HISTORIES

CARDIO
Risk factors
Smoking
Alcohol
Diabetes
Hypertension
Hyperlipidaemia (high chol)
PMH: angina, MI, CVA, IHD, PVD
FHx: above + DM
Lifestyle: diet, exercise, stress (ask occupation and recent changes in lifestyle!)

Palpitations
Drum out beat- how fast, regular, etc
Duration- how long have you had palpitations? How long does each episode last- interval between episodes?
How frequently do you get them?
What were you doing at the time- does it come on at a particular time?
Precipitating factors: nicotine, stress, caffeine
PMH:
Anxiety/panic attacks?
AF
Stroke
Angina
ASx:
SoB
Chest pain
N&V

Asthma (Salbutamol)
thyrotoxicosis (tremor, sweat, goitre)
DM- hypoglycaemia (hunger, jittery, faint, confusion)

Dizzy, faint
LoC, syncope, collapse
Grey, sweaty, cold peripheries

FLAWS: fever, lethargy, appetite, weight loss, sweats/shakes (rigors)

Impact on daily life
Dyspnoea- Shortness of Breath
Describe- hungry for air? Chest tightness?
What were you doing when it started?
Gradual or sudden? Intermittent or constant?
How long?
Getting worse? Is it worse at any particular time of day/week? Seasonal variation?
Previous episodes?
Rest/exercise? Define exercise tolerance- distance + flat/uphill
Sleep apnoea (snore at night, tired in day, waking up)
HF:
Exercise tolerance
PND, orthopnoea (# pillows)- waking up from sleep?
Ankle oedema

Resp:
Cough +/- sputum (quantity, colour, smell, taste, frothy)
+ ?haemoptysis
Wheeze, stridor
Chest pain/tightness- which came first SoB/ chest pain?

PMH & PSH:

Asthma (ask about normal and latest PEFR, inhalers, diurnal variation, PASTO), COPD, Infections esp TB, CA
IHD or Valvular HD,
SHx: stairs
PASTO: pets, asthma/allergies, smoking, travel, occupation
FLAWS: fever, lethargy, appetite, weight loss, sweats/shakes (rigors)
Impact on daily life
2

Leg Pain
How long?
Progression?
Previous episodes?
Claudication distance (exercise tolerance)? Flat/uphill? SoB- is it the SoB or pain that is the limiting factor?
- Before how far could you walk?
Site- one or both legs? Where on leg?
Onset- gradual or sudden?
CharacterRadiation- thigh, buttocks?
Alleviating factors- hanging legs off bed? analgesia
Timing- pain at rest or after exercise?
Exacerbating factors- walking uphill, against wind, cold?
Other pain- chest pain, back pain?
Ulcers
Oedema
PMH: MI (how treated? Thrombolysis?), PVD, angina, T2DM, HTN

ASx (DVT)
Warm
Tender
Swelling
Red
RFs: Hx, immobility (long haul travel, sedentary
lifestyle), recent op (esp pelvis or knee), bleeding
disorders, pregnancy, OCP, FHx, smoking, HTN

ASx (IC)
Cold
Pale
Numb
Change of sensation
Leriches syndrome: buttock claudication, impotence

Rule out spinal stenosis: bladder and bowel dysfunction, distance of onset to pain is variable (unlike vascular causes
where its constant), cycling or leaning forwards makes pain better

Oedema
Site- one or both legs?

RESP
COUGH
When did it start?
Progression?
Previous episodes?
- More than 3 months for 2 consecutive years
- Recurrent infections as a child
Time of day- worse in morning (chronic bronchitis) or night (LVF, asthma)? Time of week/year
(occupational/seasonal)?
Affected by posture? (bronchiectasis)
Character of cough- brassy, barking, bovine, post-prandial, night
Anyone else youre in contact with having similar symptoms?
ASx
Sputum- colour, quantity, thickness, taste, smell
Haemoptysis- all the time/occasionally, quantity (fresh blood, specks, altered blood), previous episodes,
SoB- acute (PE), chronic (infection)
Wheeze, stridor
Chest pain
Sinusitis/rhinitis- nasal discharge, sinus pressure
HF- SoB, ankle oedema, PND/orthopnoea, exercise tolerance
GORD- heartburn

PMH: asthma (inhalers), COPD, TB, infections, CA, drugs eg ACEi

PASTO
FLAWS

Pneumonia
myalgia, confusion, diarrhoea, rashes

Asthma
POORLY CONTROLLED
Duration- when diagnosed? Getting worse?
Normal asthma control- medical
DHx: medication, frequency of inhaler use
Normal PEFR reading
PMH: previous asthma admissions
- Ventilation?
ASx:
Cough- nocturnal?
Sputum
Wheeze- worsening?
Chest pain- pleuritic?
Disturbance of sleep

NEW ONSET
Lack of sleep due to cough and wheeze
Hx of atopy
FHx: asthma, atopy

PASTO
FLAWS

PASTO
FLAWS
4

COPD
Chronic Bronchitis= cough productive of sputum on most days for 3 months in 1 year
ASx
Cough- sputum, haemoptysis
SoB
Wheeze
Orthopnoea, PND
Exercise tolerance
Sleep disturbance
Exclude: Angina, Oedema

Lung CA
As above + Horners syndrome
Hoarse voice
FLAWS & PASTO

PE
SoB, acute haemoptysis
Sharp pleuritic pain in left midzone worse on movement and deep inspiration
No relief
ASx: cough, sputum, wheeze, oedema, palpitations, orthopnoea/PND etc etc etc etc
RFs: Hx, immobility (long haul travel, sedentary lifestyle), recent op (esp pelvis or knee), bleeding disorders,
pregnancy, OCP, FHx, smoking, HTN

GASTRO & HEPATOLOGY

Acute Abdomen
How long?
Progression?
Previous episodes?
Pain- does it radiate or migrate?
Recent trauma? Recent travel?
What were you doing when it started?
DHx: NSAIDs
ASx
Acid reflux
Dysphagia/odynophagia
Nausea and vomiting- onset, duration, persistence, how much, frequency, duration
What came first: vomiting or pain?
What effect did the vomiting have on the pain?
Haematemesis
Change in diet
Change in bowel habit (establish normal habit)
frequency
volume
colour
mucus
blood (mixed, paper, pan, quantity)
consistency
floating, difficult to flush away
smell
Rectal bleeding
Pain on defaecation
Tenesmus
Change in urine- darker? (dark urine, pale stools)
Bowel obstruction:
Colicky abdo pain?
when did you last open your bowels? Constipation?
flatus?
distension?
vomiting?
current hernias?
Gynae: Hx of gynae, sexually active, LMP, PV bleed, PID, possibly pregnant

FLAWS

Jaundice
How long?
Progression?
Previous episodes?
RFs
Alcohol
Travel
FHx- gallstones, hepatitis
Recreational drug use
Blood transfusions
Sexual contact- prostitute
Drugs- methotrexate

ASx
FLAWS
Abdo pain (RUQ pain- tender hepatomegaly)
N&V
Dark Urine, Pale Stools
Pruritus
Rigors

Diarrhoea- IBD, IBS, Infection

what do you mean by diarrhoea?
How long?
Progression?
Previous episodes?
Travel- tropical areas? Food poisoning? Shellfish, dairy products, water, meat?
Change in bowel habit (establish normal habit)
frequency
volume
colour
mucus
blood (mixed, paper, pan, quantity)
consistency
floating, difficult to flush away
smell
Rectal bleeding
Pain on defaecation
Tenesmus
Incontinence
ASx
FLAWS
N&V
Abdo pain
Jaundice
Rashes
Mouth ulcers
Arthralgia
Back pain
Anaemia: tired, SoB, pallor
Malabsorption: weight loss, pale stools
Food poisoning: anyone else with same problem?
Diet
DHx: laxatives, antibiotics (C. diff), anti-emetics

Vomiting
frequency
volume
colour
mucus
bile
blood (quantity)
consistency
Related to food or meds?
Recent travel?
Contacts with similar symptoms?
Pregnancy?
Bulimia, anorexia, emetics abuse?
ASx
Nausea
Dyspepsia- heartburn
Dysphagia
Abdo pain
Chest pain
Neuro: migraines, motion sickness, dizzy, vertigo, tinnitus
DHx: chemo drugs, opiates, NSAIDs

Dysphagia
When did it start?
Level of dysphagia
Solids or liquids? Eg strictures (bread and potatoes get stuck)
Continuous or intermittent- diffuse oeso spasm?
ASx
Odynophagia
Heartburn, acid reflux (waterbrash)
Chest pain
Pharyngeal pouch- regurg, halitosis, gurgling
Cough
Choking
Hoarse voice
Foreign body
Mouth ulcers
Speech (dysarthria)
Weakness elsewhere
GI: N&V, regurg, haematemesis, FLAWS, jaundice, hoarse voice
PMH: GORD, PUD, previous endoscopies
FHx: oeso CA, MND

Upper GI bleeding
When did it start?
Previous episodes?
Last episode? Time between latest episodes?
Volume of blood?
Fresh blood or coffee ground?
RFs
NSAIDs
Hx PUD
Alcohol
Oeso varices

Warfarin
Steroids
Stress (Curlings ulcers)
Travel

ASx
FLAWS
Dyspepsia
Dysphagia, odynophagia
Heartburn, acid reflux
Abdo pain
Exclude: melaena, PR bleeding
Lower GI bleeding
When did it start?
Previous episodes?
Last episode? Time between latest episodes?
Volume of blood per motion? One-off or all the time? Continuous or intermittent?
Composition: fresh, red, tarry (melaena)
Drip into pan, toilet paper, coat stool
Hx: haemorrhoids, piles, fissures, fistulae
Tenesmus
Bleeding before, during, after motion
Trauma to anal canal
Nocturnal diarrhoea- UC

Weight Loss- Malabsorption

How much over what period of time?
Intentional?
Have you measured it?
Reduced appetite- why? (dysphagia, pain, depression, hyperthyroidism)
Change in physical activity
Adequate diet?
Bowel habit?
Malabsorption: steatorrhoea- pale, float, difficult to flush, stinky
Endo: thyroid (palpitations, sweating, tremor, heat intolerance); Diabetes (polydipsia, polyuria); Addisons (skin
pigmentation, weakness)
Chronic infection: fever etc
Psych: depression, anorexia, bulimia, anxiety, life events (death, separation, job change)
CA: ask questions specific to type of CA
DHx: diuretics, laxatives, diet pills/slimming agents
SHx: smoking

Neuro
Headaches
Exacerbating factors
- Morning
- After lying down
- Straining, laughing, coughing
Precipitating factors
- trauma
- Stress
- OCP
- Foods: cheese, wine, chocolate
- Alcohol

ASx
-

Prodrome- aura, visual changes

N&V
Meningism: photophobia, neck stiffness, fever, rash
Seizures
Dizzy, vertigo, faintness
LoC
Visual changes: blurring, amaurosis, fugax
Weakness
Sensory changes

FLAWS
PMH: HTN (?regular med- dose, compliance), kidney disease
FHx: migraines, PCKD, Cerebrovascular disease, renal disease
DHx: anti-HTN, OCP, rebound analegia, GTN, Nifedipine, drug/alcohol withdrawal

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Collapse
- When and where- what were you doing?
- Blackouts, LoC
- Witnesses
- Before/during/after collapse?
- Previous episodes
- Trauma
ASx
N&V
Sweating
Headache
Visual changes
Hearing loss
Meningism
Vertigo
Weakness

Muscle wasting
Fasciculations- twitching
Motor loss
Sensory loss
Palpitations
Chest pain
SoB
Post-straining?

Precipitating Factors
Hot room
Heavy meal
Dehydration
Emotion, fear
Pain
Postural hypotension- getting
up quickly

Any witnesses?

Before
o How did you feel
o Chest pain
o Prodrome/warning eg flushing, voices, sweating, aura, blurred vision, feeling in tummy

During
o
o
o
o

LoC- do you remember what happened?

how long did it last
seizures: fitting/jerking, tongue-biting, urinary incontinence
sustained any injuries? (injury suggests no warning)

After
o
o
o

How long did it take to recover?

How did you feel? Muscle ache, tired, headache, vomiting
Post-ictal state: Todds paresis

Cardio:
-

Vasovagal syncope
Palpitations
TIA, stroke
Carotid artery stenosis: amaurosis fugax,

CV RFs: smoking, Hyperlipidaemia, HTN, alcohol, DM, FHx

DVT Sx: leg swelling, redness, hot,
Hypoglycaemia: Hunger, jittery, faints, palpitations, sweating, headache, confusion, coma
PMH: febrile convulsions as a child
DHx: medication for HTN (SE: postural hypotension)
FHx: epilepsy, stroke, TIA
Trauma, mechanical fall
Alcohol, Recreational drugs
FLAWS

11

Myaesthenia Gravis
Characterise weakness: Increased fatiguability with repeated movements.
Exclude:
Wasting
Fasciculations- twitching
Change in tone in the lower limbs
Fits
LoC
Headaches
Tremor
Change in sensation
Associated problems:
Speech
Eating, chewing
Swallowing
Visual problems:
Facial weakness

Motor Neurone Disease

UMN in lower limbs, LMN in lower limbs
Bulbar palsy
No sensory loss
Wasting
Fasciculations- twitching
Swallowing problems
Speech problems
Exclude:
Visual changes
Hearing loss
Comprehension

Headaches
Fits
LoC

FLAWS
Multiple Sclerosis
Visual changes- early signs
Retro-orbital pain (dull)
Visual loss
Peripheral neuropathy & paraesthesia
Exclude:
Wasting
Fasciculations
Tremor
LoC
Headaches
Fits

Dizziness
Swallowing problems
Speech
Comphrension
Hearing loss

RF for sensory neuropathy: Diabetes, Alcohol, Drugs, Vit B deficiency

FLAWS

12

Stroke/TIA
Sudden onset?
Complete resolution within 24 hours?
Previous episodes?
Facial drooping
Speech
Swallowing (dysphagia)
Aphasia, dysphasia
Dysarthria
Exclude: headache, LoC, fits
Sensory and motor weakness- contralateral side
TIA- amaurosis fugax
PMH: AF, HTN, IHD, PVD, valve disease
RF: PMH, FHx (atherosclerotic), smoking, HTN, Hyperlipidaemia, alcohol, lifestyle (diet, exercise), weight

13

Urology & Renal

Haematuria
Blood
-

How long
Every time
Where in the stream
Painful
Frank or specks

Dysuria
Frequency
Polyuria, fluid intake
Urgency, nocturia, hesitancy, poor stream, terminal dribbling
Colour
Frothy
Incontinence
Incomplete voiding

ASx
Urine

Loin pain, back pain

Masses or swelling
FLAWS
N&V
Trauma to back
Renal biopsy, recent catheterisation
Recent infection- recent throat infection (post-Strep GN)
Rash
Resp Sx: haemoptysis (Goodpastures, PAN, Wegeners)
PMH: TB (?renal TB!), Schistosomiasis, anaemia
FHx: PCKD, deafness
Renal Failure
Haematuria plus.....
ASx
Nausea
Anorexia
Itching
Rash
Hiccups
Lethargy
Confusion

Myalgia, arthralgia
Headache
Visual disturbances
Numbness
Neuropathy
Peripheral oedema

PMH: HTN, DM, UTI, childhood renal disease, vascular disease

Hx trauma, dialysis, dyes
DHx: Gentamicin, NSAIDs, recent ACEi
FHx: PCKD, strokes, sudden death
FLAWS
14

UTI
Haematuria
Pyelonephritis: haematuria + fever + rigors
Confusion in elderly
Suprapubic pain
Recurrent UTIs- PCKD, indwelling catheter (>5 days)

Renal Stones
Urine
-

Strangury
Dysuria
Frequency
Urgency, nocturia, hesitancy, poor stream, terminal dribbling
Colour
Frothy
Incontinence
Incomplete voiding
Cloudy or offensive (dialysis pts)

Loin groin colicky pain (ureteric colic- 10/10 severity pain)

Hypercalcaemia: abdo pain, depression, thirsty, bone pain
PMH: gout (hyperuricaemia)

Renal Cell Carcinoma & Bladder CA

Renal
Loin mass, dull loin pain, frank haematuria
Night sweats
FLAWS
Cannonball mets in lungs

Bladder
Frank haematuria
Suprapubic pain
SHx: aniline dyes

Nephrotic Syndrome
Oedema
Frothy urine
Exertional dyspnoea
Signs of hypercholesterolaemia (corneal arcus, xanthelasma)
Leukonychia
Urine
-

Frequency
Urine output
Dysuria
Frothy
Urgency, nocturia, hesitancy, poor stream,
terminal dribbling

Colour
Incontinence
Incomplete voiding
Cloudy or offensive (dialysis pts)
Strangury

Rule out CV Hx
15

Urinary Retention
- Previous flow
- Progressive worsening
- Overflow incontinence
- Hydronephrosis (loin swelling)
Frequency
Urgency
Nocturia
Hesitancy
Poor stream
Terminal dribbling

Incomplete voiding
Incontinence
Poor stream
Dysuria
Haematuria
Suprapubic pain

Acute: Painful
Chronic: Painless

Stress Incontinence
- Hx abdo surgery
- pelvic surgery
- pregnancies
- obstetric injuries
- Hx: UTI, PID

BPH
Previous episodes?
Hx of urinary retention?
Hesitancy
Frequency
Poor stream with stop-start flow
Terminal dribbling
Double micturition
Urgency
Incomplete voiding
Incontinence
Nocturia
FLAWS

Back pain- advanced prostate CA

FHx: prostate CA
Occupation

16