Systems enquiry Flashcards
Cardiovascular S/e
Chest pain
Palpitations
Pre-syncope / syncope
Shortness of breath
Orthopnoea
Exercise intolerance
Peripheral oedema
Respiratory S/e
Shortness of breath
Cough
Sputum
Wheeze
Haemoptysis
Chest pain
Gastrointestinal S/e
Weight loss
Appetite change
Working down body:
- Dysphagia
- Nausea & vomiting
- Indigestion / heartburn
- Abdominal pain
- Abdominal distension / bloating
- Jaundice
- Bowel habit
- Tenesmus
- Blood/mucous in stool
What are some changes in bowel habit?
Constipation
Dialarhoea
Steatorrhea (light = fat malabsorption)
Melaena (dark = blood)
Urological s/e
Storage:
- Frequency
- Volume
- Urgency
- Nocturia
- Any incontinence?
Infection:
- Dysuria
- Haematuria
- Odor
- Pelvic pain
Prostatic:
- Hesitancy
- Poor flow / dribbling
- Incomplete emptying
- Haematuria
Neurological
Weakness
Sensory - Numbness, pins & needles
Changes in sight, smell, hearing or taste
Loss of consciousness (funny turns)
Dizziness
Balance
Memory problems / confusion
Headache
Speech
Neck stiffness / photophobia
Ear s/e
Hearing loss / tinnitus
Pain (otalgia)
Discharge
Ear fullness
Nose s/e
Runny nose (rhinorrhoea)
Sneezing
Epistaxis (nose bleeds)
Menstrual history
LMP
Cycle length (duration)
Cycle regularity - are they predictable?
Heavy or light
Painful
Gravida/para
Menarche
Contraception
Last smear
Discharge
MSK s/e
Pain
Stiffness:
- Morning vs day
- Improves / worsens with activity
Joint swelling
Decreased range of motion
Crepitus
Locking
Breast s/e
Rashes / discoloration
Pain
Lumps
Discharge
Psychiatry s/e
Depression - low mood
Anxiety
Self harm / suicidal ideation
Sleep pattern
Difficulty concentrating
Body image
Paranoia
Anhedonia
Lack of energy
Mania episodes
Personality changes
Hyperthyroid s/e
Prefer cold weather
Mood swings
Sweaty
Diarrhoea
Oligomenorrhoea (infrequent)
Weight loss with increased appetite
Tremor
Palpitations
Visual disturbance
Hypothyroid s/e
Prefer hot weather
Slow
Tired
Depressed
Thin hair
Croaky voice
Heavy periods
Constipation
Dry skin
Diabetes s/e
Polydipsia (excessive thirst)
Polyuria
Appetite
Hypoglycaemia - dizziness, sweating, headache, hunger
Adrenal s/e
Blood pressure:
- Postural hypotension
- Hypertension
Darkened skin
Fatigue
Weight loss
Muscle weakness
Anaemia s/e
Shortness of breath
Fatigue
Weakness
Palpitations
Dizziness
Pallor
Bleeding episodes
Dietary intake
Lymphoma s/e
Painless swollen lymph nodes
B-symptoms:
- Night sweats
- Fever
- Weight loss
Fatigue
Loss of appetite
Throat s/e
Sore throat
Odynophagia
Dysphagia (solids vs liquids)
Fever, chills, night sweats
Weight loss
Cough
Rheumatology s/e
Joints - pain, stiffness, swelling
Work down body:
- Skin (rashes, ulcers, Raynaud’s)
- Hair loss
- Eyes (redness, dryness)
- Mouth (dryness)
- Chest (breathlessness)
- G.I (IBD symptoms)
- Genitourinary (discharge)
Pregnancy s/e:
Fetal movements
Nausea & vomiting
Vaginal bleeding or discharge
Abdominal pain
Pruritis (itching = obstetric cholestasis)
Leg swelling
P.E screen - Chest pain & SOB
Anaemia screen - fatigue, SOB
Pre-eclampsia:
- Headache
- Visual disturbance
- Epigastric pain
- Oedema
Female sexual history
Abnormal discharge - volume, colour, consistency, smell
Vaginal bleeding - pattern, volume, colour, impact on QOL
Dyspareunia (pain during sex) - location, duration, nature
Vulval skin changes - lumps, bumps or rashes, itchy?
Sore throat
Enlarged lymph nodes
Male sexual history
Discharge - colour, consistency, volume/frequency, smell
Dysuria
Haematuria
Testicular pain or swelling
Skin changes or lesions
Abdominal and pelvic pain
Rectal discharge, pain, lump
Anal skin changes
Sore throat
Enlarged lymph nodes
Depression history
Low mood
Anhedonia
Lack of energy
Fatigue
Associated symptoms:
- Disturbed sleep
- Change in appetite
- Agitation
- Poor concentration
- Nihilistic
- Feelings of worthless or guilt
- Reduced libido
- Thoughts of self-harm or suicide
Mania history
High mood
Irritability / impatience
Reduced sleep
Appetite
Associated symptoms:
- Reduced social inhibitions
- Reckless spendings
- Inappropriate sexual encounters
- Persecutory delusions
- Reduced concentration
- Self-neglect
- Loss of insight
Anxiety history
Worries
Feel wound up or tense
Always anxious or only sometimes
Panic attacks
Dissociation
Physical symptoms:
- Palpitations
- Chest pain
- Breathlessness
- Sweating, dizziness
- Dry mouth
- N&V
- Depression?
Psychosis history:
Hallucinations
- Hear noises and voices
- Being touched
- Insects crawling beneath skin
Delusions
OCD history:
Unpleasant thoughts or images
Unwanted thoughts
Repeatedly check things
Arrange, touch or count things repeatedly
Alcohol abuse screening - CAGE:
C - have you ever though of cutting down your drinking
A - have people annoyed you by criticising your drinking
G - have you ever felt guilty about drinking
E - have you ever felt you needed a drink in the morning to steady your nerves
Alcohol withdrawal history
Screen - CAGE
Nausea & Vomiting
Tremor
Sweating
Anxiety
Agitation
Tactile disturbance - bugs crawling on skin
Auditory disturbance - harsh sounds
Visual disturbance - photophobia
Headache
Orientation
Eating disorder history
Weight history (SLIM):
S - weight at different stages in life
L - periods of weight loss
I - ideal weight
M - minimum & maximum weights
Eating behaviour - breakfast, lunch + dinner
Adaptative behaviour:
- Exercise
- Binge eating
- Purging
Psych:
- Mood
- Social withdrawal?
Physical symptoms:
- Amenorrhoea
- Fatigue
- Constipation
- Dizziness
Red flags in anorexia?
Rapid weight loss
HR < 40
Low temperature
Recurrent syncope
ECG abnormalities
Severe dehydration
Unable to stand up from squatting
Paediatric s/e
Diet and fluid intake
Urine output
Stool
Vomiting
Weight & growth
Fever
Rash
Cough / SOB
Behaviour
Activity / alertness
Rashes
Headaches, abnormal movements
Paediatric red flags:
Loss of skills
Not fixing/following objects
Hearing loss
Low muscle tone/floppy
Persistent toe walking
One hand used more
5mo - Can’t hold objects
12mo - Can’t sit unsupported
18mo - No speech
18-24mo - Can’t walk
Paediatric history
