History - Systemic and Targeted Questioning

Question 1

What are the general symptoms/signs?

Answer 1

• Fatigue/Increased tiredness
• Fever
• Skin - rashes, brusing, bleeding, itching
• Night sweats
• Sleep disturbances
• Neck lumps
• Changes in appetite
• Changes in weight
• Changes in thirst

Question 2

What are the respiratory symptoms/signs?

Answer 2

• Cough - bringing up sputum? What colour is it? Blood?
• Shortness of breath
• Chest pain (sharp)
• Wheeze
• Sinusitis symptoms - blocked nose and runny nose, facial pain.

Question 3

Cardio signs/symptoms?

Answer 3

• Chest pain
• Shortness of breath
• Palpitations
• Ankle oedema (have you noticed swollen legs?)
• Claudication (legs sore on walking)
• Varicose veins (dilated twisted veins in legs)

Question 4

GI?

Answer 4

• Appetite changes
• Weight changes
• Difficulty swallowing
• Nausea/vomiting
• Blood in vomit
• Abdominal pain or heartburn
• Abdominal distension

-Changes in bowel habits - frequency, type of faeces (diarrhea, melena) blood or mucous in stools?
Perianal- pain, hemorrhoids, itching

Question 5

Neuro?

Answer 5

Speech disturbances
Headache
Fits or faints
Dizziness or room spin
Changes in vision, balance of hearing
Weakness anywhere
Numbness, tingling or pins and needles

Question 6

Urinary?

Answer 6

Frequency of peeing 
Volume of pee - oliguria, anuria, polyuria
Peeing more at night 
Pain on peeing
Blood in urine
Unable to go when you feel like you need to
Dribbling
Erectile dysfunction/impotence

Question 7

For sensitive ones, like pee and stools, what is a good thing to do before asking?

Answer 7

Sign post and say you realise it may be embarrassing to discuss, but the questions are important and there is nothing to be embarrassed about as it is completely normal

Question 8

What is JAMTHREADS and when is it used?

Answer 8

Jaundice
Anaemia
MI
Thyroid issues/TB
High BP
Rheumatic fever
Epilepsy
Asthma
Diabetes
Stroke

Used in past medical Hx

Question 9

Male GUS?

Answer 9

Prostatic symptoms - difficulty peeing, stream, dribbling
Impotence/ED
Sexually Active?

Question 10

Female GUS?

Answer 10

Last period
Post-menoupausal bleeding (are they still having periods or not? Are the menopausal?)
Pregnancy, date of expected delivery
Cycle - regulartity, duration and degree of bleeding (is this normal for you or not?)
Vaginal bleeds at a time when not on period
Bleeding after sex
Date of last cervical smear
Obstetric Hx (previous pregnancies)
Any vaginal discharge

Question 11

MSK?

Answer 11

Any pain or stiffness in your muscles, joints or back
Can you dress yourself independently and easily
Can you go up stairs easily
Any Hx of Trauma?

Question 12

Psych?

Answer 12

How is their mood? - Elated, depressed or euthymic
Anxiety or panic symptoms (next card)
Memory problems or confusion
Abnormal thought content - paranoia, odd ideas, obsessions
abnormalities in perception - delusions/hallucinations
Risk to self/others
Do they have insight into their illness