Chief Complaint
Elicit the patient's chief complaint or reason for visit.
History of Presenting Illness (HPI)
Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.
Seizures
- Seizure history
- Age of onset
- Frequency
- Symptom pattern
- Compliance with medication(s)
- Precipitating factors
- Preceding abnormal smells, thought processes, sensations
- Loss of consciousness
- Description of seizure if observed
- Tonic-clonic activity
- Incontinence of bladder or bowel
- Post-ictal state
- Drowsiness
- Impaired memory
- Headache
- N.B. Seizures are often confused with syncope. Features most suggestive of seizures are tongue lacerations, abnormal posturing, and head turning during event.
Loss of Consciousness
- History of fainting
- Feeling faint versus “light-headed”
- Flushing, nausea, warmth or tunnel vision
- Syncope during exertion
- Events preceding LOC
- Description of event if observed
- Tonic-clonic activity
- Incontinence of bladder or bowel
- Prodromal experience
- Rate of recovery (syncope recovery should be no longer than few minutes)
Vertigo or dizziness
- Lightheadedness
- Perception that room is spinning (vertigo)
- Associated nausea, double vision, difficulty speaking
- Association with head movement or changes in position
- New or change to medications
- Difficulty with gait or balance
- History of falls
Visual disturbance
- Episodic or progressive
- Diplopia (monocular or binocular)
- Visual field loss
- Photophobia
- Eye pain
Headache
Ask about:
- Onset and frequency
- Early morning (increased intra-cranial pressure)
- Changing pattern from acute to chronic headache or progressively severe headaches increase likelihood of tumour, abscess or other mass lesion(s)
- Location
- Time between onset and maximum severity
- Red flags:
- First or characteristically unlike previous headaches
- Maximum severity at onset (thunderclap headache)
- Neck stiffness or meningismus
- New onset headache in pregnancy or postpartum
- Age>50
- Change in mental status, level of consciousness
- Tender over temporal artery
- Weight loss, fever, night sweats, fatigue
- Associated symptoms:
- Nausea
- Vomiting
- Fever
- Tearing
- Diaphoresis
- Visual changes
- Parasthesias
- Dizziness
- Balance disturbances
- Tinnitus
Specific Types of Headaches
- Tension headache
- Occipital or temporal
- Unilateral or bilateral
- Non-pulsating criteria
- Not aggravated by routine criteria
- No nausea, no vomiting
- Only one of phonophobia or photophobia
- Cluster headache
- Usually unilateral, periorbital
- Occur daily, usually at night for several weeks
- Often associated with ipsilateral autonomic symptoms: conjunctiva injection or lacrimation, nasal congestion rhinorrhea, eyelid edema, forehead diaphoresis, miosis or ptosis
- Lasts 15 minutes to 3 hours
- Migraine
- Unilateral (sensitivity: 66%, specificity: 78%)
- Nausea and/or vomiting (sensitivity: 82%, specificity 96%)
- Episodes last 4-72 hours
- Can be with our without aura
- Aura: flickering of lights, spots or lines (scintillating scotomas-sensitivity 54%, specificity 74%), blurred vision, parasthesias - Completely reversible, lasts <60 minutes
- Pulsating quality, photophobia, phonophobia
- Aggravated by routine physical activity
- Temporal/giant cell arteritis
- Tenderness over temporal artery
- Age>50 (99%)
- Fever (50%)
- New headache (60%)
- Jaw claudication (50%)
- Visual loss or blindness (15-20%)
- Polymyalgia rheumatica (50%)
- Fatigue
- Anorexia
- Weight loss
- Nausea and/or vomiting
Weakness, difficulty moving, falls, paralysis
- Generalized versus localized weakness
- Sudden v gradual onset
- Pattern of onset (ex. Distal to proximal)
- One or both sides of the body affected
- Worsen with repetitive motion and improve with rest
Abnormal movements, tremors or fasiculations
- Trembling
- Body movements that patient seems unable to control
- Rigidity of movements
- Difficulty initiating movements
- Gait abnormalities
- Action tremor
- Postural, kinetic, intention
- Rest tremor
Paraesthesia
- Loss of sensation/numbness
- Tingling/“pins and needles”
- Distorted sensations in response to a stimulus (dysesthesias)
- Hypesthesia: diminished ability to perceive a simple sensation (pain, temperature, touch, vibration)
- Anesthesia: complete inability to perceive a simple sensation
- Hypalgesia: decreased sensitivity to painful stimuli
- Analgesia: complete insensitivity to painful stimuli
- Hyperpathia, hypereshesia, allodynia all refer to increased sensitivity to sensory stimuli
Other
- Use of analgesia
- Difficulty hearing, tinnitus
- Loss of taste or smell (anosmia)
- Difficulty with gait, balance, and coordination
- Dysphasia or speech impairment
- Difficulty with sphincter control or sexual function
- Difficulty with thinking or memory (cognitive or memory impairment)
- Changes in sleep pattern
- Depression
Past Medical History (PMHx)
Specifically ask about:
- Previous episode
- Headaches
- Stroke, TIA
- Cardiovascular disease
- Seizures
- Diabetes
- Head trauma
- Infectious disease
- Cancers (Systemic symptoms)
- Thyroid disease
- Past surgical history
Family History (FmHx)
Specifically ask about:
- Cardiovascular disease
- Stroke, TIA
- Cancers
- Movement disorders
- Diabetes
- Myopathy
Social History (SocHx)
Specifically ask about:
- Travel history
- Exercise
- Diet
- Alternative healthcare practices
- Work routine and occupational exposures
Substance Use History (SubHx)
Specifically ask about:
Medications
Gather complete list, including particularly relevant drugs such as:
- Anticonvulsants (Valproic acid)
- Antiparkinsonian drugs (L-dopa)
- Skeletal muscle relaxants
- Headache meds (Triptans)
- Pain meds (GABApentin, opioids)
- Psychiatric drugs
Allergies
Note allergies and ensure they concord with those listed in the EMR
Review of Systems
Conduct a review of systems, keeping other etiologies from your differential in mind.
References
- Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolter Kluwer Health; 2009.
- Lincoln, Matthew, McSheffrey eds. Essentials of Clinical Examination Handbook. 6th ed. Toronto, ON: University of Toronto Medical Society: 2010.