Focussed histories Flashcards
Headache
SOCRATES
Site –migraine tends to be unilateral
Sudden onset, worst pain ever –suggests SAH –“hit on head with baseball bat
”Progressively getting worse = expanding SOL
Band around head, high stress job = tension headache
Cluster = young M, really severe, same every day for 6-12 weeks (come in clusters), over one eye, red watery eye, same time every day/night
Trigeminal neuralgia = unilateral, pain lasts seconds, divisions trigeminal, triggered touching area eg eating shaving washing face.
Triggers –lights/sound/PMS/chocolate/cheese/wine –migraine
Aura = can tell if it’s coming on = migraine
Visual changes/motor and sensory changes = migraine
Exclude meningism –stiff neck, photophobia, rash
Encephalitis –focal neurological signs (can alsobe stroke if drooping face etc)
Collapse/blackout/dizziness/nausea/vomiting
Any head trauma, even ages before (subdural, alcoholics etc)
Raised ICP signs –increase pain on coughing/straining, worse in morning, worse lying down, nausea in morning
Sinusitis = pain on palpation sinuses, recurrent URTIs, pain bending over/leaning forward
GCA = transient blindness, loss of vision, scalp tenderness, jaw claudication eating/talking
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats)
Meds –OCP, painkiller overuse
Smoking/alcohol, caffeine deprivation
PMHx = epilepsy, migraines
FHx –aneurysms, epilepsy
Investigations= cranial nerve exam, neuro exam, obs, fundoscopy, ESR/CRP for GCA, CT head, LP = meningitis, NOT IF RAISED ICP
Management= analgesia, call senior/surgery
DDx= migraine, tension, GCA, trigeminal, SOL, meningitis, encephalitis
Thyroid Focused History
PC could be tiredness, weight gain, anxiety, palpitations, it’ll probably be with a thyroid exam or they’ll just say “Endo”
SOCRATES –how long etc, or just say “Tell me how you’ve been feeling”
Fatigue/lethargy/sleep
Appetite change
Bowel habit
Wt gain/loss
Cold/warm
Tremor/palpitations
Mood –anxiety/depression
If F –periods (Hypothyroid can turn into amenorrhoea)
FHx –other autoimmune stuff
PMHx –neck surgery, AI stuff
Investigations –exam, thyroid exam, obs (temp), TFTs, FBCs
Dietary History
Probably DM or hypothyroid
PC –probably fatigue, SOCRATES etc
SPECIFICALLY ASK –polyuria, polydipsia, nocturia, change appetite
Weight = gain/loss, clothes tighter/looser, INTENTIONAL OR NOT
Ask about typical days food/drink
Ready meals, late night snacks, drinks, caffeine
Special diets = vegan, religious, cultural
Allergies, intolerances
Smoking & alcohol etc
Occupation, exercise
FHx–diabetes, autoimmune stuff,
Investigations= exam, obs, urine dip, random blood glucose, FBG, OGTT, HbA1c (worldwide gold standard), FBC, Us Es, GFR Creatinine etc
Blackout
-SOCRATES –ever happened before!-
Any warning –if no, most likely cardiac arrhythmias, aura –epilepsy, dizziness -vasovagal-
Palpitations –can precede arrhythmias-
Any precipitating factors? Standing up –orthostatic hypotension.
Bright lights –epilepsy.
Fear etc –vasovagal.
Head turning –carotid sinus hypersensitivity-
Any tongue biting? = pathognomonic epilepsy-
Twitching, incontinence –can be epilepsy AND vasovagal-
How long unconscious ? Seconds –vasovagal or arrhythmia-
What do they look like unconscious? Grey and sweaty –vasovagal. Cyanotic –epilepsy. Flushed –Stokes Adams (arrhythmia)-
Spontaneous recovery –likely not hypoglycaemia, or neuro (apart from epilepsy)-
Were they confused after? Yes –epilepsy, slow recovery-
Alcohol? Smoking? DRUGS?! Cocaine/amphetamines-
Medications –antihypertensives, insulin, oral hypoglycaemics, vasodilators-
PMHx –epilepsy, cardiac, brain surgery-FHx –epilepsy, sudden death
Investigations= exam, CN exam, obs, blood glucose, FBC, Us&Es, ECG, EEG, Echo for cardiac, CT (only if new onset epilepsy progressing –ie a SOL)
Management= stabilise, refer to senior/neuro/cardio
DDx= epilepsy, cardiac arrhythmias, vasovagal, anti HTN medication
Shortness of Breath
SOCRATES –previous episodes –will hint at angina/asthma
Pain –radiation for MI etc -
Sudden onset = PE
Exacerbation = exercise = angina, cold air/exercise = asthma, breathing in = pneumothorax, PE-
SOB = + pain (you can put a finger on the pain = PE)-
Cough = dry (asthma), productive (LRTI or exacerbation), haemoptysis (PE)-
When is cough worse? Night –asthma.
Wheeze?
Cardio assoc symptoms = dizziness/blackouts
/sweating/palpitations
Heart failure = exercise tolerance, peripheral oedema, orthopnoea, PND
Claudication = leg pain worse on walking, goes away when rest = cardiac-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats) –think Lung Ca or TB-
If thinking PE –ask DVT, travel, recent surgeries, pregnant etc-
If asthma/COPD –ask about inhalers-
Resp = PASTO = Pets, Allergies, Smoking, Travel, Occupation -
Allergies = eczema, hayfever, allergies-Cardio RFs = DM, HTN, high cholesterol,
FHx-CVD and allergies/hayfever/asthma-
PMHx = heart disease, DVTs, TB, asthma, COPD-FHX =
Investigations= Examine, Obs if they’re acutely unwell, ECG if cardiac, peak flow, FBC, blood cultures if infected, spirometry.
Management= if acutely unwell ABCD approach, learn the acute asthma management.
DDx= MI, heart failure, asthma, exacerbation asthma, PE, LRTI, COPD
Palpitations
SOCRATES –previous episodes
MI questions –pain radiation, sweating etc-
Blackouts –any notice beforehand? (Cardiac arrhythmias –sudden).
What colour does face go? Red –Stokes Adams-
SOB = panic etc-
Cardio assoc symptoms = dizziness/blackouts/ sweating/palpitations-
Heart failure = exercise tolerance, peripheral oedema, orthopnoea, PND
Hyperthyroid = change in appetite, wt loss, change in bowel habit-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats) –rarely an issue-
Alcohol, smoking!
ANXIETY AND CAFFEINE!!!-
Cardio RFs = DM, HTN, high cholesterol,
PMHx = stroke, peripheral vascular disease, Heart disease-
FHX = CVD, sudden deaths in family (SENSITIVELY)
Investigations= Examine, Obs if they’re acutely unwell, ECG, FBC, Us&Es, TFTs, troponin if MI suspected, blood cultures if IE, 24 ECG if arrhythmia suspected (Holter), echo
Management= if acutely unwell ABCD approach, painkillers, call senior, ACS approach.
DDx= arrhythmias, anxiety, caffeine, hyperthyroid, infective endocarditis, ACS, MI (rarer)
Chest pain
SOCRATES –previous episodes –will hint at angina-
Radiation –jaw, shoulder, arm etc (Back –women, diabetics, Asians for MI)-
Exacerbation = exercise = angina, leaning forward = pericarditis, breathing in = pneumothorax, PE-
SOB = + pain (you can put a finger on the pain = PE)-
Cough = dry (GORD), productive (pneumonia), haemoptysis (PE)-
Vomiting –BEFORE pain = Boerhaave’s, AFTER pain = MI-
Cardio assoc symptoms = dizziness/blackouts/ sweating/palpitations-
Heart failure = exercise tolerance, peripheral oedema, orthopnoea, PND-
Infection symptoms = muscle pain + sore throat (pericarditis), productive cough (pneumonia)-
Claudication = leg pain worse on walking, goes away when rest = cardiac-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats) –rarely an issue-
Alcohol, smoking! -
Cardio RFs = DM, HTN, high cholesterol, FHx-If thinking PE –ask DVT, travel, recent surgeries, pregnant etc-
PMHx = stroke, peripheral vascular disease, Heart disease, previous DVTs-
FHX = CVD and parents’ deaths
Investigations= Examine, Obs if they’re acutely unwell, ECG, FBC, Us&Es, LFTs, CRP, troponin, CXR, D dimer for PE, H. pylori if GORD, sputum cultures if pneumonia, echo
Management= if acutely unwell ABCD approach, painkillers, call senior, ACS approach.
DDx= MI, ACS, heart failure, pericarditis, PE, GORD, pneumonia, Boerhaave’s
Change in bowel habit
AGE! Old person + change in bowel habit + little bit anaemic = Ca most probs-
SOCRATES –timing-Check pain!-
Frequency and volume, consistency etc, when (if nocturnal –organic NOT functional)-
Blood –on paper or in toilet, then colour, etc (pale, mucous, melaena etc)-Is passing stool painful? Typically fissures.
Haemorrhoids = itching, PR bleeding on paper-
Vomiting –blood? What colour? Coffee ground? -
Tenesmus? (Feeling still need to void after opening bowels)-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats) -
IMPORTANT-Travel!
Alcohol! Drugs! Smoking!
Meds = if you suspect ulcers, ask NSAIDs-
If you’re super stuck, ask anxiety + diet.
Also NB: blood in stool will increase frequency, blood is a laxative-
PMHx = surgeries, ulcers-
FHx = Ca, IBD
Investigations= Examine, Obsif they’re acutely unwell, DRE/proctoscopy, FBC, Us&Es, LFTs, CRP, TFTs if constipated, H.pylori breath test if it sounds like an ulcer, abdo X Ray, flexi/rigid sig
Management= acutely unwell/obstructed –IV fluids, NBM, Group & Save, call senior/surgery.
DDx= Colon/Rectal Ca, GI bleed (Ca or ulcer), IBD (if young), IBS, haemorrhoids, fissures
Dysphagia
SOCRATES obvs-
Where does the food get stuck? High -usually systemic/neuromusc, Low –usually local obstruction-
Regurgitation –immediate or delayed (level of obstruction)-
Heartburn/waterbrash –reflux disease (also nocturnal cough/wheeze)-
Gurgling –pharyngeal pouch-
What’s getting stuck? Solids, semi, liquids? Was it solids, now to everything?-
Neuro symptoms –tiredness eating, difficulty coordinating swallowing, early dysphagia liquids-
New onset dysphagia in elderly –Ca until proven otherwise esp with wt loss-
Hx GORD –probs oesophageal carcinoma (smoking –RF)-
Investigations = OGD, barium swallow
Abdo pain (not the best cover, mainly epigastric)
SOCRATES, timing super important-
Radiation –to back (dissecting aorta or pancreatitis), to shoulder tip (diaphragm), to jaw (cardiac)-
Exacerbating –eating (gastric ulcer, contrast duodenal), fatty foods (biliary colic, gallstones), pleuritic (pneumonia!), exercise (cardiac)-
Relieving –sitting forward (pancreatitis), eating (duodenal)-
Change in bowel habit –frequency, blood, colour, etc -
Eating & drinking, nausea & vomiting-
Vomiting –blood? What colour? Coffee ground? Green = bilious = obstruction = bad-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats) –if appetite flagged up consider dysphagia questions-
Travel! Alcohol! Drugs! IV drugs!
Procedures/gallstones (pancreatitis)-Meds = if you suspect ulcers, ask NSAIDs-
Investigations= pretty much anything, examine, Obs if they’re acutely unwell, FBC, Us&Es (dehydration), LFTs, AMYLASE, H.pylori breath test if it sounds like an ulcer, pregnancy test if F, abdo X Ray if obstruction, Murphys sign!, MRCP/ERCP gallstones
Management= pancreatitis/obstruction/gallbladder/appendicitis –IV fluids, NBM, Group & Save, call senior/surgery. (F)
DDx= will depend on location etc, commonly = appendicitis, pancreatitis, ulcer, gallstones, strangulated hernia, ectopic/ovarianif F Uncommonly = DKA, MI, lower lobe pneumonia, gastric/oesophageal Ca, achalasiaObstruction = severe pain, won’t move (peritonitic), bilious vomiting, can be complete constipation (no flatus)
Jaundice
SOCRATES, EVER HAD IT BEFORE-
Abdo pain –always ask, SOCRATES it-
Nausea + vomiting? Fevers? Rigors?-
ITCHING = sign CONJUGATED, usually obstructive post hepatic jaundice (can be hepatic too)-
Change stool & urine colour, explicitly if stools pale and urine dark = obstructive, usually post hepatic-
Systemic –FLAWS (Fever, Lethargy, Appetite, Wt loss, night Sweats)-
Liver signs - ankle or abdominal swelling, easy bruising,
Travel (Hep A), blood transfusions/ops (overload or Hep C), ALCOHOL (hepatitis), Drugs (IV explicitly –Hep C),tattoos (abroad usually –Hep C), sexual (Hep C)-
FHx –gallstones, Ca, hepatitis-
Investigations–examination, urine for urobilinogen, FBC, LFTs, viral screen.
Think about your pt–Female Fat Forty Fertile? Probs gallstones
Note = there’s about a million causes for Jaundice, Oxford Cases has a good list.
DRE focussed history
Presenting complaint –SOCRATES
Urinary = FUNDHITS (frequency, urgency, nocturia, dysuria, haematuria, incontinence, terminal dribbling and hesitancy, signs like fever suggesting urosepsis or nausea suggesting pyelonephritis)
Bowel = change in bowel habit, blood (quantify, in stool/on paper), change in stool colour, tenesmus, pain
Systemic = fever, lethargy, wt loss, appetite etc
Pain in flank
WHAT DOES THE PATIENT LOOK LIKE–writhing in pain = kidney stones-completely still = peritonitis
SOCRATES pain –kidney stones usually bilateral, then unilateral, very severe, colicky (peristalsis of ureter) + radiates to groin-
Ask obstructive symptoms-
Haematuria! Clots (usually)-
Fever! Rigors! -pyelonephritis-
Ask about recent UTIs-
PMHx –kidney stones, recurrent UTIs-FHx –kidney stones-
Investigations–urine dipstick, examine pt, pregnancy test if F, CT KUB (stones)
Management= stones (conservative, lithotropsy, surgical), pyelonephritis –usually IV Abx
DDx= Kidney stones, pyelonephritis, appendicitis, ovarian pathologies + ectopic (F)
Increased urinary frequency/haematuria
FUNDHITS = Frequency, Urgency, Nocturia, Dysuria, Hesitancy/Haematuria, Incontinence/incomplete voiding, Terminal dribbling, Stream
For frequency = ask if increased volume as well (then polyuria –see diabetes)-
Ask UTI questions –dysuria, frequency, fever-
Ask any blood in urine, then if colour has changed (clarify)-
For all of these: onset, timing, worsened, exacerbating/relieving factors-
Rule out renal stones –colicky loin pain-
Systemic symptoms: weight loss, lethargy, BONE PAIN(pancreatic mets)-
Obstructive symptoms: Frequency/Hesitancy/ Poor stream/Terminal dribbling -
Sexual symptoms: Any problems? Difficulty ejaculating? Any blood in semen?
Investigations–urine dipstick, examine pt, DRE, PSA, ALP
DDx= BPH, Prostate Ca (which is more common?)
Blackout (Laz)
· HPC
o What happened BEFORE the blackout?
§ Warning – aura (epilepsy), palpitations (cardiac), dizziness (vasovagal)
§ Precipitants – standing up (postural), straining/fear/heat (vasovagal), exercise (cardiac), head turning (carotid sinus hypersensitivity)
§ Head trauma – subdural haematoma develops slowly
o What happened DURING the blackout?
§ Duration – vasovagal and arrhythmias are short-lived
§ Tongue-biting/limb movement/incontinence
o What happened AFTER the blackout?
§ Spontaneous recovery – cardiac, vasovagal
§ Post-ictal confusion/exhaustion – epilepsy
o Did they miss a meal this morning?
· PMH
o Previous episodes
o Diabetes – hypoglycaemia, dehydration and autonomic dysfunction
o Heart disease
o PVD – increased risk of heart disease
o Epilepsy diagnosis
o Psychiatric illness
· FH
o Sudden death < 65 yrs
· DH
o Insulin + hypoglycaemic
o Antihypertensives
o Diuretics
o Antiarrhythmics
o Anti-depressants
· SH
o Stimulant recreational drugs (e.g. cocaine) à tachyarrhythmia
Haematemesis
HPC o Volume of blood o Character of vomit o Melaena or frank blood in stool o Did vomiting trigger the bleed? o FLAWS o Dysphagia o Liver failure symptoms (easy bruising, distended abdomen, puffy ankles) o Heartburn and waterbrash
· PMH o Previous episode o GORD (heartburn + epigastric pain) o Aortic repair with grafts o Bleeding tendency o Chronic liver disease
· FH
· DH
o Anticoagulants
o Drugs that cause PUD
o Drugs that cause liver toxicity
· SH
o Alcohol abuse
o Smoking
o Viral hepatitis risk factors: IVDU, tattoos, unprotected sex, foreign travel
Cough
HPC
o Acute or chronic
o Constant (intrinsic cause) or intermittent (extrinsic trigger)
o Productive – yellow/green sputum (infection), clear sputum (COPD), large volumes of rusty sputum (bronchiectasis), dry (asthma/GORD)
o Blood – blood-streaked (infection, bronchiectasis), pink/frothy (pulmonary oedema), frank blood (TB, cancer, PE)
o Timing – worse at night/early morning (asthma), worse when lying flat (pulmonary oedema/GORD)
o Character – wheeze (asthma, COPD), bovine (vocal cord paralysis), dry (bronchitis, interstitial lung disease), gurgling/wet (bronchiectasis)
o Associated Symptoms:
§ FLAWS
§ SOB
§ Chest pain (pleuritic?)
§ Wheeze
§ Rhinorrhoea/frequent throat clearing
· PMH o Asthma o GORD o Heart failure o Chest infection
· FH
· DH
o ACE inhibitors
· SH
o Environmental irritants (smoking, occupation, pets, change of house/office)
o Travel to TB-endemic regions
o Close contacts with similar symptoms
Haemoptysis
HPC
o What are you coughing up? – frank blood (vascular), blood-stained sputum (infection, bronchiectasis), frothy pink sputum (pulmonary oedema)
o How much is being coughed up?
o Did it happen suddenly (PE, erosion of cancer into blood vessel)? Or has it gradually got worse (chronic e.g. bronchiectasis)?
o Associated Symptoms
§ Productive cough (infection or bronchiectasis)
§ Fever (infection)
§ Weight loss (lung cancer or TB)
§ Pleuritic chest pain (pneumonia, PE)
§ SOB – sudden-onset (PE) or gradual (e.g. heart failure)
§ Haematuria/oliguria – pulmonary-renal syndromes (vasculitides, Goodpasture’s syndrome and SLE)
· PMH
o Prior lung disease
o VTE risk factors (e.g. long-haul travel, surgery, active malignancy)
o Anticoagulants/bleeding diathesis
· FH
o Similar respiratory disease in the family
· DH
o Anticoagulants
· SH
o Smoking
o Occupation (e.g. asbestos)
o Recent travel/growing up abroad
Laz SOB
HPC
o Time of onset and gradual vs sudden
o Alleviating/Exacerbating factors
§ Most SOB is worse on exertion
§ Heart failure worse when lying flat
§ Asthma worse at certain times of the year and early in the morning
§ Psychogenic hyperventilation occurs at times of stress
o Associated Symptoms
§ Cough
· Pneumonia – persistent, productive, a few days
· Chronic bronchitis – persistent, productive, most days of 3 months spanning years
· Asthma – dry cough, worse at night
· BLOOD – PE, lung cancer, atypical pneumonia, bronchiectasis
§ Chest Pain
· Pleuritic pain – PE, pneumothorax, pneumonia, pleurisy, pericarditis
§ Muscle Weakness or Fatigue
· Neuromuscular disease – Guillain-Barre, myasthenia gravis, Lambert-Eaton
§ Tender Limbs
· DVT
§ FLAWS
· Malignancy
§ Blood Loss
· E.g. melaena, menorrhagia
· Can lead to anaemia
· PMH
o Previous episodes
o Autoimmune conditions (e.g. SLE, rheumatoid arthritis)
o Atopic disease (e.g. eczema, hayfever, rhinitis)
· FH
o Similar respiratory disease in the family
· DH
o Certain drugs cause interstitial lung disease (e.g. amiodarone, methotrexate, nitrofurantoin)
· SH o Smoking o Pets o Occupational exposure (e.g. asbestos, silica) o Travel abroad/growing up abroad
Laz epigastric pain
HPC – SOCRATES
o Site – diffuse, spreading towards chest, more in RUQ
o Onset - sudden (perforated viscus), 10-20 mins (pancreatitis, biliary colic), hours (inflammation e.g. cholecystitis, pneumonia)
o Character – crushing (MI), sharp/burning (PUD, gastritis), deep/boring (pancreatitis)
o Radiation – back (AAA, pancreatitis), shoulder-tip (diaphragmatic), jaw/neck/arm (cardiac)
o Attenuating Factors – leaning forwards (pancreatitis), association with eating (PUD)
o Exacerbating Factors – movement (peritonitis), inspiration (pleuritic), fatty meals (biliary colic)
o Severity – HIGH (pancreatitis, perforated ulcer, MI)
o Associated Symptoms
§ Nausea and vomiting (SBO, inferior MI)
§ Fever
§ Dyspepsia/waterbrash (GORD)
§ Change in stool – pale (biliary obstruction), steatorrhoea (pancreatic exocrine insufficiency)
§ Cough – acute (basal pneumonia), chronic (GORD)
· PMH
o Biliary disease (gallstones)
o Peptic ulcer disease (background of gnawing epigastric pain)
o GORD
o Vascular disease (MI and mesenteric ischaemia)
· FH
o Cardiovascular disease
· DH
o Drugs that cause PUD
o Drugs that cause pancreatitis (sodium valproate, thiazides, steroids)
· SH o Alcohol (pancreatitis) o Smoking (PUD, MI, mesenteric ischaemia)
Constipation
HPC
o Establish normal frequency of bowel movements
o Hard/lumpy stools (dehydration, lack of fibre)
o NO faeces of flatus (absolute constipation à obstruction)
o Time-course (acute à obstruction)
o Associated Symptoms: § FLAWS § Diarrhoea (IBS, diverticular disease, overflow diarrhoea) § Tenesmus § Blood § Bloating § Hypothyroid symptoms § Bone pains (metastases à hypercalcaemia) § Polyuria/polydipsia (hypercalcaemia)
· PMH
o History of bowel, endocrine or neurological disease
· FH
o FAP/HNPCC
o Peutz-Jegher’s syndrome
· DH
o Opiates, anticholinergics, CCBs
· SH
o Intake of dietary fibre
o Hydration
Diarrhoea
HPC o Description of STOOLS § Mucoid or jelly-like § Foul-smelling and floating § Unusually pale § Blood o Description of BOWEL HABIT § Establish normal bowel habit § Nocturnal diarrhoea § Rushing to the toilet § Tenesmus § Variable (intermittent diarrhoea AND constipation) § Previous episodes § Association with any particular food (e.g. gluten in Coeliac)
o Associated symptoms: § Vomiting § Abdominal pain § Relief of pain on defecation § Bloating § Weight loss (and time course) § Hyperthyroid symptoms § Extra-GI manifestations (eyes, ulcers, rashes and joints)
· PMH
· FH
o IBD
o Coeliac disease
o FAP/HNPCC
· DH
o Some medications cause diarrhoea (e.g. antibiotics)
· SH
o Foreign travel
o Eating unusual food
o Close contacts with similar symptoms
Rectal bleeding
HPC o How much blood has been passed? o Duration and frequency of bleeding o Appearance of blood/stools o Relationship between blood and stool o Pain or prolapse on defecation o Tenesmus o Change of bowel habit o Weight loss o Anaemia symptoms (e.g. SOBOE, fatigue)
· PMH o Previous PR bleed o Ulcerative colitis o Recent bowel trauma (e.g. colonoscopy) o Aortic surgery (aorto-enteric fistula) o Radiotherapy to rectum o Bleeding tendency o Upper GI bleed risk factors (e.g. peptic ulcer disease, liver disease)
· FH
o GI diseases
· DH
o Anticoagulants
o Drugs associated with peptic ulcer disease (e.g. NSAIDs, steroids)
o Antibiotics and PPIs (increased risk of C. difficile colitis)
· SH
o Alcohol (chronic liver disease à varices)
o Smoking
Polyuria
HPC
o Clarify polyuria or high urinary frequency (ask VOLUME)
o Temporal pattern (nocturia?)
o Fatigue, weight loss, recurrent infections (diabetes mellitus)
o LUTS (hesitancy, urgency, frequency, terminal dribbling, imcomplete voiding) à less likely to be polyuria, more likely to be poor urinary output
o UTI symptoms (dysuria, frequency, change in colour and smell)
· PMH
o Renal conditions
o Precipitants of chronic renal failure (e.g. vasculitides, hypertension)
o Cancer (hypercalcaemia)
o Psychiatric illness (psychogenic polydipsia)
· FH
o Similar symptoms
· DH
o Diuretics
o Lithium (causes diabetes insipidus)
Limb weakness
HPC
o EXACT TIME of onset (4.5 hr window)
o Speech or visual disturbance
o Headache (SAH, hemiplegic migraine, tumour)
o Seizure or loss of consciousness (Todd’s paresis)
o Neck or back pain (disc prolapse, Guillain-Barre)
o Trauma (slowly expanding haematoma)
· PMH
o Stroke risk factors (previous TIA/stroke, AF, atherosclerotic risk factors)
· FH
o Stroke/TIA
· DH
· SH
o Smoking
o Housing situation/dependants
Laz Headache
HPC o SOCRATES o RED FLAGS: § Decreased consciousness § Sudden-onset, worst headache ever § Seizure or focal neurological defect (e.g. weakness, dysarthria) § Previous episodes § Reduced visual acuity § Worse when lying down/early morning nausea § Progressive, persistent headache § Constitutional symptoms § Head trauma
o Other key features: § Other types of headache § Triggers (migraines have triggers) § How disabling are the headaches? § Aura
· PMH
o History of malignancy (brain metastases)
o History of immunosuppression (increased risk of intracerebral infection)
· FH
o Migraines can be common in families
· DH
o Medication-overuse headaches
o COCP – contraindicated in migraine
· SH
o Cramped accommodation – increased risk of meningitis
Breast focussed history
WIPER
Open question
Lump - (size, smooth and fixed?, duration, pain, happened before?, change with periods?, trauma?)
Local symptoms - pain, discharge (blood, cheesy, volume), skin changes
Nipple - inversion, discharge, blood, pain
Systemic - FLAWS, cx or back pain, lymph node swelling, other lumps or bumps
Estrogenic risk factors - COCP, HRT, early menarche (median is 14), late menopause (about 50), no breast feeding, first child after 30
PMHx - previous breast disease or cancer, last screen
FHx - breast or ovarian cancer
SH - Smoking (risk factor for periductal mastitis)
ICE
DDx - fibrocystic change - cyclical - pain Duct ectasia - cheesy discharge and pain Fibroadenoma - pain All diffs - ductal carcinoma in situ
