Exploring symptoms

• 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

• 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)

• Pattern of weakness
• Characterise weakness (e.g. fatigable in myasthenia gravis)
• Associated neurological symptoms (see systems review)

• • 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

• Current vs. normal exercise tolerance (what makes them stop?)
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Diurnal/seasonal variation if chronic
• Associated cardiorespiratory symptoms (see systems review)

• Productive or non-productive
• Triggers
• Nocturnal
• Associated cardiorespiratory symptoms (see systems review)

• How much, how often
• Colour, consistency
• Any blood

• Volume and frequency
• Fresh or altered blood
• Nature of associated sputum if any? Mixed in?

• 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)

• 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)

• Solids/liquids/both, which came first
• Constant/intermittent, progressive/non-progressive
• Odynophagia
• Weight loss, food intake
• Associated gastrointestinal and neurological symptoms (see systems review)

• Explore as pain
• Associated gastrointestinal symptoms (see systems review)

• Quantity
• Colour (including blood), odour, itching
• Associated gynaecological symptoms (see systems review)

• 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)

• General: weight loss, stress, exercise, diet
• Head: visual problems, headaches
• Thyroid: heat intolerance, tremor, palpitations, diarrhoea
• Torso: hirsutism, acne
• Abdomen: possibility of pregnancy

• Explore as pain
• Early morning stiffness
• Sciatica
• Urinary incontinence/retention, faecal incontinence/constipation
• Associated neurological symptoms of lower limbs (see systems review)

• 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)

• Explore as pain
• Stiffness/swelling
• Movement restriction/ability to weight-bear
• Mechanical symptoms: locking, giving way
• Neurological symptoms distally: weakness, numbness, paraesthesia

• • Core: mood, anhedonia

• • Biological: sleep, energy, appetite

• • Future (including risk): hopelessness, suicidal thoughts/plans for suicide

• • Others: history of mania/hypomania

• 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

• Voice detail: male/female, familiar/unfamiliar, always same/different, when heard etc.
• Real/pseudo: out/inside of head
• 2^nd/3^rd person: to you/about you, comments
• What they say (including commands)
• Risk to self/others
• Associated psychiatric symptoms (see psychiatric history)

• Expand and challenge the delusion
• Risk to self/others
• Associated psychiatric symptoms (see psychiatric history)

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

• 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

• As normal, but include hydration questions (wet nappies, fluid intake, drowsiness)

• 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)

• 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)

• 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)

• Ages of milestones (see examination notes on child developmental assessment)
• Mobility
• Hand dominance
• Balance problems
• Behavioural problems
• Associated neurological symptoms (see systems review)

• 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)

• 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)

• 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

• 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)

• 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)

Oops! This section is restricted to members. Click here to signup!

Oops! This section is restricted to members. Click here to signup!

Oops! This section is restricted to members. Click here to signup!