Histories - exploring the symptoms

Question 1

Explore the symptoms of tiredness

(what other questions to ask in HPC?)

Answer 1

Tiredness

• what do they mean by ‘tiredness’: what, constant/episodic, duration
• how it affects the patient?
• sleep (amount, quality, any snoring/apnoeic episode)
• anaemia: SOB on excretion, dizziness, headache
• hypothyroidism: menorrhagia, intolerance to cold, weight gain
• depression: mood, early waking
• diabetes symptoms: polyuria, polydipsia

Question 2

Explore the symptoms of headache

(what other questions to ask in HPC?)

Answer 2

Headache

• SOCRATES
• meninginsm: rash, fever, photophobia, neck stiffness
• temporal arteritis: jaw claudication, scalp tenderness (e.g. while brushing hair), visual problems
• glaucoma: halos around the lights, visual blurring, red eyes
• associated neuro symptoms: fits, falls, LOC, dizziness, weakness, incontinence, numbness, tingling
• red flags (different flashcard)

Question 3

Red flags for headache (6 categories)

Answer 3

• intracranial bleed (thunderclap headache, recent trauma)
• raised intracranial pressure (posture/ valsava manouver relate)
• other: immunosupression, malignancy, focal neurology, age >50y
• meningitis (rash, fever, neck stiffness, photophobia)
• temporal arteritis (visual problems, scalp tenderness, jaw claudication)
• glaucoma (halos around the lights, blurring, red eye)

Question 4

Explore the symptoms of fit/fall/syncope

(what other questions to ask in HPC?)

Answer 4

*Get a collateral history

• Before: warning, circumstance
• During: LOC, color, movements, tongue biting/incontinence
• After: speed of recovery, weakness, amnesia, sleepiness/ confusion

*injuries from a fall?

Background to attacks: previous episodes, frequency, impact on life

Associated symptoms: cardio/respiratory/neuro (RoS)

*check if pt drives - may be restriction

Question 5

Explore the symptoms of SOB

(what other questions to ask in HPC?)

Answer 5

SOB

• current and previous/normal exercise tolerance (what makes them stop?)
• Orthopnea
• Paroxysmal Nocturnal Dyspnoea
• diurnal/ seasonal variation (if chronic)
• associated cardio-respiratory symptoms

(chest pain, palpitations, wheeze, cough, sputum, haemoptysis, leg swelling)

Question 6

Explore the symptoms of cough

(what other questions to ask in HPC?)

Answer 6

Cough

• productive/non-productive
• sputum
• hemoptysis
• diurnal/nocturnal variation
• triggers
• associated cardio-respiratory symptoms (SOB, wheeze, palpitations, chest pain, dizziness, leg swelling,)

Question 7

Explore the symptoms of sputum

(what other questions to ask in HPC?)

Answer 7

Sputum

• quantify: how much and how often
• color
• consistency
• any blood

Question 8

Explore the symptoms of hemoptysis

(what other questions to ask in HPC?)

Answer 8

• volume and frequency
• fresh vs altered blood
• nature of associated sputum/ mixed in

Question 9

Explore the symptoms of palpitations

(what other questions to ask in HPC?)

Answer 9

Palpitations

• slow or fast
• regular/irregular (ask pt to tap out palpitation rhythm on the table)
• any dizziness, SOB, sweating/clamminess, LOC, nausea
• associated cardiorespiratory symptoms (haemoptysis, wheeze, SOB,chest pain, cough, sputum, haemoptysis, leg swelling)

Question 10

Explore the symptoms of diarrhoea/ constipation

(what other questions to ask in HPC?)

Answer 10

• how much/how often
• colour/consistency/ content (mucus, blood)
• weight loss/appetite
• associated GI symptoms: dysphagia, nausea/vomiting, indigestion, heartburn/reflux, abdominal pain, bowel habit, tenesmus, blood/mucus in stool

Question 11

Explore the symptoms of dysphagia

(what other questions to ask in HPC?)

Answer 11

Dysphagia

• solid/liquids (what came first)
• constant/intermittent, progressive/non-progressive
• odynophagia
• weight loss, food intake
• associated GI and neuro symptoms

Question 12

Explore the symptoms of dyspepsia/reflux

(what other questions to ask in HPC?)

Answer 12

Dyspepsia

• SOCRATES
• associated GI symptoms
• red flags (different flashcard)

Question 13

Red flags for dyspepsia/reflux

(mnemonic + extras)

Answer 13

A L A R M S

A - anemia

L - loss of weight

A - anorexia

R - recent onset progressive symptoms

M - melaena/haematemesis

S - swallowing difficulties

* age >55 years

* >4 weeks relapsing symptoms

*persistent vomiting

Question 14

Explore the symptoms of vaginal discharge

(what other questions to ask in HPC?)

Answer 14

• quantity
• colour/ blood
• smell
• itching
• associated gynae symptoms: 4 P’s (different flashcard), examples: bleeding, dyspareunia, pain

Question 15

Obstetric and Gynae RoS/symptoms

(4 P’s)

Answer 15

PV bleeding: mennorhagia, intermenstrual, post-coital, post-menopasusal

PV discharge

Pain: pelvic, dysmenorrhoea, dyspareunia

Pregnancy:

• chance of pregnancy
• if pregnant: foetal movements, contractions/tightening, PV loss, pre-eclampsia symptoms (headache, visual disturbance, epigastric pain, oedema)

*also menstrual, obstetric,sexual and contraception/cervix history (MOSC)

Question 16

M O S C for gynae Hx

Answer 16

M - menstrual

O - obstetric

S - sexual

C - contraception and cervical

+ 4 P’s:

PV bleed

PV discharge

Pain

Pregnancy

Question 17

Explore the symptoms of abnormal PV bleeding

(what other questions to ask in HPC?)

Answer 17

• Type: menstrual/menorrhagia, intramenstrual, post-coital, post-menopausal
• Quantity: number of sanitary towels/tampons
• any clots/flooding
• associated pain
• anemia symptoms
• thyroid symptoms
• chance of pregnancy
• associated gynae symptoms (4 P’s)

Question 18

How to ask about/explore the symptoms in secondary amenorrhoea?

Answer 18

Work down the body

General: weight loss, stress, exercise, diet

Head: visual problems, headaches

Thyroid: hyperthyroidism symptoms

Torso: hirsutism, acne

Abdomen: possibility of pregnancy

Question 19

Explore the symptoms of back pain

(what other questions to ask in HPC?)

Answer 19

• explore as pain (SOCRATES)
• early morning stiffness
• sciatica
• urinary incontinence/retention; faecal incontinence/constipation
• neuro symptoms of lower limbs (paraesthesia, pain, weakness)
• red flags (separate flashcard)

Question 20

Red flags for back pain - manes of conditions only

Answer 20

• Cauda Equina
• Infection or cancer
• Spondyloarthropathy

Question 21

Red flag symptoms for cauda equina

Answer 21

• urinary incontinence/retention
• faecal incontience/constipation
• bilateral leg pain
• severe/progressive neuro deficit
• decreased anal tone
• saddle anaesthesia

Question 22

Red flags symptoms for infection/ cancer in back pain

Answer 22

• age <20 or >55
• weight loss
• fever/night sweats
• recent infection
• IVDU
• cancer history
• immunosupression

Question 23

Red flags symptoms for fracture in back pain presentation

Answer 23

• trauma
• severe central spinal pain
• structural spine deformity
• spinal tenderness

Question 24

Red flags symptoms for spondyloarthropathy in back pain

Answer 24

• early morning stiffness
• night pain
• worse with rest

Question 25

What two features would suggest an inflammatory cause of joint problems?

Answer 25

joint pain/stiffness/swelling

• worse in the morning
• last for longer than >30 minutes

Question 26

Joint pain/stiffness/swelling and …

A. Better with exercise

B. Worse with exercise

Possible causes

Answer 26

A. better with an exercise - inflammatory

B. worse with an exercise - osteoarthritis

Question 28

Describe lesion in a dermatology

Answer 28

1. Distribution and side (distal, flexor, extensor, generalised/localised, dermatomal)
2. Characteristics (SEC)

S- shape (circular, linear, annular, irregular)

E - edge and elevation (well-demarcated, ill-defined, raised/flat)

C - colour (erythematous, pigmented/depigmented, purpuric)

3. Secondary features: crust, scale, pigmentation, keratosis, lichenfication, erosion, excoriation, fissure, ulceration