History Taking Flashcards
What order should you take a history in
Presenting complaint
Hx of presenting complaint
Systems review
Past Medical Hx
Drug Hx, including allergies
Family Hx
Social Hx
What should you ask about in a general Hx taking
Fatigue/ malaise
Fever/rigors/ night sweats
Weight/ appetite
Skin (rashes/bruises)
Sleep
What should you ask about in a CVS Hx taking
Chest pain
SOB
Palpitations
Ankle swelling
What should you ask about SoB for clarification
on exercise/ orthopnoea/ PND
What should you ask about in a resp Hx taking
Chest pain
SoB; wheeze
cough
sputum/ haematemesis/ haemoptysis
What should you ask about in a GI Hx taking
appetite/ weight loss
dysphagia
Nausea/ vomiting/ haematemisis
Indigestion/ heartburn
Jaundice
abdo pain
bowel changes: diarrhoea/ constipation/ blood/ mucus
do others in the house/ contact have similar symptoms
What should you ask about in a gynae/ urological Hx taking
frequency/ dysuria/ nocturia/ polyuria/ oliguria
haematuria
incontinence/ urgency
prostatic symptoms
menstrual symtoms:
-menarche
- duration and heaviness of bleeding
- menorrhagia
- dysmenorrhoea/ dyspareunia
- menopause/ post-menopausal bleeding
What should you ask about in a neuro Hx taking
headache
fits/ faints/ loss of consciousness
dizziness
vision - acuity/diplopia
hearing
weakness
numbness/ tingling
loss of memory/ personality changes
anxiety/ depression
What should you ask about in a MSK Hx taking
key questions: Pain/ swelling/ stiffness - muscles/ joints/ back
able to wash/ dress without difficulty
able to ascend/descend stairs without help
other helpful questions:
morning stiffness
diffuse or localised pain
What are the likely diagnoses for a patient with no early morning stiffness and diffuse pain
chronic pain syndromes
fibromyalgia
malignancy
these patients rarely have joint swelling
What are the likely diagnoses for a patient with early morning stiffness and diffuse pain
polymyalgia rheumatica
inflammatory myositis
What are the likely diagnoses for a patient with no early morning stiffness and localised pain
OA/ Arthropathy
Tendinopathy
Bursitis
these patients rarely have joint swelling
What are the likely diagnoses for a patient with early morning stiffness and localised pain
Monoarticular:
-sepsis
-crystals
-reactive spondylarthritis
Polyarticular:
-Rheumatoid
- viral (if <6 weeks)
-SLE
-spondylarthritis crystals
Give a mnemonic to remember the most common causes of peripheral neuropathy
The mnemonic DANG THERAPIST is helpful in recalling the more common causes of
peripheral neuropathy:
Diabetes Mellitus
Alcohol
Nutritional (B12 deficiency)
Guillain-Barre Syndrome
Toxins (Pb, As, Zn, Hg)
Hematologic (paraproteins)
Endocrine (hypothyroid)
Rheumatologic (SLE, rheumatoid arthritis, vasculitis)
Amyloid
Porphyria
Infectious (syphilis, HIV)
Sarcoid
Tumor (paraneoplastic neuropathy)
Describe a chest pain Hx
WIPERQQ
Ask about presenting complaint
SOCRATES
-for associated symptoms ask about cardio-respiratory symptoms such as SoB, palpitations, orthopnoea, paroxysmal nocturnal dyspnoea, haemoptysis, sputum, calf swelling
-systemic symptoms eg fevers, weight loss, nausea/ vomiting, other pains
Ask for VTE risk factors:
-recent surgery, flights, past VTEs, FHx of clotting disorder, malignancy (think Wells Score)
Ask for heart disease risk factors:
- diabetes, HTN, FHx, cholesterol, previous heart disease/ interventions
PMHx (including previous episodes and treatment) and drug(+allergy) Hx
Social - job, alcohol, drugs, smoking, exercise, diet
In the context of a TIA/stroke patient, what is important to look for throughout the hx
pay attention to how the patient is communicating with you to identify neurological signs such as:
Dysarthria: a motor speech disorder resulting in poor articulation.
Dysphasia: a language disorder resulting in difficulties in the generation of speech (expressive dysphasia) or difficulties in the comprehension of speech (receptive dysphasia).
In a TIA/stroke Hx, what is a useful way to ask about the presenting complaint (after open questions and golden minute)
Due to the nature of TIAs and strokes, it can be useful to first ask some simple questions, such as the patient’s age, the month and what they believe your job role to be. This can enable you to quickly establish:
- if the patient is orientated
- if the patient is able to understand you
- if you are able to understand the patient
A collateral history is often very valuable in the context of suspected stroke or TIA, particularly when the patient is unable to communicate effectively.
In a TIA/stroke history, what are important features of the presenting complaint to find out (7)
Onset
Severity
Course
Precipitating factors
Associated features
Previous episodes
Dominant hand
Why is discovering the onset of a stroke/TIA important
How could you ask this?
What may make the answer more complicated/unclear?
The time at which the patient’s symptoms developed is very important as this helps to both differentiate between a TIA and stroke as well as informing management options (e.g. thrombolysis window).
Establish the onset time of the patient’s symptoms:
“When did you first notice the symptom(s)?”
“How long have the symptom(s) been present?”
If a patient has woken up with symptoms (but had none before going to sleep) the onset time is assumed to be when they went to sleep. Make sure to ask the patient if they got up in the night for any reason (e.g. toilet) and if they noticed symptoms at that time, as this may make the difference between whether they are within the thrombolysis window or not.
How can you determine the severity of a stroke/TIA from a history (7)
Explore the severity of the patient’s symptoms:
Weakness: subtle (e.g. clumsy hand), moderate or complete paralysis.
Sensory disturbance: paraesthesia or complete loss of sensation.
Visual disturbance: roughly quantify how much of the visual field is affected.
Expressive dysphasia: clarify if the patient was able to speak at all.
Receptive dysphasia: clarify if the patient is able to understand any communication.
Dysarthria: ask if the patient’s speech was mildly slurred or incomprehensible.
How do you ask about the course of a stroke/TIA
Explore how the patient’s symptoms have evolved since their onset:
“Have the symptoms improved since they first began?”
“When were your symptoms at their worst?”
“Are the symptoms coming and going?”
How do you ask about the precipitating factors of a stroke/TIA
Try to identify if there was an obvious trigger for the symptoms:
“What were you doing at the time that the symptoms developed?”
In cases of carotid artery dissection (a rare cause of ischaemic stroke), there may be a history of neck trauma. In most cases, however, there is no obvious precipitant.
What associated symptoms should you look for in a stroke/TIA hx (5)
Headache, nausea, vomiting, neck stiffness: associated with raised intracranial pressure (e.g. malignant middle cerebral artery syndrome), subarachnoid haemorrhage and bacterial meningitis.
Unilateral headache: suggestive of migraine which can present with neurological symptoms that mimic stroke (e.g. hemiplegic migraine).
Fevers: may indicate infective aetiology such as septic emboli in infective endocarditis.
Nausea, vomiting and dizziness: associated with posterior circulation strokes.
Palpitations: associated with atrial fibrillation which may be the underlying embolic source.
Why ask for a possible stroke/TIA patient’s dominant hand
It is useful to know this prior to performing clinical examination.
Give key stroke/ TIA symptoms that you should ask direct/focussed questions on when taking a hx (8)
Weakness
Sensory disturbance
Visual disturbance
Speech disturbance
Ataxia
Dysphagia
Reduced level of consciousness
Pain
How should you assess for ataxia in a stoke/TIA hx
Ask the patient if they have noticed any problems with their balance or coordination:
“Have you noticed any difficulties with balancing or problems with coordinating the movement of your arms or legs?”
Gather more details about the ataxia including:
Impact on the patient’s ability to walk and use their limbs to carry out tasks.
Presence of associated symptoms suggestive of a posterior circulation stroke (e.g. vertigo, nausea).
What might different speech problems sound like in a stroke
Clarify the type of speech disturbance:
Expressive dysphasia: “I knew what I wanted to say, but I couldn’t get it out”
Receptive dysphasia: “I wasn’t able to understand anyone, they were speaking gibberish”
Dysarthria: “My speech was really slurred, it sounded like I was drunk”
What is a symptom of stroke/TIA that can be dangerous if missed
Dysphagia
Ask the patient if they have noticed any dysphagia:
“Have you experienced any difficulties when trying to swallow food or liquids?”
Gather more details about the dysphagia including:
Solid foods: “Are you able to manage solid foods?” “Does it feel like they get stuck in your gullet?”
Liquids: “Do you struggle to drink liquids?” “Do you find yourself coughing after drinking liquids?”
Dysphagia is common in stroke and if not recognised early it can lead to aspiration pneumonia and choking episodes
What drugs might a patient be on if they have previously had a stroke
Medications commonly prescribed to patients with stroke or TIA include:
Antiplatelets (e.g. aspirin, clopidogrel)
Anticoagulants (e.g. warfarin, apixaban, rivaroxaban, dabigatran)
Antihypertensives (e.g. lisinopril, amlodipine)
Statins (e.g. atorvastatin)
Name 2 medications that increase the risk of stroke
Medications which increase the risk of ischaemic stroke include:
Combined oral contraceptive pill
Oral hormone replacement therapy
What are 2 important parts of a TIA/stroke social hx that might be forgotten
occupation:
Assess the patient’s level of activity in their occupation (sedentary jobs are associated with increased cardiovascular risk).
If the patient is experiencing TIAs it is important to advise them to take time off work until they have been fully investigated, particularly if working at heights or with heavy machinery.
Driving
If the patient drives and has presented with TIAs or stroke it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues. A TIA or stroke may result in temporary or permanent restrictions on the patient’s ability to continue driving (this will depend on the clinical features of the episode and residual neurological deficits).
In a headache history, what are important features of the pain that should be picked up upon?
site - Migraines typically present as a unilateral headache whereas bilateral headache is most commonly associated with a tension headache.
Onset -
In a headache history, what are important features of the pain that should be picked up upon?
site - Migraines typically present as a unilateral headache whereas bilateral headache is most commonly associated with a tension headache.
Onset - sudden thunderclap in SAH
Radiation - to the neck =meningitis; face may = trigeminal neuralgia; eye = acute closed-angle glaucoma.
Time - worse in the mornings are suggestive of raised intracranial pressure (e.g. space-occupying lesion).
What may exacerbate or relieve headaches
Triggers for headaches may include caffeine, excessive codeine use, stress, coughing (suggestive of raised ICP), lying flat (suggestive of raised ICP) and standing up (suggestive of low ICP).
Relieving factors for headaches may include hydration, standing up (suggestive of raised ICP) and lying down (suggestive of low ICP).
Give 10 associated features of headaches and what they may indicate
Nausea and vomiting: may indicate raised intracranial pressure (e.g. space-occupying lesion).
Visual disturbance: may be migraine aura related or secondary to local neural compression by a space-occupying lesion or haemorrhage.
Photophobia: most commonly associated with migraine, but also a typical finding in meningitis which may be chemical (e.g. subarachnoid haemorrhage) or infective (e.g. bacterial meningitis).
Neck stiffness: commonly associated with meningitis but may also be due to musculoskeletal issues of the neck which can also cause headaches (cervicogenic headache).
Fever: indicative of an infective process which may be viral (e.g. HSV encephalitis), bacterial (e.g. cerebral abscess) or fungal (e.g. fungal meningitis).
Rash: a non-blanching purpuric rash may indicate meningococcal sepsis.
Weight loss: may indicate underlying malignancy (e.g. primary intracranial tumour or brain metastases).
Sleep disturbance: headaches which disturb sleep are concerning for serious underlying pathology (e.g. raised intracranial pressure).
Temporal region tenderness: associated with temporal arteritis. Patients may report tenderness when brushing their hair.
Neurological deficits: these may include motor or sensory deficits, cognitive symptoms or a reduced level of consciousness. Different patterns of these symptoms may be present in a wide range of pathology (e.g. migraine, space-occupying lesions, intracranial infection and intracranial haemorrhage).
What are the red flag symptoms to ask about in a headache hx (8)
Sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid haemorrhage).
Worsening headache associated with fever, meningeal irritation (i.e. neck stiffness) and altered mental status (suggestive of bacterial, viral or fungal meningitis).
New onset focal neurological deficit, personality change or cognitive dysfunction (e.g. intracranial haemorrhage, space-occupying lesion, encephalitis, meningitis).
Decreased level of consciousness (e.g. raised intracranial pressure).
Recent head trauma within the last 3 months (e.g. subdural haemorrhage).
Headache which is posture dependent (e.g. a headache worse on lying down and when coughing is suggestive of raised ICP).
Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication (e.g. temporal arteritis).
Headache associated with severe eye pain, reduced vision, nausea and vomiting (e.g. acute angle-closure glaucoma)
What should you ask for in the systematic review of a patient with headache (6)
What would each be indicative of
Systemic: fevers (e.g. cerebral abscess, meningitis), weight change (e.g. malignancy)
Respiratory: dyspnoea, cough (e.g. lung cancer)
Gastrointestinal: dyspepsia, nausea, vomiting, dysphagia, abdominal pain (e.g. gastrointestinal malignancy)
Genitourinary: oliguria (e.g. dehydration)
Musculoskeletal: neck pain (e.g. cervicogenic headache)
Dermatological: rashes (e.g. meningococcal sepsis)
What condition is important to screen for in the drug history part of a headache hx
Medication-overuse headache
counterintuitively associated with medications used for the treatment of headache. Overuse of these medications is defined as use on more than 15 days of a month. Medications which are associated with medication-overuse headaches include:
Opiates (e.g. codeine and co-codamol)
Triptans
NSAIDs (e.g. ibuprofen, aspirin)
Paracetamol
What recreational drugs are associated with headaches
alcohol withdrawal headaches.
cocaine, amphetamines and cannabis.
What are the following associated with?
Dysuria
Urinary frequency
Urinary urgency
Nocturia
Haematuria
Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
Urinary frequency: commonly associated with UTIs.
Urinary urgency: may be associated with UTIs or detrusor instability.
Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hyperplasia).
Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
What urological problems are the following usually associated with
Urinary hesitancy, terminal dribbling and poor urinary stream.
Urinary incontinence
Fevers and rigors
Nausea and vomiting
Weight loss
Uraemic symptoms
Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hyperplasia).
Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
Fevers and rigors: typically associated with pyelonephritis.
Nausea and vomiting: typically associated with pyelonephritis.
Weight loss: associated with malignancy and uraemia.
Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.
What systematic symptoms should you screen for in a urological history
Systemic: fevers (e.g. UTI), weight change (e.g. malignancy)
Cardiovascular: palpitations (e.g. electrolyte derangement), chest pain (e.g. uraemic pericarditis)
Respiratory: dyspnoea (e.g. pulmonary oedema secondary to renal failure)
Gastrointestinal: abdominal pain (e.g. peritoneal dialysis associated infection)
Neurological: confusion (e.g. uraemic encephalopathy)
Musculoskeletal: muscle wasting (e.g. end-stage renal failure)
Dermatological: uraemic frost (e.g. end-stage renal failure)
Give 6 medical conditions that may be relevant to urological disease
Recurrent UTIs
Urinary incontinence
Prostate disease (e.g. benign prostatic hyperplasia, prostate cancer)
Renal disease (e.g. renal stones, pyelonephritis, chronic kidney disease)
Diabetes
Bleeding disorders (e.g. haemophilia)
Give 4 drugs often used to treat urological disease
Diuretics (e.g. furosemide): a common cause of nocturia and can cause acute kidney injury.
Alpha-blockers: commonly used to treat prostatic enlargement
Nephrotoxic medications (e.g. ACE inhibitors, NSAIDs): may cause acute or chronic kidney injury.
Antibiotics: commonly required for recurrent UTIs and may be prescribed as prophylaxis.
Why is it important to screen for drinking, occupation, and fluids/diet in urological history taking
Working with industrial dyes, textiles, rubber, plastics and leather tanning are associated with an increased risk of bladder cancer.
Patients who are chronically dehydrated are at increased risk of UTIs and renal impairment.
Alcohol is a significant risk factor for malignancy.
How can you remember the key symptoms to explore in a rheumatological history
PRISMS
Pain
Rashes, skin lesions and nail changes
Immune
Stiffness
Malignancy
Swelling and sweats
What does the R in PRISMS stand for in the rheumatology history
What should you be looking for
Rashes, skin lesions and nail changes
The presence of salmon pink plaques on extensor surfaces and nail changes such as onycholysis would suggest a diagnosis of psoriasis, which is closely associated with psoriatic arthritis.
What immune syndromes should you look out for in the rheumatology hx
SLE
Sjorgren’s (Dry eyes; Dry mouth; Chronic cough)
CREST
What are the key features of systemic sclerosis
key clinical features of systemic sclerosis can be remembered using the CReST acronym:
Calcinosis: the formation of calcium deposits in soft tissue.
Raynaud’s phenomenon: stress and cold temperature trigger arterial spasm causing reduced blood flow to the fingers and toes resulting in discolouration.
Oesophageal dysmotility: dysphagia affecting the mid to lower oesophagus.
Sclerodactyly: the progressive thickening of the skin distal to the metacarpophalangeal joints.
Telangiectasia: dilated capillaries which appear on the palms of the hands as well as the face and mucous membranes.
Name 4 rheumatological disease that lead to joint stiffness
Rheumatoid arthritis
Ankylosing spondylitis
SLE
Reactive arthritis
Ask the patient when the joint stiffness is at its worst (e.g. early mornings) and how it impacts on their daily activities (e.g. writing, buttoning up a shirt, brushing hair).
Why should you consider malignancy in a rheumatology hx
Rheumatological disease can present with similar features to malignancy such as fatigue, malaise and weight loss, therefore it’s important to consider malignancy in your differential diagnosis. Rheumatological disease can also develop secondary to malignancy due to paraneoplastic phenomena.
Give 4 extra-articular manifestations of rheumatological disease and what disease it is associated with
Uveitis (associated with ankylosing spondylitis)
Dry eyes (associated with Sjogren’s syndrome)
Interstitial lung disease (associated with rheumatoid arthritis and SLE)
Urethritis (associated with reactive arthritis)
Why is it important to ask about fevers in a rheumatology hx
The presence of joint swelling and fever requires urgent review and investigation to rule out septic arthritis.
What are symptoms that should be assessed in the systems review of the rheumatology hx
Systemic: fevers (e.g. discitis, septic arthritis), weight change (e.g. malignancy)
Cardiovascular: chest pain (e.g. pericarditis, myocarditis, costochondritis)
Respiratory: dyspnoea, cough (e.g. interstitial lung disease, sarcoidosis), pleuritic chest pain (e.g. pleuritis)
Gastrointestinal: nausea, dyspepsia, abdominal pain (SLE)
Genitourinary: dysuria (urethritis)
Neurological: seizures (SLE)
Musculoskeletal: joint pain, reduced range of joint movement (e.g. rheumatoid arthritis, psoriatic arthritis)
Dermatological: rashes (e.g. psoriasis), butterfly rash (e.g. SLE)
Medical conditions relevant to rheumatological disease include…?
Pre-existing rheumatological disease
Other autoimmune conditions
Previous gastrointestinal bleeding (NSAIDs contraindicated)
Recent infections including sexually transmitted infections (if considering septic arthritis or reactive arthritis)
Medications prescribed to patients with rheumatological disease include…?
Analgesics (e.g. paracetamol, NSAIDs, opiates)
Corticosteroids (e.g. prednisolone)
Anti-TNF agents (e.g. infliximab)
Biologics (e.g. rituximab)
