Histories Flashcards
Chest Pain
Associated features?
Nausea
sweating
dyspnoea
Jaundice
Weight loss
Differential Diagnoses
Heart attack- Chest Pain > 20 minutes, radiating to shoulder and jaw (left side), past history and family history of Cardiovascular Problems and CV risk factors
Pulmonary Embolus-chest pain radiating to jaw, shoulder, back, dyspnoea, recent immobility, history of clotting disorder, syncope
Transient Ischemia (angina/ claudication/ etc) – pain on exersion, pain <20 minutes
Muscle Strain – context
Infection – fever, joint and muscle pain, potential weight loss, fatigue, (travel history), organ specific features (eg liver and jaundice)
Fracture – context
Abdominal pain –possible jaundice, gallstones, kidney infection/ damage, (investigate further to differentiate cause)
Cancer – family history, past history, weight loss, fever
Palpitations
Key Questions
Tap out the rhythm
Medication changes
Stress
Coffee drinking
Associated Features
SOB
Chest Pain
Fatigue
Dizziness and blackouts
Thyroid problems
Differential Diagnosis
Heart Failure-Past History, Family history of heart problems, Past MI, Shortness of Breath, Dizziness
Thyroid problems –Weight loss, enlarged neck, insomnia, anxiety, insensitivity to heat, (popping eyes), family history
Pulmonary Embolus – chest pain radiating to jaw, shoulder, back, dyspnoea, recent immobility, history of clotting disorder, syncope
Heart Attack – Chest Pain > 20 minutes, radiating to shoulder and jaw (left side), past history and family history of Cardiovascular Problems
Anaemia – fatigue, paleness
Social – context, stress, coffee, anxiety, exercise
Syncope
Key Questions Ask about prodrome, during and after. Ask for witness Ask about Injury to oneself-tongue biting Incontinence Ask about recovery Ask for Cardiovascular risk factors Were they standing or sitting when it happened Frothing at mouth, sweaty, pallor tongue biting head turning cry or moan tonic clonic Slow or fast recovery Any confusion afterwards
Differentials Vasovagal TIA Cardiogenic Seizure
Oedema
Swelling in both legs?
How many pillows do you sleep with (pulmonary oedema)
Wake up with SOB?
Is the swellling worse at the end of the day
Associated symptoms
SOBOE
Orthopnoea
Fever
Pain (chest, abdomen)
Excessive urination
Differential Diagnosis
Congestive Heart Failure – Past History, fatigue, shortness of breath, chest pain, needing to sleep with multiple pillows, Family History of Heart problems
Cancer – Family History, Past History, weight loss, fever
Liver Failure – alcohol history, jaundice, abdominal pain
Local Infection/ Allergies – fever, fatigue, context, allergies
Kidney Failure – excessive urination, fatigue
Deep Vein Thrombosis – Unilateral swelling, redness, pain in calf, travel, certain medications, family history of DVTs/ clotting disorders
Dyspnoea
Key questions
SOB at rest or on exertion
Nocturnal dyspnoea
How many pillows
Associated symptoms
Chest pain
cough
wheeze
fever
leg swelling
orthopnoea
anxiety
Differential Diagnosis
Pulmonary Embolus – sudden onset, chest pain radiating to jaw, shoulder, back, recent immobility, history of clotting disorder, syncope
Cardiac Failure – oedema, fatigue, past medical and family history, chest pain
Asthma – Context, past history, allergies
COPD – smoking history
Lung Cancer – smoking history, past and family history, haemoptysis, fever
Respiratory Infection – fever, productive cough, context, travel + duration (TB?)
Reflux – chest pain, past history, worse with eating
Anxiety – context
Pneumothorax – Young, male, sudden onset, asthma
Asthma
Key questions
What does the asthma feel like
what does it stop you from doing?
Have you ever been hospitalized?
How often do you use your puffer?
Time course of asthma–how long?, proghresion over time?
What are the triggers for your asthma
What medications are you on for the asthma
Do you have allergies? atopic dermatitis?
Smoking
What do you smoke How much for how long When do you normally smoke? Can you go on a long flight without smoking? Do you smoke first thing in the morning Have you ever tried to quit? Are you thinking about quitting now? How does smoking affect your health?
Cough
Do you cough up anything What colour is the sputum is there any blood how much sputum what does it smell like? Is the cough waking you up at night Ask about recent travel? anyone else coughing in your family? Is it worse when you are lying down? Do you have asthma? Associated symptoms SOB Wheeze ankle swelling night sweats weight loss Differential Diagnoses Cardiac Failure – oedema, fatigue, past medical and family history, chest pain Pulmonary Embolus – sudden onset, chest pain radiating to jaw, shoulder, back, recent immobility, history of clotting disorder, syncope Asthma – Context, past history, allergies COPD – smoking history Cancer – smoking history, past and family history, haemoptysis, fever, weight loss. Respiratory Infection – fever, productive cough, context, travel + duration (TB?), recent cold Reflux – chest pain, past history, worse with eating
Vomiting
Is ther blood? How much vomit? what colour? Do you feel nauseas before Do you vomit first thing in the morning? Do you anyone else that has been sick? Any possibility of pregnancy? Associated features Nausea Diarrhoea Fever abdominal pain headache vertigo dehydration weight loss pain (hepatic gallstones MI) Differential Diagnosis Gastroenteritis – fever, fatigue, pain Pregnancy – context, loss of periods, frequent urination, breast enlargement Medication – context, recent chemotherapy Heart Attack – chest pain (+ radiation), sweating, past and family history of heart problems Alcohol – context, alcohol history
Dysphagia
Where does the food get stuck?
Is it difficulty in swallowing or difficulty in getting the food down?
Is it solids and liquids?
Associated features
Past stroke
Parkinsons disease
MS
Coughing
Choking
Reflex problems
Loss of appetite
Weight loss?
Regurgitating food or stomach contents?
Differential Diagnosis
Stroke – family history, past history of cardiovascular problems, high cholesterol, hypertension, sensorimotor loss, sudden onset, other neurological problems. tr4ouble initiaitng nthe swallowing.
Parkinson’s Disease – short steps, tremors, loss of smell, rigid movements
Multiple Sclerosis – Muscle Weakness, Visual disturbances, Hearing disturbances, Dizziness
Reflux – past history, chest pain, pain with or after eating
Oesophageal Cancer – past history, family history, weight loss, chest pain, history of reflux, coeliac disease, fever, initially solids only
Achalasia (loss of peristalsis in oesophagus) – context, rule out cancer, liquids from onset as well as solids.
Diarrhoea
How watery is the diarrhoea
what colour?
Any blood in the diarrhoea?
how often to the toilet?
anyone else sick that you know?
Eaten anything lately that could have triggered it?
ANy overseas travel?
changes in medications?
Any food in particular that trigger it?
Associated symptoms
Fever
nausea
vomiting
abdominal pain
weight loss
dehydration
Infection/ Food Poisoning – Fever, Vomiting, context, other contacts
Cancer – past history, family history, weight loss, blood in stools (but diarrhea itself will cause weight loss), fever
Inflammatory Bowel Disease – time course, blood in stools, loss of appetite, weight loss
Changes in Diet or Medication
Hyperthyroidism - Weight loss, enlarged neck, insomnia, anxiety, insensitivity to heat, (popping eyes), family history, light periods
Coeliac Disease/ Intolerance – bloating, only with certain foods, nausea
Constipation
what coluour? Is there any blood? How often do you use the toliet? How often do you usually use the toilet? Changes in diet? changes in medication? Associated symptoms Abdominal pain Rectal bleeding Weight gain Anaemia Insensitivity to cold Changes in mood Fever Changes in appetite Differential Diagnosis: Bowel Cancer – family history, past history, dark red blood in stools, weight loss, fever Medication – current medication/ change in medication at time of onset Diet – change in diet at time of onset Hypothyroidism – Weight gain, insensitivity to cold, depression, loss of hair, neck enlargement, heavy periods Parasitic Infection – Travel, migration, increased appetite, anaemia.
Rectal Bleeding
Is the blood mixed in or separate?
How often are you using the toilet
How often do you normally use the toilet?
Any changes in diet or medication
Associated features
Constipation
Abdominal pain
Vomiting/Nausea
Fever
Loss of appetite
Differential Diagnosis
Bowel Cancer – family history, past history, dark red blood in stools, weight loss, fever
Melaena – black stools
Haemorrhoids – Bright red blood, pain when passing stools, age
Anal Fissure – Bright red blood, sharp pain when passing stools
Jaundice
Time course
Vaccinations to hepatitis
Tattoot or peircings
Unproteced sex
Overseas travel
Eaten ice
IVDU
Anyone else with the same symptoms?
Ask about alcohol use?
Gall stone pain
Associated symptoms
Pain
Pale poop
Dark urine
Itchiness
Fever
nausea
vomiting
oedema
anaemia
Differential Diagnosis
Hepatitis A + E – recent ravel, nausea, other contacts, vaccination history (A)
Hepatitis B + C – risky sex, IV drug use, piercings and tattoos, vaccination history (B)
Haemolysis –
• Malaria – travel, fever, fatigue, chills, headache, nausea and vomiting, possible dark urine
• Other Infection - fever, fatigue, chills, headache, nausea and vomiting, possible dark urine
• Genetic (eg Sickle Cell) – fatigue, family history of sickle cell anaemia, normal urine and stools
Drug reactions and medication - medication (eg rifampicin- antibiotic), dark urine
Chronic Liver Disease – Alcohol History, Hepatitis in the past, ascites, peripheral oedema, dark urine, pale stools (but may be normal)
Gallstones – Transient Severe Abdominal Pain, intermittent jaundice, high cholesterol, change in diet, recent attempts to lose weight, obesity, dark urine, pale stools
Muscle weakness
Where is it?
same weakness on both sides?
Single muscle or group of muscles?
Has the weakness been spreading?
Is it worse after activity
Associated symtpoms
Pain?
Visual disturbances
Fatiugue
Loss of sensation/tingling/numbness
Muscle atrophy
Blood in urine
Differential Diagnosis
MS
MS - visual disturbances, sensory loss, family history Myasthenia Gravis – muscle become fatigued, family history
Stroke - family history, past history of cardiovascular problems, high cholesterol, hypertension, sensorimotor loss
Emotional – depression, lack of motivation
Sarcopaenia – Old, loss of muscle mass
Cancer – Loss of muscle mass, weight loss, fatigue, loss of appetite, family history of cancer, age, fever
Joint Pain – Pain in joint where weakness is, context
Motor neuron Disease/ Neurodegen – context, family history, distal weakness
Nerve compression – possible pain, past trauma
Myasthenia Gravis – Fatiguability, History of Autoimmune conditions, Generalised pattern of motor weakness
Metabolic Disorders – exercise intolerance, myoglobinuria, heart problems
Hypothyroidism - Weight gain, insensitivity to cold, depression, loss of hair, neck enlargement, heavy periods
Addison’s Disease – Fatigue, skin pigmentation, nausea, vomiting, diarrhoea, weight loss, low blood pressure, recurrent infections
Medications- eg statins
Muscle damage/ Muscle overuse – context, pain
Sensory diustrubance
Is the same in both sides?
Glove and stocking pattern (peripheral nerve)
Dermatome pattern (nerve root lesion)
Is it a particular nerve.
Hemisensory loss (spina cord or brainstem)
Is it upper and lower limbs?
Positive signs or negative signs (so paraesthesia, hyperaesthesia, hyperalgaesia, allodynia or hypoaesthesia, anaesthesia, analgesia)
Do you experience any other sensations anywhere else
How does it effect your life
what does it stop you from doing?
Is it worse at night?
Is it spreading?
Is it worse after activity? (for positive signs)
Associated symptoms
Pain
visual disturbances
fatigue
muscle weakness
other sensory disturbances
muscle atrophy
Weight loss
Diabetes
Differential Diagnosis
MS – visual disturbances, muscle weakness, family history
Stroke - family history, past history of MI, high cholesterol, hypertension, sensorimotor loss
Trauma – context (recent surgery, injury)
Nerve compression (eg carpal tunnel, disc prolapse, etc.) – possible pain, past trauma, possibly worse at night
Cancer – Loss of muscle mass, loss of weight, fatigue, loss of appetite, family history of cancer, age, fever
Diabetic neuropathy – age, overweight, high blood pressure, prolonged high blood glucose, family history
Excessive Alcohol consumption – alcohol history
Memory loss
Hav you behaved unssually
How it it affecting you?
How are you coping?
Has anone made any comments about your behaviour?
Differential Diagnosis
Dementia – time course, age, type of memory loss, behavioural changes
Trauma – context
Infection – context, fever, recent travel, photophobia, stiff neck, muscle pain
Psychiatric - tests
Stroke – family history, past history of MI, high cholesterol, hypertension, sensorimotor loss
Hypoglycaemia – context (fasting, diabetes, etc), sweating, tremors, anxiety
Malnutrition – check diet for vitamin insufficiency
Headache
At what time of day does the headache start
ask about trauma
Do you have any visual disturbances, any hearing disturbances, double vision, focal neuralgia?
Any muscle weakness?
Is it unilateral or not?
Differential diagnosis
Cancer – Neurosequelae, headache worse when lying, family history, weight loss, fever
Trauma – context, also possible in dementia (patient may forget fall)
Meningitis – photophobia, neck stiffness, fever, progressive headache
Eye strain – context
Sinusitis – context
Subarachnoid haematoma– “thunderclap headache”, sudden onset
Referred pain – pain at other sites
Cluster headache – pain behind the eye
Malignant hypertension – blurred vision, difficulty breathing, chest pain, dizziness
Preeclampsia – sudden weight gain, abdominal pain, dizziness, difficulty breathing, urinary retention, vomiting and nausea
Dizziness
What does it feel like? it it dizzy or is it vertigo-spinning
WHat does it stop you from doing?
Have you eve lost conciousness?
Have you had gentamycin?
Associated symtpoms
Nausea/vomitng
visual disturbances
double vision
lack of coordination
facial weakness
headaches
head injuries
stroke
fever
Pre syncope – Context (posture, medication, anxiety, fasted state)
Vertigo – Sudden movements, viral infection, vestinualr neuritis is viral. could also be BPPV or meneirs disease
Disequilibrium – Gait disturbance, quality (wobbliness), Parkinson’s Disease
Non-specific – quality (‘woozy’, ‘foggy’), hyperventilation, anxiety/ depression
Cardiogenic cause - Family history, other cardiac signs (arrhythmias, high blood pressure, high cholesterol, past history of MI, etc.)
Neurogenic cause – visual, hearing, motor and sensory disturbances
Weight loss
Are you losing it on purpose? How much have you lost do your clothes feel loose time course have you changed diet or medicaitons have you been travelling recently Associated symptoms increased apetite decreased apetite fever change in stools bloated hearing problems difficulty swallowing increased urination increased thirst tremors, palpitaitons sweating irregular menstrual cycle Differential Diagnosis Dieting – context Eating disorder – context, stress Cancer – family history, past history, decreased appetite, fever Hyperthyroidism – Increased appetite, Tremors, palpitations, sweating, heat intolerance, bulging eyes, enlarged thyroid, irregular menstrual cycle T1DM – Polydipsia, Polyuria, Polyphagia Coeliac Disease/ Malabsorption – context (change in diet), bloating, change in stools Neurological? – Difficulty swallowing, cognitive decline Infection/ parasite – Recent travel, fever, nausea/ vomiting, anaemia
Urinary problems
UTI-FUND Frequency Urgency, nocturia, dysuria
Obstructive–Hesitancy, dribbling, straining, nocturia, possible blood)
Is there any blood
Is the urine volume increased
How it it affecting you?
Does it wake you up at night?
Have you had changes to your diet or your medications?
Associated symptoms
pain
loin pain
bleeding
proteinuria (frothy urine)
Excessive thirst
hunger
oedema
dehydration
weight loss
Fever
Differential Diagnosis
Renal Cancer – blood in urine, family history, fever, weight loss
Prostatic hyperplasia – male, age, straining, hesitancy, dribbling, difficulty finishing, nocturia
Stones – severe pain, blood in urine, intermittent pain
T1DM – Polydipsia, Polyuria, Polyphagia
Infection – more likely female, recent catheter, frequency, fever, malaise
Diabetes Inspidus – tests (can’t be worked out from history alone)
Chronic renal failure – oedema, proteinuria, anaemia, bone pain
Knee pain
Any other joints affected? Is there swelling? is the knee hot to touch? is there a clicking sound Was there any trauma? Is the ROM affected Is the pain present at rest Is the pain worse at any time of day Associated features swelling redness clicking fever reduced ROM Differential Diagnosis Rheumatoid Arthritis – swelling, redness, multiple joints, pain worse in the morning, family history of autoimmune conditions, female (3:1) Osteoarthritis – pain worse in the evening, old, past knee trauma Septic Arthritis – redness, swelling, hot to touch, fever Referred Pain – dull, non-specific pain Muscle strain - context Deep Vein Thrombosis – family history and/ or long period of immobility, unilateal Baker’s cyst – swelling behind leg, stiffness Trauma - context Gout-transiet episode, previous episodes, diet as well. presence of tophi?
Shoulder pain
Both shoulders or one?
is the pain spreading?
is the rom affected?
Ay trauma?
is the pain present at rest?
Associated featurtes
Swelling
Redness
Reduced ROM
SOB
Crushing chest pain
Differential Diagnosis
Rheumatoid Arthritis – swelling, redness, multiple joints, pain worse in the morning, family history of autoimmune conditions, female (3:1)
Rotator Cuff tear – context, elderly, decreased ROM
Calcific tendonitis – elderly, decreased ROM
Subacromial bursitis – exercise, painful arc syndrome (60-120°)
Trauma – context
Referred Pain – dull, non-specific pain
Ischaemic Heart Disease – pain on exertion, cardiovascular problems, family history of cardiovascular disease
Myocardial Infarction – left shoulder pain, crushing pain, cardiovascular problems, nausea, shortness of breath, sweating family history of cardiovascular disease
Back pain
Is ther epain at night?
Have you ever used IV drugs
Does bending forwards make it better
Associated symptoms
swelling
redness
reduced rom
pins and needles in the leg
weight loss
fever
night sweats
past history of cancer
fecal or urinary incontinence
Differential Diagnosis
Osteoarthritis – age, worse when moving, worse in the evening
Fracture – age, chronic steroid use
Cancer/ Metastases – age, family history, past history, weight loss, fever
Disc Prolapse – Context, Worse with movement, nerve impingement symptoms
Sciatica – Radiating pain down leg, worse when walking, better when bending over
Abdominal Aortic Aneurysm – Cardiovascular risks, family history
Kidney Infection – female, fever, malaise
