History Taking Flashcards
Tiredness
History of Presenting complaint
O - open question S - specific reason? O - onset? C - character of sleep? R - refreshment from sleep? A - associated features T - timing? E - exacerbating/ relieving factors? S - severity/ social impact?
Tiredness
Screening questions?
V - viral? (cough? sore throat? fever?)
H - hypothyroid? (cold? dry skin?)
M - menorrhagia? (Heavy periods? anaemia?)
C - cancer (weight loss?)
C - chronic fatigue syndrome? (headache? muscle ache?)
D - diabetes? (thirsty? urinary frequency?)
D - depression? (low mood?)
Tiredness
Past medical history?
Diabetes?
Thyroid?
IBS?
Fibromyalgia?
Fever
History of presenting complaint?
H - how do you feel generally? (tired? nausea? pain?)
O - onset (when did this start?)
T - timing/ triggers? (does it come and go? any triggers?)
S - screening questions
Fever
Screening questions?
Infective Respiratory (cough? sputum?) GI (diarrhoea? vomiting?) Urinary (frequency? pain?) Meningitis (stiff neck? headache?) Tropical (travel? insect bites?)
Malignancy (weight loss? cough? bowel habit? lumps?)
Other
Inflammatory arthritis (joint pain/ stiffness?)
Vasculitis (skin lesions? ulcers?)
DVT (leg swelling? hot leg?)
Rash
History of presenting complaint?
S O C - character? colour? R A - itchy? blanching? numb? SYSTEMIC SYMPTOMS T E - triggers? S - psychosocial impact?
Lumps and bumps
History of presenting complaint?
+ System review?
OSOCRATES (including pain? interference with ADL?)
SR:
Respiratory (cough? productive? blood? SOB?)
Gastro (weight loss? bowel habit? vomiting? blood?)
Urinary (pain? frequency? blood?)
MSK (aches? stiffness? pain?)
Lumps and bumps Differential: Anywhere? Abdo? Neck? Limb?
Anywhere: Lipoma, neuroma, lymph node
Abdo: Surgery, Polycystic kidney/ ovary
Neck: Thyroid, lymph node, parotid swelling
Limb: Joint fluid, ganglion, Baker’s cyst
Weight loss
History of presenting complaint?
O - open question (what have you noticed?)
Q - quantify (how much? in how long? weight?)
I - inentional?
A - appetite (any change?)
E - Exercise (any change?)
A - associated features (fever? night sweats?)
Weight loss
Systems review?
Respiratory (cough? fever? breathless?) GI (bowel habit? vomiting? blood?) Renal (frequency? pain? blood?) Neuro (Muscle weakness? pins and needles? visual?) MSK (aches? pains? stiffness?)
Jaundice
History of presenting complaint
O SOPRATES (progression NOT character) R - Ask about darkened urine/ pale stools
Jaundice
Screening questions?
Weight loss? Dark urine? Pruritis? Pale stool? Fatigue? Rash? Abdo swelling? Confusion?
Alcohol! How much? Binge? CAGE
Jaundice
Key things to ask about
PMH
Previous episodes?
Blood transfusion?
Gallstones?
SH
Drugs?
Travel?
Close contacts?
Claudication
History of presenting complaint?
Associated features?
OSOCRATES
A - Pain at night? ulcers? Hanging leg out of bed?
Assess claudication distance
Chest pain
HPC - Associated features
Nausea? Vomiting? Breathless? Orthopnoea? Palpitations? Cough? Weight loss? Exertion?
Breathlessness
History of presenting complaint?
O - onset P - progression E - exacerbating? R - relieving? A - associated symptoms? T - timing E - episodes S - severity
Breathlessness
HPC - Associated features?
C - cough? C - chest pain? F - fever? W - wheeze? A - anxiety? P - palpitations? S - sleeping flat or upright?
Palpitations
HPC - Associated features?
C - cardiac (chest pain? SOB? dizzy?)
A - anxiety
P - phaeochromocytoma (sweaty? HTN? Nausea? Abdo pain?)
T - thyroid (hot? weight loss? diarrhoea?)
Cough
History of presenting complaint?
O - onset P - progression E - exacerbating? R - relieving? T - timing (all the time? worse in morning? worse at night?) A - associated features
Cough
HPC - Associated features?
Sputum? Blood?
Wheeze? Breathless? Chest pain?
Malaise? Infection?
Weight loss? Reflux?
Haemoptysis
History of presenting complaint?
S - site (cough? nose bleed? mouth/ gums?)
O - onset
C - character? colour?
T - timing (how often blood when you cough?)
A - amount (streaks? cupfuls?)
Haemoptysis
Differential diagnosis?
Malignancy - chronic cough, weight loss
PE - chest pain, pregnancy/ flight/ surgery
Lung abscess - foul smelling production, swinging fever, preceding infection
TB - night sweats, travel
Pneumonia - rusty brown sputum
