History taking important questions

Question 1

Visual problem screening questions

Answer 1

ONE EYE OR both eyes?
Gradual or sudden?
Central or peripheral?

Pain?
Redness
Blurriness
Haloes or glare in vision (cataract)
Black blobs or floaters (viteous haemorrhage, retinal detachment from neovascularization)
Episodic loss of vision (amaurosis fugax)
Double vision
Bumping into stuff (visual field)
Long or short sighted
Colour vision
a. Optic neuritis
b. Optic atrophy
c. Retinitis pigmentosa
v. Night vision
vi. Distortion (ARMD)

Question 2

Headache

Answer 2

SOCRATES (sudden/gradual onset)

Primary headache
- Visual disturbances/aura
- Photophobia/phonophobia
- Vomiting
- Eye pain

Infection
- As above +
- Neck stiffness
- Ear pain

Trauma

GCA
- Pain in jaw (site onset, relieving factors) + muscle stiffness and pain (characteristic and muscle group)

Red flags
- SAH = thunderclap headache
- Raised ICP = worse on lying down, coughing, visual disturbance
- Stroke = focal neurology

Question 3

Palpitation

Answer 3

Arrhythmia (AF, SVT)
- Episodic? Constant?
- Triggers e.g. caffeine?
- Hyperthyroid? - tremors, heat intolerance, diarrhoea
- Infection?
- FH SCD
- LOC (LQTs, brugada, HOCM)
- Chest pain (MI, ACS)
- SOB
- Exercise tolerance

Anxiety

Question 4

Joint pain

Answer 4

Spondyloarthropathy
- Back pain (AS)
- DIP sparing?
- Enthesitis
- Dactylitis
- Diarrhoea (IBD)
- Psoriasis
- Oral ulcers (SLE)
- Flu-like sx (reactive)
- Sexual history (Reactive)

Crystal
- Other endocrine conditions like hyperparathyroid (pseudogout)
- Diet rich in meat (gout)
- Recent chemo (gout)

Septic
- Fever

Question 5

Diarrhoea

Answer 5

Endocrine
- Heat intolerance
- Weight loss
- Tremor

Gastro
- Malabsorption (coeliac, chronic pancreatitis, bile salt malabsorption, small intestinal bacterial overgrowth) - pale smelly stool difficult to flush
- Inflammatory (IBD) - tenesmus, weight loss, nocturnal sx, incontinence, mouth ulcers, bloody diarrhoea
- IBS - certain food, mixed constipation diarrhoea
- Infective - bloody diarrhoea, unclean food, travel history

Question 6

SOB

Answer 6

Cardiac
- Chest pain
- Palpitations
- PND
- Orthopnoea
- Exercise tolerance
- Swollen legs

Resp
- Wheeze
- Cough
- Haemoptysis
- Weight loss
- Night sweat
- Pets
- Occupational
- Diurnal variation
- Smoking

Haem
- Blood loss

Question 7

Unilateral weakness

Answer 7

Neurology
- Headache (thunderclap/migraine)
- Visual changes (flashing lights, scintillating)
- Change in smell
- Change in voice
- Drooping face
- Sensation or power change
- Neck pain/stiffness (vertebral artery dissection)
- LOC

Question 8

Falls

Answer 8

Fall with LOC
- Syncope (reflex, vasovagal, cardiac) - triggers, palpitations, any prodromal sx
- Postural hypotension
- Seizures
- TIA/stroke
- Hypoglycaemia

Fall without LOC
- MSK (proximal myopathy, myositis) - muscle pain or shoulder pain or weakness getting up from sitting position
- Balance (parkinsons, diabetes, cerebellar ataxia)
- Vision (poor eyesight)

Question 9

Parkinsonism

Answer 9

Rule in idiopathic parkinsons
- Handwriting
- Walking
- Sleep disorder

Rule out parkinsonism
- Postural hypotension
- Gaze palsy
- Incontinence
- Visual hallucination
- Cognitive impairment

Question 10

Connective tissue disorder screen

Answer 10

• Oral ulcers (SLE)
• Dry mouth dry eyes (sjogren)
• Difficulty swallowing (SS)
• Tight thin skin (SS)
• Diarrhoea (SS)
• Rash on hands (Dermatomyositis)
• Painful muscles (DM)
• Photosensitivtiy rash (SLE)
• Raynauds (SS, SLE, RA)
• Red eyes (RA, SLE)

Question 11

Fever in returning traveller questions

Answer 11

1. Which country and what exactly they did there
   - ?swimming (schistosomiasis) ?desert (MERS) ?long grass (tick) funeral (viral haemorrhagic fever) ?mosquito (Malaria, dengue)
2. Mosquito repellent/mosquito nets?
3. Pre-travel vaccine?
4. When did you start becoming unwell? (incubation period)
   - <10d = bacterial; >3 months = parasitic
5. Systematic screen
   - Rash
   - Joint pain
   - Headache
   - Chest pain, breathless, palpitations
   - Cough, phlegm
   - Diarrhoea (enteric fever), abdo pain, swallowing
   - Urinary sx, blood in urine, dark urine
6. Sexual history + urethral discharge
7. Fever
   - duration? highest temp? cyclical?
8. Close contact

Question 12

General management strategy

Answer 12

Non pharmacological
- Lifestyle advice
- OT/Physio
- Rehab

Pharmacological
- Medication

Speciality doctor referral

Question 13

Systemic screening questions

Answer 13

Changes to
2) skin
3) joints
4) hair
5) eye
6) mouth
7) period (in females)
8) endocrine
- cold or hot
- tremor
- weight
- proximal myopathy
- nipple discharge
- change in appearance, hand size feet size

Question 14

Rash screening questions

Answer 14

Sun sensitivity
Scalp involvement - hair loss (SLE)
Scarring - discoid lupus/sarcoid. Dermatomyositis don’t cause scarring
Scaling
Systems
Symptoms

Question 15

Weight loss differential

Answer 15

Hyperthyroid
Malignancy
Infection
Malabsorption
Chronic disease

Question 16

Leg claudication differential

Answer 16

PAD - ABPI + pulse + bergers test

Lumbar canal stenosis - MRI spine, worse on walking downhill

Sciatica - MRI spine, unilateral symptom

Cauda equina - MRI spine, urinary retention