General symptom systemic inquiry

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It is inconceivable that any patient will require to be asked all the questions that may be important on some occasions. For example, enquiry about contact with birds may be critical in a patient with atypical pneumonia but is a waste of time in many situations. It follows that the choice of questions selected to ensure that the history, as obtained, is sufficiently comprehensive is a matter of clinical judgement. As a general principle, it is important for the clinician to pay particular attention to those diagnostic options which require specific treatment.

During training experience can he obtained from undertaking a thorough general symptom inquiry, asking the patient the 'cardinal' symptoms relevant to each system (see Table LI I), Otherwise, ii is useful to start with an open inquiry such as 'what olher symptoms have you noticed?" or 'tell me about your health in general' (i.e. not "have you any other symptoms'?'). A positive response prccipitatcs an examination of the system cluster - and its layers - as undertaken for the presenting complaint, but usually in less detail.

There are other cues to checking cardinal symptoms in one or more systems:

• when the putative diagnosis for the presenting complaint raises possibilities of disease or disorder in other systems, e.g. a patient presenting with palpitations due to atrial fibrillation may have hyperthyroidism

Consider:

Alcoholic Myopathy Symptoms

Fig. 1,9 Alcohol-related disorders,

Consider:

Alcoholic dementia (cortical atrophy)

Subdural haematoma (falls)

Withdrawal convulsions

Delirium tremens

Cardiomyopathy

Hypertension

Alcoholic hepatic cirrhosis

Portal hypertension Pancreatitis

Dupuytrens contracture Proximal myopathy Peripheral neuropathy

TABLE 1.11 The general symptom inquiry: cardinal' symptoms if

Genera/ health

If appropriate, mental attitude to sex (libido), morning erections, frequency

General wel-being

of intercourse, ability to maintain erections, ejaculation, urethral

Sleep

discharge

Appetite

Females

Weight change

If premenopausal, age of onset of periods (menarche). regularity of periods

Energy

(e,g, 28-day cycle), length ol period, blood loss (e.g, clots, flooding), date

of last period, contraception if relevant, presence of vaginal discharge

Cardiovascular system

If post-menopausal, bleeding

Ankle swelling

Stress and/or urge incontinence

Palpitations

If appropriate, libido, pain during intercourse (dyspareunia)

Brealhlessness when lying flat (orthopnoea)

Attacks of nocturnal brealhlessness (paroxysmal nocturnal dyspnoea)

Central nervous system

Chest pain or exertion

Headaches

Pain in legs on exertion

Fits

Faints and blackouts

Respiratory system

Tingling (paraesthesiae)

Shortness of breath: exercise tolerance

Numbness

Whee2ing

Muscle weakness

Cough

Hearing symptoms (e.g. deafness, tinnitus)

Sputum production (colour, amount)

Chest pain reiated to respiration or coughing

Visual

Blood in spulum (haemoptysis)

Appearance of eyes Pain

Alimentary

Disturbance of vision, Including dyplopia

Condition of mouth

Difficulty with swallowing (dysphagia)

Locomotor

Nausea and vomiting

Joint pain or stiffness

indigestion

Muscle pain or weakness

Heartburn

Abdominal pain

Endocrine

Wetght loss

Heat intolerance

Change in bowel habit

Cold intolerance

Colour of motion (e.g pale, dark, black, fresh blood)

Change in sweating

Prominence of eyes

Urogenital

Swelling in neck

Pain on passing urine (dysuria)

Excessive thirst

Frequency of passing urine by day or night (nocturia)

Abnormal colour of urine (e.g. blood)

Number ot sexual partners

Males

If appropriate age, prostatic symptoms such as difficulty in starting to pass

urine, poor stream, terminal dribbling

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