History - Presenting complaint Flashcards
1
Q
Pain
A
SOCRATES
2
Q
All symptoms
A
Timeframe - duration, onset (sudden/gradual), progression, timing (intermittent/continuing)
3
Q
Tiredness
A
- Timeframe
- Sleep - hours, quality
- How it affects patient
- Associated symptoms
- Anaemia - breathless, dizziness, headache
- Hypothyroidism - constipation, weight gain, cold interolerance, menorrhagia
- Depression - mood, early morning wakening
- Diabetes - polydipsia, polyuria
4
Q
Headache
A
- Explore like pain
- Meningism - rash, fever, neck stiffness, photophobia
- Giant cell arteritis - visual problems, jaw claudication, scalp tenderness
- Glaucoma - visual blurring, red eye, halos around lights
- Neuro symptoms
5
Q
Weakness
A
- Pattern
- Characteristic features
- Neuro symptoms
6
Q
Fit/fall/syncope
A
- Before - warning, circumstance
- During - duration, movements, incontinence/tongue biting, complexion
- After - amnesia, muscle pain, sleepiness, injuries
- Background - previous, impact on life
- Cardiorespiratory and neuro symptoms
- Check if drives
7
Q
SOB
A
- Current v normal exercise tolerance
- Orthopnoea
- Paroxysmal
- Diurnal/seaonsal variation
- Cardioresp symptoms
8
Q
Cought
A
- Productive
- Triggers
- Nocturnal
- Cardioresp symptoms
9
Q
Sputum
A
- How much, how often
- Colour, consistency
- Blood
10
Q
Haemoptysis
A
- Volume and frequency
- Fresh or altered
- Any sputum
11
Q
Palpitations
A
- Fast or slow
- Regular or irregular
- DIzziness, LOC, nausea, sweating, dyspnoea
- Cardioresp symptoms
12
Q
Diarrhoea/constipation/vomiting
A
- How much, how often, night
- Colour, consistency and contents
- Weight loss, apetite
- GI symptoms
13
Q
Dysphagia
A
- Solids/liquids/both, which first
- Odynophagia
- Weight loss, food intake
- GI and neuro symptoms
14
Q
Dyspepsia/reflux
A
- Explore as pain
- GI symptoms
15
Q
Vaginal discharge
A
- Quantity
- Colour
- Gynae symptoms
16
Q
PV bleeding
A
- Type
- Quantity
- Pain
- Anaemia symptoms
- Thyroid symptoms
- Gynae symptoms
17
Q
Secondary amenorrhoea
A
- Work down body
- General - weight loss, exercise, diet
- Head - visual problems, headaches
- Thyroid - heat intolerance, tremor, palpitations, diarhoea
- Torso - hirutism, acne
- Abdomen - pregnancy
18
Q
Back pain
A
- Explore as pain
- Early morning stiffness
- Sciatica
- Urinary incontinence/retention
- Neuro symptoms of lower limbs
19
Q
Joint pain/stiffness/swelling
A
- Worse in morning and how long for
- Better with exercise
- Sleep disturbance
- Loss of function
- Rheumatology symptoms
20
Q
Bone/tissue/joint injury
A
- Explore as pain
- Stiffness/swelling
- Movemenet restriction/ability to weight bear
- Mechanical - locking, giving way
- Neuro distal symptoms
21
Q
A
22
Q
Rash
A
- Sites, size, shape
- Description - appearance, blisters, raised areas, colour, blanch
- Seconday - itchy, painful, crusty
- Exacerbating and relieving factors
- Rheumatology symptoms