Ophthalmic history
(6)
- Ask which eyes are affected (i.e. one or both)
- Ask about when and how the problem started (including history of trauma)
- Ask about key ophthalmic symptoms (e.g. visual disturbance, red eye, discharge/watering, grittiness/dryness, itching, photophobia, swelling/tenderness)
- Explore visual disturbance (if relevant): affected eye(s), onset, continuous or intermittent, severity, exacerbating factors, relieving factors, distance and/or near vision affected, central or peripheral visual field affected, double vision, positive visual symptoms, visual distortions)
- Explore eye pain (if relevant): use SOCRATES
- Explore eye trauma (if relevant): mechanism (e.g. chemical, blunt, sharp), size, speed, nature of flying object
Past ocular history
(5)
- Previous similar episodes
- Previous eye problems/diagnoses
- History of eye trauma
- History of ocular surgery
- Use of prescription glasses or contact lenses
Social history
(6)
- Clarify the patient’s occupational history
- Ask if the patient has any support at home
- Take a smoking history
- Take an alcohol history
- Ask about recreational drug use
- Ask about diet and exercise
Abdo Focused History Questions
(7)
- Ask about nausea/vominting
- Ask about dysphagia
- Ask about heartburn
- Ask about recent change in bowel habit
- Ask about appetite and weight loss
- Ask about jaundice
- Ask about mouth ulcers
Cardio History Questions
(6)
- Ask about shortness of breath, orthopnoea, PND
- Ask about palpitations
- Ask about ankle swelling
- Ask about fainting
- Ask about pain in legs
- Ask about history of fatigue
Resp History Questions
(3)
Ask about cough
Ask about shortness of breath
Ask about wheeze
Neuro History Questions
(8)
- Ask about neck stiffness
- Ask about fits and faints
- Ask about vertigo
- Ask about changes in vision, hearing and smell
- Ask if they have any walking difficulties
- Ask about episodes of sudden weakness
- Ask about altered sensations in limbs
- Ask about history of speech/swallowing problems
General Endocrine History
(8)
- Ask about altered bowel habits
- Ask about impotence
- Ask about excessive sweating
- Ask about changes in hair distribution
- Ask about lethargy
- Ask about skin changes
- Ask about whether they’ve been passing urine normally
- Ask about menstrual changes
General urinary history
(7)
- Ask how many times a day the patient passes urine
- Ask how many times a night the patient passes urine
- Ask about changes in urine
- Ask about urgency
- Ask if they’ve noticed blood in their urine
- Ask if the patient struggles to begin passing urine
- Ask if they get dribbling at the end of their stream
Stages of obtaining informed consent
Assess the patient’s starting point
Explore the different options pros/cons
Facilitate the patient making their own decision
Check the patient knows what they’re agreeing to
Rosving’s Sign
Presing on the right iliac fossa gives pain on the left
McBurney’s point
the base of the appendix - point of maximal tenderness
Courvoisiers’s Law
If you have painless jaundice, it’s not because of gallstones, suggestive of gallbladder cancer or head-of-pancreas cancer
Charcot’s Triad
Jaundice
Fever
Pain
Differences large and small bowel on CXR
Large bowel: haustra
Small bowel: valvulae coniventes
Depression History (8)
What happened to precipitate the event?
Explore symptoms
- Low moood
- Poor Sleep
- Difficulty concentrating
- Low energy levels
- Inability to enjoy things
- Loss of appetite
Assess Risk
Breast History
History of Lump
- Side
- Duration
- Change in size
- mobility
- pain?
- skin changes?
Gynae history
- age of first period
- how many children?
- what age?
- use of oral contraception
