CRITICAL THINKING REQUIRES SYMPTOMS TO BE SORTED CHRONOLOGICALLY

A patient presents with right arm weakness and sensory loss associated with nausea and headache. This is a stroke, right? The symptoms cleared…okay so its a TIA, right? But he is 15…. But kids can have strokes. Let’s get an MRI… its negative.

Hold on a minute here. We listed symptoms but did not sort them chronologically. Does that matter?

Now let’s sort these symptoms chronologically. First this patient had nausea and visual scintillations, then a few minutes later right facial numbness, then a few minutes later he had right hand weakness and numbness. This was all followed by a unilateral headache. Each symptom was temporary and replaced by something new. Now you wonder and ask – yes, he has a strong family history of migraines. This was a complex migraine doing its “Jacksonian” march across various territories of the brain. The diagnosis seems obvious when presented chronologically.

When you take a medical history, ask open questions, let the patient talk without interruption, and sort out your answers in chronological order. You will probably find that you need to take scratch notes to record all the rich detail you are getting from a patient-centered narrative.

Take Home Points

-Chronology allows you think critically about what may be causing a patient’s symptoms

-Take notes if you find that helps to remember all the symptoms

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