History Taking Flashcards
Pain questions
SOCRATES
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Time frame
- Exacerbating/alleviating factors
- Severity
Tiredness questions and Ddx
- What do you mean by tiredness?
- How are you sleeping?
- How does it affect your lifestyle?
- Anaemia, CHF (Do get short of breath on exertion?)
- Hypothyroidism (Constipation, weight gain, cold intolerance)
- Depression?
- Diabetes (Do you need to go to the bathroom/drink frequently?)
Headache Ddx
- SOCRATES
- Meningitis (Rash/fever/neck stiffness)
- Temporal arteritis (visual problems, jaw claudication, scalp tenderness)
- Glaucoma (visual problems, red eyes, halos around lights)
- Neurological systems review
Weakness Ddx
- Characterise (what do you mean by weakness?)
- Pattern of weakness (where are you weak?)
- Neurological systems review
Fall questions
- Presymptoms/warning symptoms/
- What were you doing at the time?
- Did you lose consciousness? How long?
- Do you have any pain?
- Have you fallen before?
- How often do you fall?
- Cardiorespiratory, neurological systems review
Shortness of breath
- Orthopnea
- Nocturnal
- Diurnal/seasonal variation
Cough
- Non/productive - sputum/haemoptysis
- Triggers
- Nocturnal
Palpitations
- Fast/slow
- Irregular/regular
- Dizziness
- Loss of consciousness
- Nausea
- Sweating
- Dyspnea
Sputum
- Volume
- Frequency
- Colour
- Consistency
- Blood
Haemoptysis
- Volume
- Frequency
- Fresh/altered
- Associated sputum
Diarrhoea, constipation, vomiting
- Volume
- Frequency
- Colour
- Consistency
- Blood
- Bile (if vomiting)
Dysphagia
- Solids -> liquids
- Constant/intermittent
- Progressive?
- Odynophagia?
- Weight loss?
- Neurological defects
Dyspepsia
- SOCRATES
- Weight loss
- Melaena
- Swallowing difficulty
Rash
- Duration
- Progression
- Frequency
- Location
- Size/shape
- Itchy/painful
- Exacerbating/alleviating factors
- Rheumatological systems review
Back pain
- SOCRATES
- Stiffness?
- Deformity
- Sciatica
- Incontinence
Joint pain/stiffness/swelling
- Time of day
- Duration
- Better with exercise
- Sleep disturbance
- Loss of function
Bone/tissue injury
- SOCRATES
- Stiffness/swelling
- Movement restriction
- Weight bearing
- Locking/giving way
- Weakness/numbness/paresthesia
- Neurological/rheumatological systems review
Systems review - general
- Fever
- Night sweats
- Weight loss
- Fatigue
- Rash/bruising
Systems Review - Neurological
- Falls
- Headache
- Dizziness
- Weakness
- Incontinence
- Numbness
- Tingling
Systems review - ENT
- Hearing loss
- Tinnitus
- Rhinorrhoea
- Epistaxis
- Sore throat
- Odd operatic
Systems review - Cardiorespiratory
- Chest pain
- Palpitations
- SoB
- Cough
- Leg swelling
Gastrointestinal
- Appetite change
- Dysphagia
- Nausea/vomiting
- Indigestion
- Abdominal pain
- Change of bowel habits
- Blood/mucus in stool
Systems review - urology
- How often do you need to pass urine
- How much urine do you pass
- Do you get up at night to go toilet
- Dysuria?
- Haematuria
- Hesitancy, poor flow (men)
- Incomplete emptying (men)
Systems review - Rheumatological
- Joint pain, stiffness, swelling
- Ulcers
- Rashes
- Hair loss
System review - Orthopaedic
- Joint pain,stiffness, weight bearing
- Bone pain, stiffness, weight bearing
- Mechanical locking, giving way
- Weakness
- Numbness, paresthesia.
Past medical history
- Longstanding medical conditions (asks specifically if risk factors for Ddx)
- Past operations
For each, ask when dx, treatment and how well controlled.
Drug history
- Medications (dose + frequency)
2. Allergies (+adverse reaction)
Social history
- Smoking
- Alcohol
- Living situation
- Occupation
- Travel
Family history
- Diseases that run in the family
Ask specifically for Ddx
Time frame questions
When did it start?
Acute or gradual onset?
Intermittent or continuous?