Histories Flashcards
Chest pain
SOB (orthopnoea, PND, excercise tolerance)
Nausea, vomiting, sweating
Palpitations (regular, irregular)
Syncope (LOC, dizziness, light headed)
Ankle swelling (unilateral/bilateral)
Calf swelling (pain, redness)
Haemoptysis (PE, pneumonia, mitral stenosis, lung cancer, TB)
Modifiable risk factors: smoking, alcohol, hypercholesterolemia, obesity (central), hypertension, diabetes mellitus, sedentary lifestyle, poor compliance with medication, stress.
Non-modifiable risk factors: age, male, family history, previous CVD.
Productive cough
Chest pain (unilateral, worse on deep inspiration)
SOB (acute/intermediate/chronic onset)
Previous breathing problems
PND/orthopnoea
Stridor (inspiratory, upper airway obstruction by foreign body or tumour)
Wheeze (expiratory, obstruction of small airways, cardiac wheeze in pulmonary oedema, ?when: night, cold, exercise, monophonic/polyphonic)
Cough
Sputum
Haemoptysis
Ask about previous respiratory investigations (lung function test, CT scan, allergen testing)
Abdominal pain
SOCRATES
Nausea, vomiting (haematemisis, relationship with food)
Abdominal distension (bowel obstruction, ascites)
Anorexia, weight loss
Dysphagia (solids or liquids?)
Dyspepsia (OTC antacids?)
Diarrhoea (increased frequency? loose consistency?)
Constipation (last bowel movement, flatus)
Blood or mucus PR (mixed with stool, coating stool, on toilet paper, fresh blood, melena)
Urological: frequency, dysuria, haematuria, hesitency, terminal dribbling
Gynaecological: discharge, bleeding, dyspareunia, LMP
Smoking (GI malignancy, Crohn’s, protective in UC), alcohol (pancreatitis), recent travel (enterotoxogenic E.coli)
DDx for umbilical pain
Early appendicitis Intestinal obstruction Acute gastritis Peptic ulcer disease Acute pancreatitis Ruptured abdominal aortic anneurysm Gastroenteritis IBS IBD Constipation Perforated viscus
DDx for RIF pain
GI: appendicitis, diverticulitis, IBD, intestinal obstruction, Meckel’s diverticulitis, perforated viscera, obstructed/incarcerated inguinal or femoral hernia.
Gynaecological: ruptured ovarian cyst, torsion of ovarian cyst, PID, ectopic pregnancy
Urinary: UTI, renal calculi
Other: testicular torsion, musculoskeletal
Diarrhoea
Stool description (volume, consistency, colour, blood, mucus, tarry, floating)
Timing (frequency, nocturnal, duration)
Previous bowel habit
Tenasmus
Medications: ABX (C. difficile), laxatives, cytotoxics, PPIs, NSAIDs
Recent travel: food, activities, vaccinations
Contact: animals, individuals suffering with diarrhoea
Diet: meat, eggs, seafood, dairy, wheat, unusual
PMH: diabetes, IBD, abdo surgery, HIV, organ transplant, malignancy, chemo, radiotherapy, constipation
Occupation: vetinary surgeon, NHS staff symptom-free for 48h before return to work
Family Hx: IBD, coeliac’s disease
Causes of diarrhoea without blood
Enterotoxigenic E.coli (traveller’s diarrhoea)
Malaria (P. falciparium)
Giardiasis
Enterotoxin producing strains of Staph aureus
Cholera
Causes of diarrhoea with blood
Enterohaemorrhagic E.coli
Shingella, salmonella, campylobacter
Clostridium difficile
Schistosomiasis
Extra intestinal manifestations of IBD
Eye: uveitis, iritis, episcleritis
Musculoskeletal: seronegative arthritis*, osteoporosis
Dermatological: erethema nodosum, pyoderma gangrenosum. aphthous mouth ulcers
Other: AI haemolytic anaemia, finger clubbing, growth failure, primary sclerosing cholangitis~, interstitial lung disease (rare)
*More common with Crohn’s
~More common with UC
Headache
- New acute onset? Headache part of chronic/recurrent headache history?
- Exclusion of intracranial haemorrhage (SAH), intracranial infection (meningitis, encephalitis)
SOCRATES
Neurological (LOC, motor/sensory deficit, gait, disturbances in vision, speech, hearing, incontinence)
Meningism (neck stiffness, photophobia, headache)
Infection: Fever, diarrhoea, malaise
Rashes
Scalp tenderness when brushing hair/pain on chewing gum (temporal arteritis)
Nausea and vomiting
Visual disturbance/ aura
Watering of eyes/nasal congestion (cluster headaches)
Wears glasses?
PMH: kidney disease (damage kidney->hypertension->PKD->berry anneurysm-> SAH), TIA/stroke, migrain/tension headache
Subdural haemorrhage features
Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms
More common in ELDERLY and ALCOHOLICS
Extradural haemorrhage features
Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms
More common in YOUNG (dura mater less fixed to skull) and ALCOHOLICS
Intracranial haemorrhage features
Sudden onset, severe headache Symptoms of raised ICP (waking up with headache, vomiting without nausea) Focal neurology (corresponds to area of brain damaged)
Subarachnoid haemorrhage features
Sudden onset, severe headache
Meningism (neck stiffness, photophobia, headache)
Drowsiness/ LOC
Focal neurology
Meningitis/encephalitis features
Fever
Rash (non-blanching, meningococcal septicaemia)
Meningism (neck stiffness, photophobia, headache)
Infective symptoms: flu-like, sweating, malaise, joint pain, diarrhoea
Nausea and vomiting
Drowsiness/ LOC
NOTIFY PUBLIC HEALTH AUTHORITIES OF MENINGOCOCCAL INFECTION (immunisation and prophylaxis for contacts, rifampicin for ‘kissing’ contacts)
Space occupying lesion features
Absence of other clear diagnosis for headache
Old age at onset
Focal neurological symptoms and signs
Headache on walking (more commonly caused by migraine)
Vomiting without nausea
Temporal arteritis features
Usually in patients >60years Frontal or occipital Jaw pain (whilst eating or talking) Scalp tenderness Visual disturbances Malaise and proximal muscle weakness
Cluster headache features
Localised around one eye, associated with anatomical features such as lacrimation and nasal congestion
Occurs for 15 mins- 2 hours for 6-8 weeks, then subsiding for months
Cervical spondylosis features
Headache associated with neck pain
Worsens with neck movements
Migraine features
Chronic or recurrent headache
May have a prodrome or aura (only ~10% of those with migraines will have neurological aura)
Non- specific triggers (cheese, chocolate, stress)
Related to OCP
Photophobia or other visual disturbances such as zigzag lines
Nausea and vomiting
Family Hx
Tension headache features
Band-like dull ache, sometimes with sharp exacerbations
In scalp rather than cranium
Can last throughout the day, worsening in evening
May get tired or dizzy
Intermittent claudication
SOCRATES
Sudden pain: embolic>thrombotic
Radiation: dermal distribution consider nerve compression
Worse when bending/twisting: musculoskeletal pain/ spinal stenosis
Worse at night: in PVD patients hang leg off side of bed to reduce pain, improves circulation with assistance from gravity
Foot ulcers
Feet feel numb or cold? (warm if collateral vessels have developed)
Impotence (phrase sensitively)
Muscle weakness
Angina
Palpitations in context of AF
Malignancy (increased risk of thrombotic disease)
CVS risk factors
Buttock/thigh pain indicates?
Arterio-iliac disease
Calf pain indicates?
Femero-popliteal disease
Acute embolism symptoms
Sudden onset
AF/mural thrombus/post MI
No other symptoms of intermittent claudication
Cold leg (no time for collateral supply formation)
Normal vasc exam in other leg
Ix for intermittent claudication
Doppler, MRA, CTA Urinalysis, BP, ECG Bloods : FBC, U&E, lipid profile, fasting glucose Exercise testing Electrocardiography
Management for intermittent claudication
Risk factor management (stop smoking, weight loss, diet changes)
Exercise (develop collateral circulation)
Careful not to injure leg
Aspirin, statins, ACEi
Treat risk factors: hypertension, diabetes
Breast history
Breast lump:
- Site, size, consistency, painful
- Onset
- Preceding trauma
- Breast/nipple changes
- Nipple discharge (bloody?)
- Changes throughout menstrual cycle
- Similar lump in past?
- Parity, LMP
- Breastfeeding (protective)? Duration?
- SOB
- Skin changes elsewhere
- Weight loss
- Swelling (especially arm on affected side)
- Malaise
- Backache
Ask about OCP, HRT
Risk factors: previous breast cancer, smoking, early menarche, late menopause, nulliparity, family Hx of breast or ovarian cancer (age, 1st degree)
Breast cancer management
Medical:
- CMF chemo (cyclophosphamide, methotrexate, 5-flurouracil)
- Hereceptin
- Tamoxifen
- Aromatase inhibitor (letrozole, anastrozole, exemestane)
Surgical:
- Wide local excision of lump (sentinel lymph node biopsy)
- Simple mastectomy
Axilliary node clearance additionally done:
- USS/FNAC/core needle biopsy positive for metastasis
- Sentinel node biopsy positive for mets
(morbodities: lymphoedema, bruising, shoulder stiffness, reduced movement)
Cosmetic:
nipple tattoo, abdominal sheath flap, latissimus dorsi flap.
DDx for breast lump
Fibroadenoma (20-35 yrs) Fibrocystic change (20-40 yrs) Abscess (20-30 yrs, child bearing age) Cyst (40-50 yrs, perimenopausal) Malignancy (40-70)
Back pain
SOCRATES Bone pain? Constant or progressive? Nocturnal pain? Does pain radiate to foot? (Sciatic pain) Problems walking? Cancer Hx (ask about type and Tx) Incontinence (fecal/urinary) Difficulty passing urine Bowel/bladder symptoms Numbness, tingling, leg weakness (peri-anal numbness =saddle anaesthesia Fever, unexplained weight loss, night sweats Morning stiffness Leg claudication
Back pain causes in 15-30 years
Trauma, fracture, prolapsed disc, ankylosing spondylitis
Back pain causes in 30-50 years
Degenerative disease, prolapse disc, malignancy (mets e.g. breast, lung, prostate, kidney, thyroid cancer)
Back pain causes in 50 years+
Degenerative disease, osteoporosis (wedge fracture), malignancy, myeloma
Mechanical back pain:
- Low back pain arising from an anatomical structure e.g. muscle, ligament or intervertebral disc due to trauma, deformity, degenerative change
- Osteoporotic fracture
Clinical presentation: Sudden onset Eased by rest Unilateral Increased by coughing/sneezing Heavy lifting...
Muscular pain, not central (paraspinal muscles)
Inflammatory back pain:
- Inflammatory spondylitis
- Epidural abscess
- Malignancy
- Paget’s disease
Clinical presentation:
Predominant stiffness (>30mins in the morning)
Gradual onset and progressive
Increased pain with rest
Disturbs sleep
Stiff/rigid spine on examination, symmetrical restriction +/- joint tenderness
Cauda equina syndrome
Compression of the cauda equina e.g. posterior disc herniation, metastatic deposits
Urinary and fecal incontinence Urinary retention Persistant, progressive Bilateral leg pain Normal leg pulses Pain eased by leaning forward Stiff spine on examination Bladder/bowel disfunction
URGENT ASSESSMENT AND MANAGEMENT: MRI and consideration for surgery, radiotherapy
Sciatica
Compression of a lumbosacral nerve root by a protruding disc
Pain radiates from buttock down back of leg and into foot
often accompanied by paraesthesia with same distribution
Conservative management (analgaesia + physio). ?Surgery
Discitis
Fever, systemic upset
Risk factors: injecting drug user
Joint pain/stiffness/swelling
SOCRATES Morning stiffness (30mins=inflammation, 5 mins=OA) Better or worse after exercise? Sleep disturbance Loss of function
Rheumatoid arthritis
Slowly progressive Symmetrical polyarthritis Small joints (commonly hand) Deforming Early morning stiffness
Gout
First MTP joint most commonly affected
Isolated swollen, hot painful joint
Hyperuricaemia risk factors e.g. diuretics, excess alcohol (esp. beer), renal disease
Psoriatic arthritis
Associated skin plaques, nail changes
Early morning stiffness
Many patterns of joint involvement
SLE
Systemic illness, intermittent fevers
Photosensitive rash
Generalised myalgia and arthralgia
Other systemic (psychological disturbance, pleuricy, ulcers)
Enteropathic arthritis
Symmetrical arthritis of lower limb joints and sacroiliac joints
Early morning stiffness
Symptoms/diagnosis of Crohn’s or UC
Osteoarthritis
Elderly
Worse on movement (rest helps) and at end of day
Septic arthritis
Isolated, hot, red swollen joint
Agonisingly painful
Systemically unwell with fever
Drug Hx
Current and recently prescribed drugs (GP, specialists, privately)
- Ask specifically about: contraceptives, ear/eye drops, inhalers, creams/ointments, injections, patches, vitamins, food, dietary supplements.
- Smoking and alcohol
- Ask about name, strength, formulation, frequency, dose, duration
- Indications (incl. patient’s perception)
Current and recent non-prescribed drugs (OTCs, complementary and herbal/homeopathic remedies, borderline substances, recreational drugs incl. illicit substances)
Any drug related problems (ADRs)
Allergies (non drug=eggs, nuts, drug allergies) and hypersensitivities (signs, symptoms, severity and duration)
Response to treatment
Treatment failure
Adherence to treatment regimens.
Alcohol Hx
CAGE questionnaire (>2, alcohol abuse/dependence)
How much in a week? How often? Binge or steady? What time? What makes you start drinking? (e.g. stress, alcohol availability) Where? (alone, with company) What do you drink (beer, wine, spirits) How much on a typical day?
Past alcohol Hx:
When did you start?
Longest period without drinking?
Family Hx of alcoholism?
Health problems associated with alcohol?
Anaemia
Cirrhosis, pancreatitis
GORD, peptic ulcer disease
Epilepsy, ataxia, peripheral neuropathy, amnesia
Depression (assess mood), hallucinations, Wernicke’s encephalopathy, Korsakoffe’s syndrome (assess cognition)
IHD, cardiomyopathy, hypertension
Screen for alcohol dependence syndrome
Social complications:
Absenteeism, loss of job, divorce, driving convictions, decreased job productivity, relationships trouble, police encounter
Prev. Tx:
Detox programmes, AA
Maintaining factors:
Access to alcohol? Social isolation? Avoidance of withdrawal symptoms
Assess motivation to change…
Alcohol dependence syndrome features
ICD-10, 3 of 6 criteria below (over 12 months):
-Strong desire, sense of compulsion to take substance
- Difficulties controlling intake of the substance (either its onset, termination or levels of use)
- Physiological withdrawal state or use of the same/similar substance to prevent such a withdrawal state- What happens when you stop drinking?
- Tolerance- Are you finding yourself drinking more to get drunk?
- Lack of other activities and interests
- Ongoing substance misuse despite clear evidence of harmful consequences.
Urological Hx
Dysuria Polyuria (fluid intake) Frequency, volume Urgency Nocturia Haematuria (how much? tiredness, breathlessness on exertion) Hesitency/terminal dribbling Poor urinary stream Urinary incontinence Fevers, rigors Nausea, vomiting ?Catheter
Cystitis
Dysuria, burning pain on urination
Frequency and urgency
Urethritis
Dysuria
Purulent urethral discharge
Pyelonephritis
Dysuria
Loin pain
Fever/chills/rigors
Vomiting
Benign prostatic hyperplasia
Poor flow, terminal dribbling
Hesitancy
Overflow incontinence
Elderly male
Bladder transitional cell carcinoma
Painless haematuria
History of aromatic amine exposure e.g. dye washers, painters, decorators
Urethral trauma (e.g. catheter)
History of catheter use or trauma
UTI
Frequency/urgency/dysuria
Calculi
Loin to groin pain
Diabetes mellitus
Polydipsia/thirst Polyuria Weight loss Tiredness Visual disturbance
Diabetes insipidus
Polydipsia/thirst
Polyuria
Chronic kidney disease
Non-specific symptoms e.g. fatigue, weakness, puritis, dyspnoea
Stress incontinence (incompetent sphincter)
Small losses with effort e.g. coughing, bending, exertion
Risk factors: multiple pregnancies, post-menopause
Urge incontinence (Detrusor instability in idiopathic cystitis or stone. Hhyperreflexia such as in MS, CVA, spinal cord injury)
Urge to pass urine followed by uncontrollable bladder emptying
Overflow incontinence (prostatic hypertrophy, stricture or stone)
Dribbling and poor stream
Hesitency
Elderly male or history of obstruction
Fistula between bladder and vagina or urethra
Continuous urine leak
Urethral stricture
Retention
History of trauma or recurrent catheter use
Bladder neck obstruction (e.g. tumour, calculus)
Retention
Haematuria
