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
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A LIST OF COMMON SYMPTOMS IN PRIMARY CARE

             HEAD

  1. Confusion (acute, chronic, acute on chronic)
  2. Episodic loss of consciousness/Syncope  (e.g epilepsy, cardiac)
  3. Dizziness/Vertigo
  4. Hallucinations
  5. Headache
  6. Memory loss
    FACE
  7. Facial pain/rash/swelling
    NECK
  8. Neck lump/swelling
  9. Neck pain/stiffness – see under MUSCLE AND JOINTS
    EYES:
  10. Acute red eye  (painful vs non painful, itchy vs not itchy, sticky))
  11. Double vision
  12. Blurred vision
  13. Eyelid problems
  14. Loss of vision (acute, gradual)
    NOSE:
  15. Blocked nose (i.e. patency problems)
  16. Nose bleeds
  17. Runny nose/Nasal discharge (incl. blood)
  18. Alterations of smell (loss, change, metallic)
    EARS:
  19. Deafness
  20. Discharge/Pain
  21. Tinnitus
    MOUTH/THROAT:
  22. Sore throat
  23. Bad breath
  24. Bleeding/painful gums
  25. Painful tongue/mouth ulcers
  26. Snoring  (inc. sleep apnoea)
  27. Swallowing problems
  28. Hoarseness
  29. Thirst
    CHEST:
  30. Shortness of Breath  (acute, chronic)
  31. Chest pain
  32. Cough  (haemoptysis)
  33. Palpitations
    BREAST:
  34. Breast lump/pain/nipple discharge in women   +/- Breast lump in men
    ABDOMEN:
  35. Tummy Pain   (work out whether acute or chronic)
  36. Tummy Bloating/Swelling
  37. Constipation or Diarrhoea (altered bowel habit)
  38. Nausea &Vomiting
  39. Anal itching/pain/swelling/discharge
  40. PR bleeding
    LIMB & JOINTS:
  41. Abnormal gait
  42. Numbness/paraesthesia
  43. Tremor
  44. Pains all over (muscles)
  45. Single joint pain (acute vs chronic)
  46. Multiple joint pain (acute vs chronic)
  47. Back pain
  48. Neck pain/stiffness
  49. Shoulder pain
  50. Arm pain
  51. Wrist pain
  52. Hip pain
  53. Knee pain
  54. Calf pain/swelling
  55. Ankle swelling
  56. Foot pain
    SKIN, HAIR, NAIL PROBLEMS:
  57. Skin rash  (including erythema, blisters and bullae, macules, papules, nodules, purpura, petichiae, pustules, scales and plaques)
  58. Skin moles
  59. Skin abscess
  60. Skin ulcers (esp legs)
  61. Sweating +++  (night sweats, prolonged fever, fluctuating fever)
  62. Flushing
  63. Itching
  64. Itchy scalp
  65. Jaundice
  66. Hair loss
  67. Excess body hair (hirsuitism)
  68. Abnormal nails
    GENITAL/PELVIC WOMEN:
  69. UTI
  70. Urinary problems (excessive urination, frequency, incontinence, nocturia, retention)
  71. Period problems (absent, sparse, heavy, irregular, post-menopausal, pain)
  72. Pelvic pain (acute vs chronic)
  73. Vaginal discharge
  74. Painful intercourse
  75. Vaginal/Vulval irritation
  76. Vulval swelling/sores/ulceration
  77. Contraception
  78. Emergency contraception
  79. HRT
    GENITAL/PELVIC MEN:
  80. UTI
  81. Urinary problems (excessive urination, frequency, incontinence, nocturia, retention)
  82. Erectile dysfunction
  83. Scrotal swelling/pain
  84. Haemospermia
  85. Penile pain/ulcers/sore
    GENITAL/PELVIC BOTH:
  86. Blood in Urine
  87. Groin pain/swelling
  88. Loss of Libido
  89. Infertility
    GENERAL:
  90. Tiredness all the time (TATT) – sleep apnoea
  91. Falls (with LOC, without LOC)
  92. Swollen glands
  93. Weight gain
  94. Weight loss
  95. Aggression
  96. Insomnia
  97. Sleeping too much
  98. Suspected Non-Accidental Injury/Abuse in the Adult
  99. Domestic Violence (in both men & women)
    MENTAL HEALTH:
  100. Feeling anxious/tense
  101. Feeling low and depressed
  102. Psychosis
  103. Suicidal
  104. I want to come off alcohol
  105. I want to stop smoking
    PREGNANT:
  106. Pain in Pregnancy
  107. PV bleeding in pregnancy
    CHILDREN:
  108. Suspected Non-Accidental Injury/Abuse
  109. Crying irritable miserable baby
  110. The febrile child
  111. Episodic loss of consciousness  (e.g epilepsy)
  112. Cough in children
  113. Stridor in children
  114. Tummy pain in children
  115. UTI children (boys vs girls)
  116. Limping child
  117. Failure to thrive
  118. Delayed puberty
  119. Feeding difficulties
  120. 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

 

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