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

• • Mixed in with sputum?

• 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

• • Psychiatric differential questions: obsessions, compulsions, post-traumatic stress disorder symptoms (psychological trauma, flashbacks, nightmares)

• • Organic differential questions: e.g. hyperthyroidism symptoms, ACS symptoms

• • Voice detail: male/female, familiar/unfamiliar, same voice/different voices, 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

• • 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

• • Review history of toilet training

• • School toileting behaviour

• • Protest behaviour: life stresses, mental health

• • 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

• • 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 (response to commands/voice), non-verbal communication (pointing, gestures), social responses (e.g. in new situations, tantrums, how plays with others)

• 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: reduced social interaction, difficulties recognising/responding to emotions, restricted interests, repetitive behaviours

• • Pattern/triggers, frequency, persistent/intermittent

• • Reaction: wheeze, rash, sneezing/itchy eyes, abdominal pain/diarrhoea, mucosal swelling
  • Specifically ask about anaphylaxis symptoms

• • Triggers/associations: pollen/season, pets, foods  (milk/eggs/wheat/peanuts/fish/shellfish)

• • Ask about atopy in child and family (asthma, eczema, hay fever) and about food allergies

• • Home environment: heating, dampness, pets, smokers in family, exposure to pollutants

• • Duration, progression, frequency

• • Sites, size and shape

• • Description

• • Secondary features: itchy/painful, crusting

• • Associated rheumatological symptoms (see systems review)

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