Focussed histories

Question 1

Headache

Answer 1

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

Question 2

Thyroid Focused History

Answer 2

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

Question 3

Dietary History

Answer 3

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

Question 4

Blackout

Answer 4

-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

Question 5

Shortness of Breath

Answer 5

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

Question 6

Palpitations

Answer 6

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)

Question 7

Chest pain

Answer 7

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

Question 8

Change in bowel habit

Answer 8

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

Question 9

Dysphagia

Answer 9

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

Question 10

Abdo pain (not the best cover, mainly epigastric)

Answer 10

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)

Question 11

Jaundice

Answer 11

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.

Question 12

DRE focussed history

Answer 12

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

Question 13

Pain in flank

Answer 13

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)

Question 14

Increased urinary frequency/haematuria

Answer 14

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?)

Question 15

Blackout (Laz)

Answer 15

· 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

Question 16

Haematemesis

Answer 16

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

Question 17

Cough

Answer 17

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

Question 18

Haemoptysis

Answer 18

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

Question 19

Laz SOB

Answer 19

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

Question 20

Laz epigastric pain

Answer 20

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)

Question 21

Constipation

Answer 21

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

Question 22

Diarrhoea

Answer 22

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

Question 23

Rectal bleeding

Answer 23

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

Question 24

Polyuria

Answer 24

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)

Question 25

Limb weakness

Answer 25

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

Question 26

Laz Headache

Answer 26

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

Question 27

Breast focussed history

Answer 27

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