History Taking- Systematic Enquiries

Question 1

What are the systematic enquiries for ‘General Health’?

Answer 1

• Wellbeing - Energy
• Appetite - Sleep
• Weight Change - Mood

Question 2

What are the systematic enquiries for the ‘Cardiovascular System’?

Answer 2

• Chest pain on exertion (angina)
• Breathlessness:
  Lying Flat (Orthopnea)
  At night (paroxysmal nocturnal Dyspnoea)
  On Minimal Exertion; record how much
• Palpitation
• Pain in legs on walking (claudication)
• Ankle Swelling

Question 3

What are the systematic enquiries for the ‘Respiratory System’?

Answer 3

• Shortness of breath
• Cough
• Wheeze
• Sputum production (colour, amount)
• Blood in sputum (haemoptysis)
• Chest pain (due to inspiration or coughing)

Question 4

What are the systematic enquiries for the ‘Genitourinary System’?

Answer 4

• Pain passing urine (dysuria)
• Frequency passing urine (at night, nocturia)
• Blood in the urine (haematuria)
• Libido
• Incontinence (stress and urge)
• Sexual partners - unprotected intercourse

Question 5

What are the systematic enquiries for the ‘Genitourinary System - Men’?

Answer 5

If appropriate...
-Prostatic symptoms, including difficulty starting, hesitancy
Poor stream or flow
Terminal dribbling
- Urethral discharge
- Erectile difficulties

Question 6

What are the systematic enquiries for the ‘Genitourinary System - Women’?

Answer 6

• Last menstrual period (consider pregnancy)
• Timing and regularity of periods
• Length of periods
• Abnormal bleeding
• Vaginal discharge
• Contraception
• If appropriate:
  Pain during intercourse (dyspareunia)

Question 7

What are the systematic enquiries for the ‘Nervous System’?

Answer 7

• Headaches
• Dizziness
• Faints
• Fits
• Altered Sensation
• Weakness
• Visual disturbance
• Hearing problems (deafness, tinnitus)
• Memory and concentration changes

Question 8

What are the systematic enquiries for the ‘Musculoskeletal System’?

Answer 8

• Joint pain, stiffness or swelling
• Mobility
• Falls

Question 9

What are the systematic enquiries for the ‘Endocrine System’?

Answer 9

• Heat or cold intolerance
• Change in sweating
• Excessive thirst

Question 10

What are the systematic enquiries for (‘Other’)?

Answer 10

• Bleeding or bruising

- Skin rash

Question 11

What are the systematic enquiries for the ‘Gastrointestinal System - Men’?

Answer 11

• Mouth (oral ulcers, dental problems)
• Difficulty swallowing (dysphagia- distinguish from pain on swallowing, i.e. odynophagia
• Nausea and vomiting
• Vomiting blood (haematemisis)
• Indigestion
• Heartburn
• Abdominal Pain
• Change in bowel habit
• Change in colour of stools (pale, dark, tarry black, fresh blood)