how to take history from a patient or attendant ..

1. HHIISSTTOORRYY TTAAKKIINNGG
By: Syed Irshad Murtaza
Technologist
Neurophysiology Dept
AKUH Karachi
Date: 10-09-2014

2. HHIISSTTOORRYY
Derived from Greek word historia, meaning
"inquiry, knowledge acquired by
investigation“, is the discovery, collection,
organization, and presentation of
information about past events.
History is a written record of
current/past events.

3. HHIISSTTOORRYY TTAAKKIINNGG::
The medical history of a patient is
information gained by asking specific
questions, either of the patient or of other
people who know the person and can give
suitable and relevant information, with the
aim of obtaining information useful in
formulating a diagnosis and providing
medical care to the patient.

4. CCOONN’’TT PPAAGGEE
Take history directly from patient if
he/she can otherwise a person who is
in direct connection with the patient.
Sign and Symptom:
Sign” and “Symptom” are both medical
terms with different medical meanings.

5. CCoonntt’’dd
Symptoms are problems that a patient
notices or feels.
Signs are whatever a physician can
objectively detect or measure.
For example, if a patient feels hot, this is a
symptom. When a physician examines
the patient, touches the patient’s skin
and notes that it is warm and moist, this
is a sign.

6. MMEEDDIICCAALL TTEERRMMIINNOOLLOOGGIIEESS
Seizure:
Seizures are episodes of sudden disturbance of
mental, motor, sensory or autonomic activity
caused by a paroxysmal (sudden, abrupt)
cerebral malfunction.
Or A seizure is defined as an abnormal, excessive,
paroxysmal discharge of the cerebral neurons”.
Epilepsy:
The recurrence of seizures is known as epilepsy.
Status Epilepticus:
it is defined as, seizure event that lasts longer
than 5 minutes or recurring of another seizure
event before a patient regains his/her
conscious level completely. If such episode
occurs only electrographically then the term is
used as, subclinical status epilepticus.

7. Aura
Feelings(symptoms) of the patient signaling the
start of seizure.
Now Aura is considered as simple partial seizure
or it could be initial part of a seizure like
secondary generalized seizure.
Patient is aware of it and remains conscious.
Ictal:
It is a synonym of the word seizure.
Post ictal:
It is a period after seizure, usually lasting longer
than the seizure itself.
Interictal Seizure:
The time between the termination of post ictal
period and the onset of another seizure (could
be in minutes, hours, days, months or years).

8. CCoonntt’’dd
Convulsions:
Convulsions are violent involuntary contractions of
the body musculature.
In neurology, the term is usually limited to
contractions produced by cerebral seizure activity.
Sub-Clinical Seizures:
Subclinical seizures are the long lasting
electrographical epileptic discharges which may
last in min to hours and may or may not be
associated with clinical manifestations.
Epileptic Prodrome:
Abnormal symptoms, feelings or behavioral changes
hours before the onset of seizure e.g. migraine,
exciteness, disorientation, aphasia, or
photosensitivity etc.

9. PPRREEPPAARRAATTIIOONN
Introduce yourself and your surrounding
people.
 Ask the patient’s name and identify
correct patient by using the two main
identifiers (Name & Medical Record#).
Take verbal consent for taking history; if
allowed continue otherwise stop.
Relax the patient.
Give full attention to the patient.
Assure patient’s privacy and confirm that
the informations remain confidential.

10. A history should contain Info about:
Onset of event/seizure( acute or chronic)
Timings and duration of event
Progressive or decreasing (character of
condition)
Associated symptoms (aura)
Difference from previous ones
Apparent patient condition(oriented or
disoriented)
Take observations of the patient during
procedure/event

11. Current History:
Ask the patient to describe the complaints .
Listen all the complaints of patient (present
and past).
Focus on the complains with which the patient
is presented or referred for procedure.
Ask open ended questions and avoid guided
questions.
Take history of the presenting illness.
Time of onset of Symptom
Aggravating / relieving Factors of the
symptoms

12. Past History:
Have the patient had any similar episodes
in the past?
Are previous are same or different in type,
duration, frequency?
Others
Asthma
CVA (Brain haemorrhage)
Cardiac problems
Kidney, hepatic failure or infections
Head injury
Vision problem
Photo sensitivity

13. FFAAMMIILLYY HHIISSTTOORRYY
Same complaints (seizures, migraine
etc.) exists in the family or not
Any other complaints which can correlate
with present patient history.
 consanguinity in parents.

14. QQuueessttiioonnss rreellaatteedd ttoo
sseeiizzuurree
 Number of episodes until now.
First episode and Last episode
 activities before the seizure e.g. sleep
derived, medicine missing.
Duration of seizure and duration of each
episode.
Frequency of seizures (day, week or
month).

15. QQuueessttiioonnss rreellaatteedd ttoo
sseeiizzuurree
 Variation in duration, frequency and
timing of progressive increasing, same or
decreasing.
Occurrence of seizure (during sleep,
awake or anytime).
Age of onset of seizure and last attack .

16. QQuueessttiioonnss rreellaatteedd ttoo sseeiizzuurreess
Seizure Triggering factors
1.Missed medication
2.Sleep deprivation
3.Photosensitivity
4.Alcohol withdrawal
5.Fever in Children (febrile seizures)
6.Certain Medications
7.Hormonal changes (menstrual cycle)
8.Stress, anxiety
9.Dehydration

17. SSiiggnnss aanndd SSyymmppttoommss ooff
sseeiizzuurree
Jerking
Stiffness
Stretchiness
Twitching .
Numbness
Abnormal sensation.

18. AURA:
May be present or not, which could be
vertigo
Hallucinations
Blackout
Abdominal sensation, Nausea or vomiting
Headache
Twitching, stretchiness etc of limbs.
Odd sensation ,smelling or change in taste , mood
etc.
Flashes of light

19. ICTAL PHASE:
The state or phase in which patient had seizures.
Types of ictal phase:
 Focal
Remain on one side or part of body like one limb or
facial twitching
 Jacksonian March:
Starting from one part of the body and spreading
to whole body
Which part was involved and where it spread?

20.  Secondary Generalization:
Starting from focal onset and then
involving the whole the whole body.
From where it get started?
 Generalized:
Involve the whole body or all four limbs
start from the beginning.

21. HHiissttoorryy RReellaatteedd ttoo CCoonnsscciioouuss
LLeevveell
Consciousness
Responsiveness of the patient (can be asked
from patient/attendant).
Consciousness remain intact or not i.e. Loss of
consciousness.
Conscious level (confused or unresponsive)

22. IICCTTAALL PPHHAASSEE
 Any associated voices (grunting voice, shrill cry,
difficulty in breath).
 Body jerking, shivering, stiffness
 Eyes up roll, eyes deviation , staring, blinking.
 Salivation, frothing
 Mouth bleeding due tongue bite.
 Head/neck deviation or not. If yes to which side?
 urine, fecal incontinence characteristic of
generalized seizures.


23. CCoonntt’’dd
Automatism (mechanical, seemingly
aimless behavior e.g., lip smacking,
buttoning or picking at clothes), in
complex partial seizure
 Autonomic changes (Raised in heart rate,
blood pressure, respiration etc)

24. PPOOSSTT IICCTTAALL PPHHAASSEE
It is the state after just after the ictal phase.
(Period after the seizure).
Patient physical/ psychological state after
seizure.
 Including lethargy, confusion, weakness,
body ache, headache, joint dislocation etc.
Regaining of conscious level.
Normal as before event, drowsy or fell asleep.
Retrieving the memory after the seizure, by
the patient.

25. HHiissttoorryy rreellaatteedd ttoo aaggee
Infants:
Some seizures are age related e.g. infantile spasm
which occurs at the age 3 months uptil 12
months. Questions needed on ask; flexion,
extension or nodding of head and limbs.
School Going Age Youngs:
Ask about absence seizures, school performance
and attention in class.
In Adults and Olds:
Memory related questions (recent memory,
amnesia) to exclude dementia.

26. BBiirrtthh HHiissttoorryy
Birth history from birth up to 14-15 years
Normal (Full term 36-38 weeks)
Preterm or Post term
 Birth Hypoxia
 Febrile seizures
Development history:
 Neck holding 3-4 months
Sitting with support 6-7 months
Independent sitting 8-9 months
Walking 12-15 months
Vision
Hearing (3 months)
 Speech (1 year)

27. DDEESSCCRRIIBBIINNGG HHIISSTTOORRYY
 Don’t use jargon words (special profession
related terminologies).
 Use simple language to describe history
 If patient had an event describe
 Safe the patient
 Appearance of patient (semiology)
 Duration of event
 Automatisms
 Check conscious level of patient during event
 Describe what he/she saw/heard
 If patient complains of head turning or eyes
movement, describe to which side.

28. MMeeddiiccaattiioonn HHiissttoorryy
Antiepileptic drugs
Sedatives or hypnotics
Antidepressant
Anticonvulsant drugs
Some medication can also show changes in
EEG like benzodiazepines and
barbiturates.
Special Procedures in Nerve Conduction
Studies like mestinon before Repetitive
Nerve Stimulation.
Pupil dilator before Visual Evoked Potential.

29. What Staff (Tech) has to Do if?
A patient having seizure in the lab or
procedure room
 Don’t panic but stay calm.
Protect head, remove glasses, loosen tight
neck wear
Move anything hard or sharp out of the
way
Turn person on one side, position mouth to
ground
Don’t try to stop the seizure.
Check for verbal instructions may not be
obeyed

30. AAbbbbrreevviiaattiioonnss
H/O history of
K/C known case
S/P status post (after surgery)
LOC loss of consciousness
RTA road traffic accident
Diseases:
DM (diabetese mellitus)
HTN (hypertension)
IHD (ischemic heart disease)

31. AAbbbbrreevviiaattiioonnss
MCA Stroke (middle cerebral artery)
ACA Stroke (Anterior Cerebral artery)
PCA (posterior cerebral artery)
 CKD (chronic kidney disease)
 CLD (chronic liver disease)
 COPD (chronic obstructive pulmonary
disease)
 OSA (obstructive sleep apnea)
 CVA (cerebral vascular accident)


32. Déjà Vu: Feeling as if one has lived through
or experienced this moment before
Dementia: Acquired and sustained loss of
memory and other intellectual functions
that is of sufficient severity to interfere
with daily functioning.
Diplopia: Double vision. Dysarthria: Inability to pronounce or articulate
words due to disorders of the vocal apparatus
(e.g., lips, tongue, larynx).
Dysphagia: Difficulty in swallowing.
Encephalitis:
Inflammation of brain tissue
Dysphonia: Voice disorder, often related to
weakness of laryngeal muscles, in which sound
production is impaired.
Brain Death:Irreversible cessation of all
functions of the entire brain, including the brain
stem
Encephalopathy: literally, "brain suffering";
diffuse brain dysfunction that may be caused by
toxins, infection, metabolic etc.
Stroke: Sudden loss of neurological function
caused by a blockage or rupture of a blood
vessel to the brain or spinal cord, includes
infarction and hemorrhage subtypes.
Prodrome: Premonitory phenomena occurring
hours to days before headache onset in
migraine consisting of psychological,
neurological, or constitutional symptoms.
Hemiplegia: Paralysis on one side of the body. Plegia: Inability to activate any motor neurons ;
paralysis.
Stupor: Condition of unresponsiveness from
which the patient can only be aroused by
vigorous and repeated stimuli; once stimulus
ceases, patient lapses back into
unresponsiveness.
Hydrocephalus: Literally "water on the brain "
increase in size of ventricles and amount of
cerebrospinal fluid in the brain.
Hypoxia: Reduction in the supply of oxygen to
the brain or other vital organ.
Myoclonus: sudden, shock-like, jerking
contraction of a group of muscles.

33. Acute: sudden or developing over minutes to hours Chronic-Progressive: Developing over weeks months to years
Anosmia: Loss of sense of smell. Aphasia: lack of speech caused by brain disease or injury.
Infarction: Permanent tissue damage and death of all
cellular elements (neurons, glia, vessels) due to
prolonged or severe ischemia.
Ischemia: Impairment of tissue function due to a reduction in
blood supply relative to metabolic demand.
Meningitis: Inflammation of meninges.
Aphonia: Complete loss of voice
Hematoma: A hematoma is a collection of blood. It can occur due
to spontaneous bleeding, such as from the rupture of an
arteriovenous malformation.
Hyponatremia (Low Blood Sodium): Condition where
the level of sodium in the blood is low.
Hyperglycemia: A high blood sugar. An elevated level specifically
of the sugar glucose in the blood.
Paroxysmal:
An abrupt onset, rapid attainment of a maximum and
a sudden termination.
Clonus:
Clonus (from the Greek for "violent,
confused motion") is a series of involuntary muscular contractions
due to sudden stretching of the muscle.
Ataxia: Incoordination of movement usually due to
disease of cerebellar or sensory pathways.
Flaccidity: Severe form of hypotonicity.
Atonia: Loss of muscle tone.
Cortical: Referring to the cerebral cortex, the
outermost layer of the cerebrum.
Craniotomy: surgical removal of a section of bone (bone flap) from
the skull for the purpose of operating on the underlying tissues, in
which the bone flap is replaced at the end of the procedure

34. Microcephaly:
head circumference that is smaller than normal because
the brain has not developed properly or has stopped
growing; most often caused by genetic abnormalities.
Hypercapnia: More than the normal level of carbon
dioxide in the blood.
Hypocapnia: Less than the normal level of carbon dioxide
in the blood.
Nystagmus: Involuntary, rhythmic oscillation or trembling
of the eyeballs.
Syncope: Temporary loss of consciousness due to a lack of
blood flow to the brain.
Vertigo: subjective sense of imbalance usually noted as an
illusion of moving or spinning of the external world
Alexia: Inability to read, usually due to a lesion of dominant
occipitotemporal .
Ischemia: Impairment of tissue function due to a
reduction in blood supply relative to metabolic demand.
Ipsilateral:Located on the same side of the body (brain).
Contra lateral: Located on the opposite side of the
body (brain)
Phonophobia:
Abnormal intolerance to sound that commonly occurs in
migraine and other headaches.
Photophobia:
Abnormal intolerance to light, usually associated with eye
pain; characteristic of meningeal irritation, migraine, optic
nerve disease, and ocular or retinal disorders.
Diffuse:
Occuring over large areas of one or both sides of the head.
(generalized)
Unilateral:
Confined to one side of the head.
Hypothermia: low body temperature.
Hyperthermia: increase in body temperature.
Hypocalcemia: decrease in calcium level.
Hypercalcemia: increase in calcium level.

35. QQuueessttiioonnss
Patient presented with vertigo and black out before seizure and
patient recall it. (SK)
Patient remains drowsy for 1 hour after the last episode. (HA)
Patient suddenly started scratching and lips smacking but was
unaware of his/her surrounding. (SS)
A patient has complaint of smelling of bad odor and hearing sound,
which the surrounding people are unable to experience. (MZ)
Abnormal symptoms, feelings or behavioral changes hours to days
before the onset of seizure, like migrain, abnormal behaviour.
(AD)

36. THANKS FOR YOUR
PATIENCE….