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Systems review

A full systems review is not necessary for every patient. You should only review systems relevant to the presenting complaint with the aim of identifying/excluding significant associated features. For example, for left iliac fossa pain, a complete history will include questions about gastrointestinal, urological and, if female, obstetric and gynaecological systems. In addition, some questions within each system review will be more or less relevant depending on the presenting complaint, and you do not have to ask them all. You must also go on to ask further symptom-specific questions for each positive symptom (see exploring symptoms).

General

  • Fever/rigors/night sweats
  • Weight loss
  • Fatigue
  • Skin rashes/bruising

Neurological

  • General

    • Fits/falls/LOC
    • Headache
    • Dizziness
    • Vision/hearing
    • Memory loss
    • Neck stiffness/photophobia

  • Motor

    • Weakness
    • Incontinence

  • Sensory

    • Pain
    • Numbness
    • Tingling

ENT

  • Ear

    • Hearing loss
    • Tinnitus
    • Otalgia

  • Nose

    • Rhinorrhoea
    • Epistaxis

  • Throat

    • Sore throat
    • Odynophagia

Cardiorespiratory

  • Chest pain
  • Palpitations
  • SOB/wheeze
  • Cough
  • Sputum
  • Haemoptysis
  • Leg swelling

Gastrointestinal

  • Weight

    • Weight loss
    • Appetite change

  • Work down body

    • Dysphagia
    • Nausea/vomiting
    • Indigestion/heartburn
    • Abdominal pain
    • Bowel habit
    • Tenesmus
    • Blood/mucus in stool
    • Flatus

Urological

  • Storage

    • Frequency
    • Volume
    • Urgency
    • Nocturia
    • Incontinence (overflow/stress/urge)

  • Infection

    • Dysuria
    • Haematuria
    • Odour

  • Prostatic/voiding (if male)

    • Hesitancy
    • Poor flow/dribbling
    • Feeling of incomplete emptying

Obstetric and gynaecological

  • PV Bleeding

    • Menorrhagia
    • Intermenstrual
    • Post-coital
    • Post-menopausal

  • PV Discharge
  • Pain

    • Pelvic
    • Dysmenorrhoea
    • Dyspareunia

  • Pregnancy

    • Chance of pregnancy
    • If pregnant: fetal movements, contractions/tightening, PV loss, pre-eclampsia symptoms (headache, visual disturbance, epigastric pain, oedema)

Rheumatological

  • Joints

    • Pain
    • Stiffness
    • Swelling

  • Work down body

    • Skin (rashes, ulcers, Raynaud’s)
    • Hair loss
    • Eyes (redness, dryness)
    • Mouth (dryness)
    • Chest (breathlessness, SOB)
    • GI (IBD symptoms)
    • Genitourinary (discharge)

Orthopaedic

  • Joints/bone/soft tissue

    • Pain
    • Stiffness
    • Swelling
    • Movement restriction/ability to weight-bear

  • Mechanical symptoms

    • Locking
    • Giving way

  • Neurological symptoms distally

    • Weakness
    • Numbness
    • Paraesthesia

Why don’t you test yourself?

You are taking a history from a patient with breathlessness. What system review questions would you ask?

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What would be in your differential diagnosis for breathlessness? Ensure you structure your answer!

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  • Cardiac

    • Myocardial infarction
    • Heart failure

  • Respiratory

    • LRTI/pneumonia
    • Asthma
    • COPD
    • Pneumothorax
    • PE
    • Pulmonary fibrosis

  • Haematological

    • Anaemia

There’s lots more information here, including clues to point to differentials.[armelse]

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A patient who is 30 weeks pregnant presented with lower abdominal pain. You are taking the history. Which systems review questions would you ask?

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How about trying some history-taking OSCE stations?

  1. Hip pain
  2. Lower leg weakness
  3. Abdominal pain
  4. Dysphagia
  5. Right toe pain
  6. And there’s lots more to try!

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