History Taking

Question 1

Pain questions

Answer 1

SOCRATES

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

Question 2

Tiredness questions and Ddx

Answer 2

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?)

Question 3

Headache Ddx

Answer 3

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

Question 4

Weakness Ddx

Answer 4

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

Question 5

Fall questions

Answer 5

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

Question 6

Shortness of breath

Answer 6

1. Orthopnea
2. Nocturnal
3. Diurnal/seasonal variation

Question 7

Cough

Answer 7

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

Question 8

Palpitations

Answer 8

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

Question 9

Sputum

Answer 9

1. Volume
2. Frequency
3. Colour
4. Consistency
5. Blood

Question 10

Haemoptysis

Answer 10

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

Question 11

Diarrhoea, constipation, vomiting

Answer 11

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

Question 12

Dysphagia

Answer 12

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

Question 13

Dyspepsia

Answer 13

1. SOCRATES
2. Weight loss
3. Melaena
4. Swallowing difficulty

Question 14

Rash

Answer 14

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

Question 15

Back pain

Answer 15

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

Question 16

Joint pain/stiffness/swelling

Answer 16

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

Question 17

Bone/tissue injury

Answer 17

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

Question 18

Systems review - general

Answer 18

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

Question 19

Systems Review - Neurological

Answer 19

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

Question 20

Systems review - ENT

Answer 20

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

Question 21

Systems review - Cardiorespiratory

Answer 21

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

Question 22

Gastrointestinal

Answer 22

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

Question 23

Systems review - urology

Answer 23

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)

Question 24

Systems review - Rheumatological

Answer 24

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

Question 25

System review - Orthopaedic

Answer 25

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

Question 26

Past medical history

Answer 26

1. Longstanding medical conditions (asks specifically if risk factors for Ddx) 2. Past operations For each, ask when dx, treatment and how well controlled.

Question 27

Drug history

Answer 27

1. Medications (dose + frequency) | 2. Allergies (+adverse reaction)

Question 28

Social history

Answer 28

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

Question 29

Family history

Answer 29

1. Diseases that run in the family | Ask specifically for Ddx

Question 30

Time frame questions

Answer 30

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