Table of Contents
For every symptom you elicit (whether it’s the presenting complaint or not), you must ask a series of further, symptom-specific questions – this is called exploring the symptom. After this, you must also ask relevant system review questions to determine the presence/absence of any significant associated features (see systems review).
For all symptoms also review the timeframe
- Duration
- Onset: sudden or gradual (if sudden, what were they doing at the time?)
- Progression
- Timing: intermittent or continuous (if intermittent, are there any triggers/associations?)
Pain
Generalised symptoms
Tiredness
- Clarify what they mean by tiredness
- What?
- Constant or episodic?
- Onset?
- Duration?
- Ask about sleep
- Hours
- Quality
- Snoring/apnoeic episodes
- How it affects the patient
- Associated symptoms
- Anaemia symptoms: breathlessness on exertion, dizziness/headache
- Hypothyroidism symptoms: constipation, weight gain, cold intolerance, menorrhagia
- Depression symptoms: mood, early morning waking
- Diabetes symptoms: polydipsia, polyuria
Cerebral symptoms
Headache
- Explore as pain
- Meningism symptoms: rash, fever, neck stiffness, photophobia
- Giant cell arteritis symptoms: visual problems, jaw claudication, scalp tenderness (e.g. when brushing hair)
- Glaucoma symptoms: visual blurring, red eye, halos around lights
- Associated neurological symptoms (see notes on systems review)
Headache Red Flags:
- Intracranial bleed: thunderclap headache, recent trauma
- Raised intracranial pressure: posture/Valsalva-related
- SOL: immunosuppression, malignancy, focal neurology, onset >50 years
- Meningitis: rash, fever, neck stiffness, photophobia
- Giant cell arteritis: visual problems, jaw claudication, scalp tenderness
- Glaucoma: visual blurring, red eye, halos
Weakness
- Pattern of weakness
- Characterise weakness (e.g. fatigable in myasthenia gravis)
- Associated neurological symptoms (see systems review)
Fit/fall/syncope
- Fit/fall/syncope (get corroboration!)
- Before: warning, circumstance
- During: duration, LOC, movements (floppy/stiff/jerking), incontinence/tongue biting, complexion
- After: amnesia, muscle pain, confusion/sleepiness, injuries from fall
- Background to attacks: previous episodes, frequency, impact on life
- Associated cardiorespiratory/neurological symptoms (see systems review)
! Check if patient drives – there may be driving restrictions
Chest symptoms
SOB
- Current vs. normal exercise tolerance (what makes them stop?)
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Diurnal/seasonal variation if chronic
- Associated cardiorespiratory symptoms (see systems review)
Cough
- Productive or non-productive
- Triggers
- Nocturnal
- Associated cardiorespiratory symptoms (see systems review)
Sputum
- How much, how often
- Colour, consistency
- Any blood
Haemoptysis
- Volume and frequency
- Fresh or altered blood
- Nature of associated sputum if any? Mixed in?
Palpitations
- Fast or slow
- Regular or irregular (ask patient to tap out palpitation on table)
- Any dizziness, LOC, nausea, sweating/clamminess, dyspnoea
- Associated cardiorespiratory symptoms (see systems review)
Abdominal symptoms
Diarrhoea/constipation/vomiting
- How much, how often, any at night
- Colour, consistency and contents (mucus, blood if diarrhoea; blood, bile if vomiting)
- Weight loss, appetite/intake
- Associated gastrointestinal symptoms (see systems review)
Dysphagia
- Solids/liquids/both, which came first
- Constant/intermittent, progressive/non-progressive
- Odynophagia
- Weight loss, food intake
- Associated gastrointestinal and neurological symptoms (see systems review)
Dyspepsia/reflux
- Explore as pain
- Associated gastrointestinal symptoms (see systems review)
Dyspepsia / Reflux red flags – ALARMS:
- Anaemia
- Loss of weight
- Anorexia
- Recent onset progressive symptoms
- Melaena/haematemesis
- Swallowing difficulty; also: >55 years old, >4 weeks/relapsing symptoms, persistent vomiting
Gynaecological symptoms
Vaginal discharge
- Quantity
- Colour (including blood), odour, itching
- Associated gynaecological symptoms (see systems review)
Abnormal PV bleeding
- Type: menorrhagia, intermenstrual, post-coital, post-menopausal
- Quantity of loss: number of sanitary towels/tampons, passage of clots/flooding
- Pain with blood loss
- Anaemia symptoms: tiredness, breathlessness on exertion
- Thyroid symptoms
- Chance of pregnancy
- Associated gynaecological symptoms (see systems review)
Secondary amenorrhoea (work down the body)
- General: weight loss, stress, exercise, diet
- Head: visual problems, headaches
- Thyroid: heat intolerance, tremor, palpitations, diarrhoea
- Torso: hirsutism, acne
- Abdomen: possibility of pregnancy
Orthopaedic and rheumatological symptoms
Back pain
- Explore as pain
- Early morning stiffness
- Sciatica
- Urinary incontinence/retention, faecal incontinence/constipation
- Associated neurological symptoms of lower limbs (see systems review)
Back pain red flags:
- Cauda equina: urinary incontinence/retention, faecal incontinence/constipation, bilateral leg pain, severe/progressive neurological deficit, decreased anal tone/saddle anaesthesia
- Infection or cancer: age <20 or >55 years at onset, weight loss, fever/night sweats, recent infection, cancer history, injecting drugs, immunosuppression
- Fracture: trauma, severe central spinal pain, structural spine deformity, spinal tenderness
- Spondyloarthropathy: early morning stiffness, night pain, worse with rest
Joint pain/stiffness/swelling
- Worse in morning?, how long for (>30 minutes suggests inflammatory cause)
- Better with exercise (inflammatory) or worse after exercise (osteoarthritis)
- Sleep disturbance
- Loss of function
- Associated rheumatological symptoms (see systems review)
Bone/tissue/joint injury
- Explore as pain
- Stiffness/swelling
- Movement restriction/ability to weight-bear
- Mechanical symptoms: locking, giving way
- Neurological symptoms distally: weakness, numbness, paraesthesia
Psychiatric symptoms
You must assess RISK in every psychiatric history. See here for psychiatric history.
Depression
- Core: mood, anhedonia
- Biological: sleep, energy, appetite
- Future (including risk): hopelessness, suicidal thoughts/plans for suicide
- Others: history of mania/hypomania
Anxiety
- Timing: onset and duration, episodic/constant, triggers, effect on life, frequency
- Somatic symptoms: palpitations, breathlessness, chest tightness, sweating, dizziness
- Associated psychological symptoms: depression screen, stress, worry, avoidance
- Psychiatric differential questions: obsessions, compulsions, post-traumatic stress disorder symptoms (psychological trauma, flashbacks, nightmares, hyperarousal)
- Organic differential questions: e.g. hyperthyroidism symptoms, ACS symptoms
Auditory hallucinations
- Voice detail: male/female, familiar/unfamiliar, always same/different, when heard etc.
- Real/pseudo: out/inside of head
- 2nd/3rd person: to you/about you, comments
- What they say (including commands)
- Risk to self/others
- Associated psychiatric symptoms (see psychiatric history)
Delusions
- Expand and challenge the delusion
- Risk to self/others
- Associated psychiatric symptoms (see psychiatric history)
Memory loss
This is one where you need to get a collateral history.
- Short/long-term
- Insight and concerns
- Functional levels (washing, dressing etc.)
- Perform a cognitive assessment (e.g. mini mental state examination)
- Risk to self/others
Eating disorder
- BMI: weight, height
- Symptoms: avoidance of weight gain/need to lose weight, preoccupation with appearance, efforts to purge (vomiting, laxatives, exercise), any binge eating/fasting
- Food diary: what they eat each day
- Results: menstrual cycle disturbance, poor dental hygiene
- Screen for depression (including risk to self), diabetes and thyroid problems
Paediatric symptoms
Most symptoms are explored as you normally would for adults but some are specific. See here for full paediatric history.
Diarrhoea and vomiting
- As normal, but include hydration questions (wet nappies, fluid intake, drowsiness)
Soiling/enuresis
- Primary or secondary
- Full account of toilet training
- School toilet behaviour
- Protest behaviour: stressful/chaotic life
- If soiling: faeces consistency (diarrhoea/constipation – use Bristol Stool Chart) and any painful anal conditions
- If enuresis: have they ever had a dry night?
- If secondary: urinary/GI infection symptoms, spinal cord compression symptoms (see systems review)
Failure to thrive/weight loss
- Ask to see growth chart
- Input: detailed dietary history, feeding history, hunger
- Use: energy, activity level
- Output: wet nappies, stools
- Others: chronic cough (CF), recurrent infections (CF, primary ciliary dyskinesia, immunological), sweating/breathless when feeding (cardiac), behaviour, general health, happiness, parents’ health
- Associated gastrointestinal symptoms (see systems review)
Weight gain
- As for failure to thrive: see growth chart; input, use and output questions
- Hypothyroidism symptoms: growth impairment, delayed puberty, mental slowness, constipation, cold intolerance
- Cushing’s syndrome symptoms: growth impairment, proximal weakness, central obesity
- Syndromic features, e.g. Laurence-Moon (extra digits, intellectual impairment), Prader-Willi (poor muscle tone, distinct facial features, lack of eye co-ordination)
Walking/sitting delay
- Ages of milestones (see examination notes on child developmental assessment)
- Mobility
- Hand dominance
- Balance problems
- Behavioural problems
- Associated neurological symptoms (see systems review)
Speech delay
- Ages of milestones (see examination notes on child developmental assessment)
- Senses: vocals, hearing, vision
- Communication: comprehension (follows commands, responds to voice), non-verbal communication (pointing, gestures, facies), social responses (how acts in new situations, tantrums, playing, gestures)
Early puberty/late puberty/primary amenorrhoea/short stature
- Pubertal development review: testes, breast development, menarche, pubic/axillary hair, height, acne, mood changes
- Intracranial pressure symptoms: visual problems, headaches
- Family pubertal/stature history
- Symptoms of other systemic diseases (CF, thyroid disorder, anorexia, Crohn’s disease)
Behavioural disorder
- Attention deficit hyperactivity disorder symptoms: poor concentration, hyperactivity
- Conduct disorder symptoms: hostile, aggressive, cruel
- Autism symptoms: poor social interaction, reciprocal communication behaviour, restricted interests, repetitive behaviours, difficulties recognising/responding to emotions
Allergies
- Pattern, frequency, duration, persistent/intermittent
- Reaction: wheeze, rash, sneezing/itchy eyes, abdominal pain/diarrhoea, swelling of eyes/eye-lids/tongue
- Specifically ask about anaphylaxis symptoms
- Triggers/associations: pollen/season, chemicals, pets, latex, dust, foods (milk/eggs/wheat/peanuts/fish/shellfish)
- Ask about atopy in child and family (asthma, eczema, hay fever) and about food allergies
- Ensure you ask about home (heating, dampness, pets) and social (smokers in family, exposure to pollutants)
Other symptoms
Rash
- Duration, progression, frequency
- Sites, size and shape
- Description: what does it look like? Any blisters or raised areas? What colour is it? Does it blanch?
- Secondary features: itchy/painful, crusting
- Exacerbating/relieving factors, e.g. heat, sunlight, cold, treatment, allergies
- Associated rheumatological symptoms (see systems review)
Why don’t you test your knowledge?
You are taking a history from a patient with an episode of loss of consciousness. How would you explore this symptom further?
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Which systems reviews are pertinent and why?
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What conditions would be included in the differential diagnosis?
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