HISTORY TAKINGHISTORY TAKING

By: Syed Irshad MurtazaTechnologist

Neurophysiology DeptAKUH Karachi

Date: 10-09-2014

HISTORYHISTORY

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.

HISTORY TAKING:HISTORY TAKING:

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.

CON’T PAGECON’T PAGE

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.

Cont’dCont’d

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.

MEDICAL TERMINOLOGIESMEDICAL TERMINOLOGIESSeizure: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.

AuraFeelings(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).

Cont’dCont’dConvulsions: 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.

PREPARATION PREPARATION

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.

A history should contain Info about:Onset of event/seizure( acute or chronic)Timings and duration of eventProgressive or decreasing (character of

condition)Associated symptoms (aura)Difference from previous onesApparent patient condition(oriented or

disoriented)Take observations of the patient during

procedure/event

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 SymptomAggravating / relieving Factors of the

symptoms

Past History:Have the patient had any similar episodes

in the past?Are previous are same or different in type,

duration, frequency?

OthersAsthmaCVA (Brain haemorrhage)Cardiac problemsKidney, hepatic failure or infectionsHead injuryVision problemPhoto sensitivity

FAMILY HISTORYFAMILY HISTORY

Same complaints (seizures, migraine etc.) exists in the family or not

Any other complaints which can correlate with present patient history.

consanguinity in parents.

Questions related to Questions related to seizureseizure

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).

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 .

Questions related to Questions related to seizureseizure

Questions related to seizuresQuestions related to seizures

Seizure Triggering factors1.Missed medication 2.Sleep deprivation3.Photosensitivity4.Alcohol withdrawal 5.Fever in Children (febrile seizures)6.Certain Medications7.Hormonal changes (menstrual cycle)8.Stress, anxiety9.Dehydration

Signs and Symptoms of Signs and Symptoms of seizureseizure

JerkingStiffnessStretchiness Twitching .Numbness Abnormal sensation.

AURA:May be present or not, which could be

vertigoHallucinations BlackoutAbdominal sensation, Nausea or vomitingHeadacheTwitching, stretchiness etc of limbs.Odd sensation ,smelling or change in taste , mood

etc.Flashes of light

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 bodyWhich part was involved and where it spread?

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.

History Related to Conscious History Related to Conscious LevelLevel

ConsciousnessResponsiveness of the patient (can be asked

from patient/attendant).Consciousness remain intact or not i.e. Loss of

consciousness.Conscious level (confused or unresponsive)

ICTAL PHASEICTAL PHASE

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.

Cont’dCont’d

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)

POST ICTAL PHASEPOST ICTAL PHASEIt 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.

History related to age History related to age 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.

Birth HistoryBirth HistoryBirth history from birth up to 14-15 yearsNormal (Full term 36-38 weeks)Preterm or Post term Birth Hypoxia Febrile seizuresDevelopment history: Neck holding 3-4 monthsSitting with support 6-7 monthsIndependent sitting 8-9 monthsWalking 12-15 monthsVision Hearing (3 months) Speech (1 year)

DESCRIBING HISTORYDESCRIBING HISTORY 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.

Medication History Medication History

Antiepileptic drugsSedatives or hypnoticsAntidepressant Anticonvulsant drugsSome 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.

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 wearMove anything hard or sharp out of the

wayTurn person on one side, position mouth to

groundDon’t try to stop the seizure.Check for verbal instructions may not be

obeyed

AbbreviationsAbbreviations

H/O history ofK/C known caseS/P status post (after surgery)LOC loss of consciousnessRTA road traffic accidentDiseases:DM (diabetese mellitus)HTN (hypertension)IHD (ischemic heart disease)

Abbreviations Abbreviations 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)

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.

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

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.

Questions Questions 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)

THANKS FOR YOUR PATIENCE….