature of TIAs and strokes, it can be useful to first ask some simple 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
  • 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 effectively.

Onset

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 onset time 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.

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 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.

Course

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?”

Precipitating factors

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.

Associated features

Ask about other associated symptoms including:

  • Headache, nausea, vomiting, neck stiffness: associated with raised intracranial pressure (e.g. malignant middle cerebral 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 fibrillation which may be the underlying embolic source.

Previous episodes

Ask if the patient has experienced similar symptoms previously:

  • “Have you ever experienced anything like this before?”
  • “How many times have you experienced these symptoms?”
  • “How long did they take to resolve previously?”
  • “When was the last episode?”

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:

  • “What’s your dominant hand?”

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:

  • “Have you noticed any new weakness?”

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 flaccid)
  • Onset and duration of the weakness
  • Course of the weakness (i.e. improving, fluctuating, worsening)

Sensory disturbance

Ask the patient if they have noticed any changes in sensation:

  • “Have you noticed any changes in the sensation of your arms, legs or face?”

Gather more details about the sensory disturbance:

  • Distribution of the sensory disturbance
  • Severity of the sensory disturbance (e.g. completely numb, tingling, feeling slightly different)
  • Onset and duration of the sensory disturbance

Visual disturbance

Ask the patient if they have noticed any changes to their vision:

  • “Have you noticed any recent changes to your vision?”

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:

  • “Have you noticed any difficulties with balancing or problems with coordinating the movement of your arms or legs?”

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:

  • “Have you noticed any changes to your speech, such as slurring, problems getting your words out or issues understanding others?”

Clarify the 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 gibberish”
  • Dysarthria: “My speech was really slurred, it sounded like I was drunk”

Dysphagia

Ask the patient if they have noticed any dysphagia:

  • “Have you experienced any difficulties when trying to swallow food or liquids?”

Gather more details about the dysphagia including:

  • Solid foods: “Are you able to manage solid foods?” “Does it feel like they get stuck in your gullet?”
  • Liquids: “Do you struggle to drink liquids?” “Do you find yourself coughing after drinking liquids?”

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:

  • “When did the patient begin to become more drowsy?”

Gather more details about the reduced level of consciousness including:

  • History of head trauma
  • Associated symptoms such as headache, nausea, vomiting and jerking movements.

Pain

Ask the patient if they have any pain:

  • “Do you have any pain at the moment?”

Explore the pain further using the SOCRATES acronym:

  • Site: “Where is the pain?”
  • Onset: “When did the pain first start?” “Did the pain come on suddenly or gradually?”
  • Character: “How would you describe the pain?”
  • Radiation: “Does the pain spread elsewhere?”
  • Associations: “Are there any other symptoms that seem associated with the pain?”
  • Time course: “How has the pain changed over time?”
  • Exacerbating and relieving factors: “Does anything make the pain worse or better?”
  • Severity: “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
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 fibrillation
  • 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 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.

Ideas

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.”

Concerns

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?”

Expectations

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?”

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 different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

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.”

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: 

  • “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/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):

  • “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.

Allergies

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).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “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 medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
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:

  • “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?”

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 profile:

  • 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 off work until they have been fully investigated, 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 deficits).