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Flashcards in History Taking Deck (30)
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0
Q

Pain questions

A

SOCRATES

  1. Site
  2. Onset
  3. Character
  4. Radiation
  5. Associated symptoms
  6. Time frame
  7. Exacerbating/alleviating factors
  8. Severity
1
Q

Time frame questions

A

When did it start?
Acute or gradual onset?
Intermittent or continuous?

2
Q

Tiredness questions and Ddx

A
  1. What do you mean by tiredness?
  2. How are you sleeping?
  3. How does it affect your lifestyle?
  4. Anaemia, CHF (Do get short of breath on exertion?)
  5. Hypothyroidism (Constipation, weight gain, cold intolerance)
  6. Depression?
  7. Diabetes (Do you need to go to the bathroom/drink frequently?)
3
Q

Headache Ddx

A
  1. SOCRATES
  2. Meningitis (Rash/fever/neck stiffness)
  3. Temporal arteritis (visual problems, jaw claudication, scalp tenderness)
  4. Glaucoma (visual problems, red eyes, halos around lights)
  5. Neurological systems review
4
Q

Weakness Ddx

A
  1. Characterise (what do you mean by weakness?)
  2. Pattern of weakness (where are you weak?)
  3. Neurological systems review
5
Q

Fall questions

A
  1. Presymptoms/warning symptoms/
  2. What were you doing at the time?
  3. Did you lose consciousness? How long?
  4. Do you have any pain?
  5. Have you fallen before?
  6. How often do you fall?
  7. Cardiorespiratory, neurological systems review
6
Q

Shortness of breath

A
  1. Orthopnea
  2. Nocturnal
  3. Diurnal/seasonal variation
7
Q

Cough

A
  1. Non/productive - sputum/haemoptysis
  2. Triggers
  3. Nocturnal
8
Q

Palpitations

A
  1. Fast/slow
  2. Irregular/regular
  3. Dizziness
  4. Loss of consciousness
  5. Nausea
  6. Sweating
  7. Dyspnea
9
Q

Sputum

A
  1. Volume
  2. Frequency
  3. Colour
  4. Consistency
  5. Blood
10
Q

Haemoptysis

A
  1. Volume
  2. Frequency
  3. Fresh/altered
  4. Associated sputum
11
Q

Diarrhoea, constipation, vomiting

A
  1. Volume
  2. Frequency
  3. Colour
  4. Consistency
  5. Blood
  6. Bile (if vomiting)
12
Q

Dysphagia

A
  1. Solids -> liquids
  2. Constant/intermittent
  3. Progressive?
  4. Odynophagia?
  5. Weight loss?
  6. Neurological defects
13
Q

Dyspepsia

A
  1. SOCRATES
  2. Weight loss
  3. Melaena
  4. Swallowing difficulty
14
Q

Rash

A
  1. Duration
  2. Progression
  3. Frequency
  4. Location
  5. Size/shape
  6. Itchy/painful
  7. Exacerbating/alleviating factors
  8. Rheumatological systems review
15
Q

Back pain

A
  1. SOCRATES
  2. Stiffness?
  3. Deformity
  4. Sciatica
  5. Incontinence
16
Q

Joint pain/stiffness/swelling

A
  1. Time of day
  2. Duration
  3. Better with exercise
  4. Sleep disturbance
  5. Loss of function
17
Q

Bone/tissue injury

A
  1. SOCRATES
  2. Stiffness/swelling
  3. Movement restriction
  4. Weight bearing
  5. Locking/giving way
  6. Weakness/numbness/paresthesia
  7. Neurological/rheumatological systems review
18
Q

Systems review - general

A
  1. Fever
  2. Night sweats
  3. Weight loss
  4. Fatigue
  5. Rash/bruising
19
Q

Systems Review - Neurological

A
  1. Falls
  2. Headache
  3. Dizziness
  4. Weakness
  5. Incontinence
  6. Numbness
  7. Tingling
20
Q

Systems review - ENT

A
  1. Hearing loss
  2. Tinnitus
  3. Rhinorrhoea
  4. Epistaxis
  5. Sore throat
  6. Odd operatic
21
Q

Systems review - Cardiorespiratory

A
  1. Chest pain
  2. Palpitations
  3. SoB
  4. Cough
  5. Leg swelling
22
Q

Gastrointestinal

A
  1. Appetite change
  2. Dysphagia
  3. Nausea/vomiting
  4. Indigestion
  5. Abdominal pain
  6. Change of bowel habits
  7. Blood/mucus in stool
23
Q

Systems review - urology

A
  1. How often do you need to pass urine
  2. How much urine do you pass
  3. Do you get up at night to go toilet
  4. Dysuria?
  5. Haematuria
  6. Hesitancy, poor flow (men)
  7. Incomplete emptying (men)
24
Q

Systems review - Rheumatological

A
  1. Joint pain, stiffness, swelling
  2. Ulcers
  3. Rashes
  4. Hair loss
25
Q

System review - Orthopaedic

A
  1. Joint pain,stiffness, weight bearing
  2. Bone pain, stiffness, weight bearing
  3. Mechanical locking, giving way
  4. Weakness
  5. Numbness, paresthesia.
26
Q

Past medical history

A
  1. Longstanding medical conditions (asks specifically if risk factors for Ddx)
  2. Past operations

For each, ask when dx, treatment and how well controlled.

27
Q

Drug history

A
  1. Medications (dose + frequency)

2. Allergies (+adverse reaction)

28
Q

Social history

A
  1. Smoking
  2. Alcohol
  3. Living situation
  4. Occupation
  5. Travel
29
Q

Family history

A
  1. Diseases that run in the family

Ask specifically for Ddx