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Neurological history taking is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a neurological history in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
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 offering them a seat)
- 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:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, can you tell me more about that?”
Once the patient has finished speaking, it is helpful to check if there are any other issues. If the patient has multiple presenting complaints, work with them to establish a shared agenda for the rest of the consultation:
- “Ok, so you’ve mentioned that you have three problems today that you’d like addressing. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of 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 differential diagnosis.
You should let the patient describe the symptoms in their own words, but make sure you identify exactly what the patient means if they use medical jargon (e.g. numbness, vertigo, etc.). If something is unclear, try reframing or using closed questions to narrow down their response.
History of presenting complaint
Patients with neurological pathology can present with a wide variety of symptoms including but not limited to headache, involuntary movements, loss of consciousness, collapse, muscular symptoms (e.g. weakness, tremor or spasm), sensory symptoms (e.g. numbness or paraesthesia), speech disturbance, visual changes, hearing changes, olfactory changes, instability, and altered mental state.
Key neurological symptoms
Symptoms that are typically associated with neurological disorders include:
- Headache: due to a primary cause (e.g. migraine, tension-type, cluster), secondary cause (e.g. raised intracranial pressure, intracranial haemorrhage, meningitis, tumours), trauma or medication overuse
- Seizures: can be generalised (affecting both sides of the brain and causing loss of consciousness) or focal (affecting one part of one hemisphere and causing symptoms related to that area)
- Loss of consciousness: due to syncope (e.g. reflex syncope, cardiovascular syncope or orthostatic hypotension), generalised seizures (convulsive or non-convulsive) or head trauma
- Muscular symptoms: causes of weakness include stroke, multiple sclerosis, motor neurone disease, and myasthenia gravis. Parkinson’s disease and spinal cord injury can cause spasms or stiffness. Motor neurone disease can cause fasciculations (i.e. muscle twitches)
- Peripheral sensory symptoms: causes of numbness, tingling, and sensory loss include peripheral neuropathy (caused by diabetes, B12 deficiency, etc.), radiculopathy, carpal tunnel syndrome, and Guillain-Barré syndrome
- Speech disturbance: dysarthria (motor speech disorder) is likely due to motor neurological injury caused by stroke, Parkinson’s disease and motor neuron disease. Aphasia (language disturbance) can result from damage caused by stroke
- Visual changes: sudden vision loss may be caused by stroke, optic neuritis, and retinal vasculature occlusion, whereas a tumour causes a more gradual visual loss. Migraine, epilepsy, and transient ischaemic attack can also present with visual disturbances
- Hearing changes: acute onset hearing loss is likely to be infectious (e.g. labyrinthitis, vestibular neuritis), vascular (e.g. stroke) or trauma (e.g. temporal bone fracture). More gradual causes are presbycusis (age-related) or acoustic neuroma (vestibular schwannoma)
- Olfactory changes: loss of smell can be caused by trauma, neurodegeneration (e.g. in Parkinson’s or Alzheimer’s disease), infection, tumours, and congenital conditions (e.g. Kallmann syndrome). Temporal lobe seizures may cause olfactory hallucinations (e.g. burning rubber)
- Dizziness/vertigo: peripheral causes include benign paroxysmal positional vertigo (BPPV), Ménière’s disease, and vestibular neuritis. Central causes include stroke/transient ischaemic attack and cerebellar tumours/lesions, which may be associated with other neurological deficits
- Altered mental state: due to several causes, including stroke, seizures, intracranial haemorrhage, dementia, delirium, and infection
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting features in more detail. It is most commonly used to explore pain, but it can be applied to most other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Establishing the site and onset of symptoms is critical in a neurological history to make an accurate list of differential diagnoses based on anatomical location.
Site
Ask about the location of the symptom:
- “Where is the numbness?”
- “Can you point to where you are experiencing numbness?”
Onset
Clarify how and when the symptom developed:
- “When did the weakness first start?”
- “Did the weakness come on suddenly or gradually?”
- “How long have you been experiencing this weakness?”
The speed of onset and recovery of symptoms is particularly important in a neurological presentation, as this can indicate the likely cause. Vascular, epileptic and toxin/drug-related causes will present (hyper)acutely (i.e. seconds to minutes). Infective/inflammatory processes, perhaps due to another medical disorder causing neurological symptoms present subacutely (i.e. over a few days). Neurodegenerative diseases and malignancy are more likely to be chronic in their presentation.
If presenting with multiple symptoms, ask about the order in which symptoms manifested, as this can help identify the neurological level at which the problem occurs (i.e. cerebral cortex, spinal cord, peripheral nervous system).
Episodic symptoms
Following an episode of seizure, headache, and syncope, it is important to ask what happened before, during and after the episode to help narrow the differentials.
- Before the episode: aura, palpitations, visual changes, other sensory changes
- During the episode: witnesses, length of the episode, loss of consciousness, arm/leg movement, eye movement, tongue biting, incontinence
- After the episode: confusion, time for recovery, fatigue, focal limb weakness
Character
Ask about the specific characteristics of the symptom:
- “How would you describe the pain?”
- “Is the pain sharp, dull or burning?”
The character of pain is important in helping differentiate between the causes. Sharp, well-localised pain is most likely nociceptive, while burning pain is commonly associated with peripheral neuropathy.
Radiation
Ask if the symptom moves anywhere else:
- “Does the pain spread elsewhere?”
- “Does the numbness spread anywhere else?”
Associated symptoms
Ask if there are other symptoms associated with the primary symptom:
- “Are there any other symptoms associated with the pain?”
The nature of associated symptoms is a huge indicator of where the problem is occurring. Motor and sensory symptoms can point to issues at any neurological level; however, cortical problems are more likely to cause changes in cognition, language, and awareness. Spinal cord lesions are more likely to cause paralysis and autonomic dysfunction. Peripheral nerve issues may present with weakness and fatiguability.
Time course
Clarify how the symptom has changed over time:
- “How has the weakness changed over time?”
- “Is the tremor there all the time or does it come and go?”
Ask if there is a diurnal variation of symptoms:
- “Is your pain worse at a particular time of day?”
If the type of episode has occurred previously, establish the history of episodes. Ask when it first happened, the latest instance, the frequency of episodes (including their severity over time), whether the patient recovers fully between episodes and how long this takes to occur. Episodes of transient ischaemic attack or migraine would typically see a return to normal within 24 hours, whereas multiple sclerosis follows a remitting-relapsing pattern with longer recovery times.
If the symptom is intermittent, ask about the duration and characteristics of each episode and whether the patient has identified any factors (either internal or environmental) that increase the chances of this occurring.
Exacerbating or relieving factors
Ask if anything makes the symptom worse or better:
- “Does anything make the pain worse?”
- “Does anything make the tremor better?”
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
- “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?”
Collateral history
A collateral history is not always required, but asking a family member or friend for their version of events is crucial for patients presenting with loss of consciousness, seizures, or cognitive impairment. Establish what they know about the patient’s baseline functioning and what occurred before, during, and after the episode of symptoms (if applicable).
Specific neurological features
In addition to SOCRATES, it is important to narrow your line of questioning depending on the presenting complaint.
Headache
- When did the headache start, and how has it progressed?
- What is the nature of the pain (e.g. throbbing, sharp)?
- Are there associated symptoms such as nausea, visual disturbances, or sensitivity to light and sound?
- Are there any triggers or factors that relieve the headache?
Seizures
- Did the patient experience any warning signs (aura) before the seizure?
- What happened during the seizure? Was there a loss of consciousness or unusual movements?
- How long did the seizure last, and what were the post-seizure symptoms (e.g. confusion, drowsiness)?
- Did the patient have awareness during the seizure or was this impaired?
Weakness
- Is the weakness localised (e.g. one limb or side of the body) or generalised?
- Is it more pronounced proximally or distally?
- Has it been progressing over time?
Sensory changes
- Has the patient experienced any numbness, tingling, or altered sensation?
- What is the distribution of these symptoms?
- Has it been progressing over time?
Balance and coordination
- Have there been any problems with balance, clumsiness, or tremors?
- Is the patient having difficulty walking?
Visual disturbances
- Has the patient experienced any blurred vision, double vision, or loss of vision?
- Were these symptoms sudden or gradual in onset?
Speech and swallowing
- Has the patient experienced difficulty with speech, such as slurring or finding words?
- Are there any issues with swallowing?
Cognitive and behavioural changes
- Has there been any memory loss, confusion, or noticeable personality changes?
Autonomic symptoms
- Has the patient experienced dizziness and fainting?
- Is the patient having issues with bladder or bowel control?
Contextual information
Ask about any potential preceding events such as trauma, infections, or travel history. Enquire about the patient’s mental health and how their symptoms have impacted this (or vice-versa).
Neurological risk factors
When taking a neurological history, it is essential to identify risk factors for neurological disease as you work through the patient’s history (e.g. past medical history, family history, social history).
Important neurological risk factors include:
- Hypertension, diabetes, hyperlipidaemia, smoking, and obesity (stroke, vascular dementia)
- Neurological disorders (e.g. Huntington’s disease, epilepsy, Alzheimer’s), stroke, and cardiovascular disease
- Alcohol and drug use, occupational toxin exposure, and physical inactivity
- Head trauma, infections (e.g. meningitis), autoimmune diseases (e.g. multiple sclerosis), or cancer
- Birth complications (e.g. hypoxia), prematurity, or developmental delays
- Infections, vaccinations, or travel (e.g. Guillain-Barré syndrome, encephalitis)
- Stress, depression, or anxiety (may mimic or exacerbate neurological symptoms)
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 talk about your past medical history and quickly screen for any other symptoms and causes.”
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, weight change, fatigue
- Cardiovascular: chest pain, palpitations, oedema, syncope, orthopnoea
- Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
- Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
- Genitourinary: oliguria, polyuria
- Musculoskeletal: chest wall pain, trauma
- Dermatological: rashes, ulcers
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?”
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. intracranial surgery, lumbar puncture, nerve conduction studies):
- “Have you ever previously undergone any operations or procedures?”
- “When was the operation/procedure and why was it performed?”
Neurodevelopmental history
This is particularly important to ascertain in paediatric patients or adults with neurological symptoms that may have begun in childhood. If suspecting a diagnosis involving developmental delays, learning difficulties or behavioural concerns, establish a timeline of neurological signs by asking the following questions:
- Pregnancy and birth history: were there any complications during pregnancy or delivery (e.g. premature birth, low birth weight, hypoxia)?
- Milestones: did they achieve developmental milestones on time (e.g. walking, speaking)?
- Childhood illnesses: were there any significant illnesses or injuries during early development?
- Social and educational history: were there challenges in school or social interactions?
- Behavioural and emotional development: were there concerns about temperament, behaviour, or emotional regulation?
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).
Examples of relevant medical conditions
Medical conditions relevant to neurological disorders include:
- Hypertension (risk factor for stroke and vascular dementia)
- Diabetes mellitus (associated with peripheral neuropathy and stroke)
- Trauma (e.g. head injury leading to subdural hematoma or chronic traumatic encephalopathy)
- Hyperlipidaemia (increased risk of stroke and vascular dementia)
- Atrial fibrillation (risk factor for embolic stroke)
- Thyroid disorders (e.g. hypothyroidism causing myopathy or neuropathy; hyperthyroidism causing tremors or agitation)
- Autoimmune diseases (e.g. multiple sclerosis, myasthenia gravis)
- Infections (e.g. meningitis, encephalitis, HIV-encephalopathy)
- Chronic kidney disease (linked to uraemic neuropathy or encephalopathy)
- Vitamin deficiencies (e.g. vitamin B12 deficiency leading to subacute combined degeneration of the spinal cord)
- Cancer (e.g. paraneoplastic syndromes causing neurological dysfunction)
- Alcohol use disorder (associated with Wernicke’s encephalopathy, Korsakoff syndrome, and peripheral neuropathy)
- Obstructive sleep apnoea (related to cognitive impairment, stroke, and excessive daytime sleepiness)
- Psychiatric conditions (e.g. depression often overlaps with cognitive neurological disorders such as dementia and Parkinson’s disease)
- Haematological conditions (e.g. hypercoagulable states increasing risk of thrombosis and stroke)
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?”
Commonly prescribed neurological medications
Medications commonly prescribed to patients with neurological disorders include:
- Antiepileptic drugs (AEDs) (e.g. carbamazepine, lamotrigine, levetiracetam, sodium valproate)
- Anticholinesterase inhibitors (e.g. donepezil, rivastigmine): for Alzheimer’s disease or myasthenia gravis
- Antiparkinsonian medications (e.g. levodopa, dopamine agonists, monoamine oxidase inhibitors)
- Migraine prophylaxis drugs (e.g. topiramate, propranolol)
- Disease-modifying therapies (e.g. interferon beta, fingolimod)
- Neuropathic pain medications (e.g. gabapentin, pregabalin, amitriptyline)
- Corticosteroids (e.g. prednisolone): for conditions like optic neuritis or myasthenia gravis exacerbations
- Immunosuppressants (e.g. azathioprine, dimethyl fumarate)
Medications with neurological side effects
Medications with neurological side effects include:
- Antihypertensives (fatigue, dizziness)
- Statins (myopathy, neuropathy)
- Opioids (confusion, drowsiness)
- Antipsychotics (extrapyramidal symptoms, tardive dyskinesia)
- Antidepressants (dizziness, serotonin syndrome)
- Antibiotics: metronidazole (peripheral neuropathy), ciprofloxacin (seizures)
- Chemotherapy agents (peripheral neuropathy)
- Antihistamines (drowsiness, dizziness)
- Diuretics (electrolyte imbalances causing weakness or confusion)
- Anticoagulants (intracranial bleeding)
Family history
Ask the patient if there is any family history of neurological disorders:
- “Do any of your parents or siblings have any neurological problems?”
Clarify at what age the neurological disease developed (disease developing at a younger age is more likely to be associated with genetic factors):
- “At what age did you first start experiencing symptoms of this condition?”
- “Have any of your close family members experienced similar symptoms, and if so, at what age did they develop them?”
If one of the patient’s close relatives is 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 neurological 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. Smoking is a significant risk factor for neurological conditions, such as stroke and vascular dementia.
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
Ask if the patient vapes or uses E-cigarettes, even if they are an ex- or non-smoker.
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis. Excessive alcohol use can predispose patients to conditions such as Wernicke’s encephalopathy, Korsakoff syndrome, and peripheral neuropathy.
See our alcohol history taking guide for more information.
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 may be the underlying cause of a patient’s presentation with neurological symptoms:
- Cocaine: can cause seizures, strokes, or transient ischemic attacks (TIA)
- Ecstasy and amphetamines: may cause seizures, dizziness, or headaches
- Opiates: can lead to confusion, hypoxia-related neurological damage, or reduced consciousness
- Cannabis: may cause impaired cognition or coordination, particularly with high-frequency use
- Intravenous drug use: increases the risk of infective endocarditis, which can result in embolic strokes
Diet
Ask if the patient what their diet looks like on an average day, paying attention to factors that may predispose them to neurological conditions:
- High salt intake: linked to hypertension and stroke
- Vitamin deficiencies such as vitamin B12 or B1 (thiamine): linked to neuropathies and cognitive impairment
Exercise
Ask if the patient regularly exercises (including frequency and exercise type). Regular exercise is protective against neurological conditions like stroke, dementia, and Parkinson’s disease.
Occupation
Ask about the patient’s current occupation:
- Assess if their job involves exposure to neurological hazards (e.g. heavy metals, repetitive strain, or stress)
- If the patient experiences neurological symptoms (e.g. seizures, limb weakness), assess how these may affect their ability to work safely
- If the patient is experiencing episodes of syncope and works with heavy machinery or at heights, it is important to advise them to take time off work until they have been fully investigated
Driving
If the patient drives and has presented with syncope or other concerning neurological symptoms (e.g. seizures, weakness, visual changes), 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.
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.
Reviewer
Professor Paresh Malhotra
Consultant Neurologist
Editor
Dr Jamie Scriven
References
- Rees R, Moodley KK. Taking a neurological history. Medicine. 2023. Available from: [LINK].
- Thrush D. Take a Good History. Practical Neurology. 2002. Available from: [LINK].
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