symptom-based history taking
Symptom directed history-taking not a clinical system directed history taking – patients do not come in saying “can you do a cardiological survey for my shortness of breath”. They says “I have shortness of breath that I am struggling with”. The shortness of breath is a SYMPTOM. Hence symptom-DIRECTED history taking. Yet in medical school, we are taught clinical SYSTEM directed history taking.
I personally feel medical school should start by teaching CLINICAL SYSTEM directed history taken and once familiar, for medical students to then be trained UP in symptom-directed history taking.
For example,
- SOB can be respiratory, cardiac, anxiety
- Palpitations can be cardiological or anxiety or infective
A LIST OF COMMON SYMPTOMS IN PRIMARY CARE
HEAD:
- Confusion (acute, chronic, acute on chronic)
- Episodic loss of consciousness/Syncope (e.g epilepsy, cardiac)
- Dizziness/Vertigo
- Hallucinations
- Headache
- Memory loss
FACE: - Facial pain/rash/swelling
NECK: - Neck lump/swelling
- Neck pain/stiffness – see under MUSCLE AND JOINTS
EYES: - Acute red eye (painful vs non painful, itchy vs not itchy, sticky))
- Double vision
- Blurred vision
- Eyelid problems
- Loss of vision (acute, gradual)
NOSE: - Blocked nose (i.e. patency problems)
- Nose bleeds
- Runny nose/Nasal discharge (incl. blood)
- Alterations of smell (loss, change, metallic)
EARS: - Deafness
- Discharge/Pain
- Tinnitus
MOUTH/THROAT: - Sore throat
- Bad breath
- Bleeding/painful gums
- Painful tongue/mouth ulcers
- Snoring (inc. sleep apnoea)
- Swallowing problems
- Hoarseness
- Thirst
CHEST: - Shortness of Breath (acute, chronic)
- Chest pain
- Cough (haemoptysis)
- Palpitations
BREAST: - Breast lump/pain/nipple discharge in women +/- Breast lump in men
ABDOMEN: - Tummy Pain (work out whether acute or chronic)
- Tummy Bloating/Swelling
- Constipation or Diarrhoea (altered bowel habit)
- Nausea &Vomiting
- Anal itching/pain/swelling/discharge
- PR bleeding
LIMB & JOINTS: - Abnormal gait
- Numbness/paraesthesia
- Tremor
- Pains all over (muscles)
- Single joint pain (acute vs chronic)
- Multiple joint pain (acute vs chronic)
- Back pain
- Neck pain/stiffness
- Shoulder pain
- Arm pain
- Wrist pain
- Hip pain
- Knee pain
- Calf pain/swelling
- Ankle swelling
- Foot pain
SKIN, HAIR, NAIL PROBLEMS: - Skin rash (including erythema, blisters and bullae, macules, papules, nodules, purpura, petichiae, pustules, scales and plaques)
- Skin moles
- Skin abscess
- Skin ulcers (esp legs)
- Sweating +++ (night sweats, prolonged fever, fluctuating fever)
- Flushing
- Itching
- Itchy scalp
- Jaundice
- Hair loss
- Excess body hair (hirsuitism)
- Abnormal nails
GENITAL/PELVIC WOMEN: - UTI
- Urinary problems (excessive urination, frequency, incontinence, nocturia, retention)
- Period problems (absent, sparse, heavy, irregular, post-menopausal, pain)
- Pelvic pain (acute vs chronic)
- Vaginal discharge
- Painful intercourse
- Vaginal/Vulval irritation
- Vulval swelling/sores/ulceration
- Contraception
- Emergency contraception
- HRT
GENITAL/PELVIC MEN: - UTI
- Urinary problems (excessive urination, frequency, incontinence, nocturia, retention)
- Erectile dysfunction
- Scrotal swelling/pain
- Haemospermia
- Penile pain/ulcers/sore
GENITAL/PELVIC BOTH: - Blood in Urine
- Groin pain/swelling
- Loss of Libido
- Infertility
GENERAL: - Tiredness all the time (TATT) – sleep apnoea
- Falls (with LOC, without LOC)
- Swollen glands
- Weight gain
- Weight loss
- Aggression
- Insomnia
- Sleeping too much
- Suspected Non-Accidental Injury/Abuse in the Adult
- Domestic Violence (in both men & women)
MENTAL HEALTH: - Feeling anxious/tense
- Feeling low and depressed
- Psychosis
- Suicidal
- I want to come off alcohol
- I want to stop smoking
PREGNANT: - Pain in Pregnancy
- PV bleeding in pregnancy
CHILDREN: - Suspected Non-Accidental Injury/Abuse
- Crying irritable miserable baby
- The febrile child
- Episodic loss of consciousness (e.g epilepsy)
- Cough in children
- Stridor in children
- Tummy pain in children
- UTI children (boys vs girls)
- Limping child
- Failure to thrive
- Delayed puberty
- Feeding difficulties
- Behaviour problems
PALLIATIVE CARE PATIENT:
121. Pain in General (+ specific section on bone pain)
122. Nausea & Vomiting
123. Constipation
124. Diarrhoea
125. Fistulae
126. Mouth problems
127. Hiccoughs
128. Hoarse voice
129. Cough
130. Breathlessness
131. Anorexia/Cachexia
132. Drowsiness
133. Delerium
134. Restlessness
135. Fits
136. Insomnia
137. Itching
138. Swollen legs (lymphoedema vs dvt vs CHF)
139. Emergency: Spinal Cord Compression
140. Emergency: Hypercalcaemia
141. End of Life/Last few days/Dying
Great handbook for palliative care: https://www.ruh.nhs.uk/For_Clinicians/departments_ruh/Palliative_Care/documents/palliative_care_handbook.pdf
