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Exploring symptoms

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

  • 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

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Exploring 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)

  • 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

! 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
  • Cough
    • Productive or non-productive
    • Triggers
    • Nocturnal
  • 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

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
  • Dysphagia
    • Solids/liquids/both, which came first
    • Constant/intermittent, progressive/non-progressive
    • Odynophagia
    • Weight loss, food intake
  • Dyspepsia/reflux
    • Explore as pain

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
  • 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
  • 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

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
  • 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
  • Delusions
    • Expand and challenge the delusion
    • Risk to self/others
  • Memory loss (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
  • 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
  • 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

Why don’t you test your knowledge?

Practice makes perfection! Try some of these OSCE stations…

  1. Chest pain
  2. Lower back pain
  3. Difficulty hearing
  4. Here’s a hard one!
  5. And there’s lots more here!
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