INTRODUCTION:-Greet patient and introduce your self.-identify patient-confirm agenda and take consent for discussion by saying.. I have a letter from GP you have it is alright to discuss this issue today?

DD

ComplicationAssociationRisk factorsCausesDD

PRESENT HISTORY-Ask about all DD

-REVIEW OF OTHER SYSTEM

Git GG CCC HLES Period Psychatric Trauma

-PAST HISTORY -FAMILY HISTORY-DRUG HISTORY ,,,, HERBAL ,,,, VITAMINE ,,,,, OCP

SOCIAL HISTORYDiet history diabetes ,coeliacSexualhistoryVaccinationTravel history in feverDaily activityIncomeMJAlchol

Smoking

With whom you lives

Recreational drugs

HISTORY SHEET

END OF HISTORY:-I will summarize for you now the important point if you still have anything that we have not discussed and you are worried about it tells me.-ASK ABOUT PATIENT CONCERN-From what we have discussed, it is possible your symptoms could be duo to . After I examine you, we might consider doing Basic investigationadmision Confirm diagnosis.. Search for etiology and complication

HISTORY.........................

-General

Weight, any recent change in your weight, how many Kg, over how many days. Appetite, any change in your appetite. Fever any change in body temp. . Fatigue, any undue fatigue.Swelling, any lump or bumps in your body .Sleep any change in sleeping hours

-Gastroenterology

. Are you have any mouth sore, it is painful, any problem with teeth.There is any difficult of swallowing, sensation of food sticking in your throat, where does it seems to stick, and it worse by fluid or solid.Any pain during swallowing.Any feeling sick, retching or regurgitation of clear tasteless fluid.Did you getting sick, it is color, how many time, related to pain. Related to food, what relive, what exacerbate, does it contain any trace of blood, any indigestion, can you describe your indigestion to me, any heart burn, can you describe to me..Did you have any tummy pain and analysis pain.Did you have any wind, does it pass downward or upward.Ask about normal bowel habit , how many times in normal, and now how many times, what color , there is blood , slime, what is about odor, associated with abdominal pain, it is difficult to flush away, does it smell or float, there is incontinent of stool, when you try to opening bowels, you have sensation of needing to go without evacuation-Did you have any discolorations of your eyeball or skin?

-Genitourinary

.Any problem with your water work.Any pain during or immediately after passing urine.Strangury, inability to pass urine with suprapubic pain and repeated desire to micturation.Pain in the side of back.Frequency, pass the urine with repeated time without no change in volume.Urgency, sudden need to pass urine. Urge incontinence, involuntary to pass urine when an urgent need to micturate cannot be resistant.Stress incontinence, leakage of urine in response to increase intra abdominal pressure.Hesitancy delay in initiation of urine flow.Poor urinary stream and dribbling of urine after micturation.Polyuria, pass amount of urine more than normal, it is associated with increase drink of water, passes urine at night.Coloure of urine

.I want to ask you some rather personal questions is that ok?.Have you a regular sexual partner, male or female, are you practicing safe sex, are you worried about that you might have picked anything from sexual intercourse.Any change in sexual desire or abilityAsk about scrotal pain, swellingAsk about anal discharge, rectal bleedingAsk about ulcer at penis, rash, wart.Ask about menses, purities valve, sores, dysparunia, post coital bleeding

Cardiovascular system- Chest pain, shortness of breath, orthopnea, paroxysmal dyspnea-Ankle swelling-Awareness of heart beat-Blackout-Leg pain (Claudiacation)Chest-Cough, phlegm, haemoptysis-Shortness of breath-Noisy chest-Chest pain-Sleep affection, snore during sleep-Change the voice character

Neurological

-Headache, eye affection, photophobia, neck pain, confusion, fever and drowsiness-Faint or blackout-Funny turns or fits-Weakness or numbness, tingling sensation (pin and needle in limbs)Special sense, smell, hearing, taste, eye, and swallowing-Unsteadiness, in the dark and during walk-Gait-Water work and back passage-Did you have any change in your mood, concentration, memory or behaviors?

Hematology

-Any bleeding spot under skin, from teeth, gums or from nose

LocomotorsJoint pain, stiffness, swelling and deformity

SkinSkin rash, colour, size, shape, itching, discharge, Hair loss of hair or abnormal growth of hairSweating

Past medical history (PATMIS)-Procedure, admission and blood transfusion-Medical examination for check up-ImmunizationSerious illnessAllergyDrugs

Family history

-Similar condition-Any illness runs in your family

Social-Alcohol, smoking and recreational drugs-Marital status-Sexual history-Job and finance-Lives with -Travel, vaccination and diet history-Daily activity

-After end of consultation tell the pt is there is anything that we have not discussed and you are worried about it-From what we have discussed, it is possible your symptoms could be duo to . After I examine you, we might consider doing

- During discussion

I will request Basic investigationConfirm diagnosisSearch for aetiology and complication

Management plan-Symptoms control-managed underling disease process-General management

How you can practice history taking? 1-Introduction2-Open question................. I have a letter from GP that you have ............... It is alright to discuss that today3-Tell pt can you tell me more about that4- Analysis complain....... In details 5-Focused history according to complain ........ As if the complain is cough so ask about chest symptoms 6-Ask about the DD in details every DD ask about causes , risk factor, symptoms, complication ,,,,,,,,,,,,, ask about everything even if symptoms in past or family history7-Review of other system and please don't repeat the question again8-Past history including drug history9-Family history10-Social history

DD INABILITY TO WAHK

1- WITHOUT SENSORY LEVELA- FLACID (LMNL)- Muscle disease congenital as myopathy

inflammatory as polymyositis and dermatomyositisDrugs as steriod and statinMetabolic as hypokalemia and hyperkalemiaEndocrine as cushing, hypothyrodism, thyrotoxicosisParaneoplastic syndrome- Preipheral nerveMotor preipheral neuropathy -Neuro musculare junction as mythenia gravis and botulism-poliomylities

B- Spastic( UMNL)-Hereditary spastic paraplegia-Tropical spastic paraplegia-cerebral palsy-Parasagital meningoma-Multiple sclerosis-Motor neuron disease

2- With sensory level

1- DISC PROBLEM2- Infection as TB ,3- Vascular as anterior spinal artery occlusion4- Malignancy ,,, primary or metastatic5- Pathological fracture as in multiple myloma and osteoprosis

3-Intermittent episode of inability to move

Hypokalemia periodic paralysisThyrotoxicosis associated with hypokalemia periodic paralysisMyasthenia gravesNarcolepsy and cataplexyPsychologically stress

Causes of collapse

CNS,,,,, as stroke, Parkinson, epilepsy, and disequilibriumCVS,,,,,,, as ACS, valve stenosis, arrhythmia, vasovagal, carotid hypersensitivity syndrome, HOCMHypotension (especially with autonomic neuropathy) hypoglycemiaSituational syncopeAlcohol related fallsDrugs causes hypotensionAddisonDehydrationHemorrhageHyperventilation and anxiety

Ask if attack happened during supine Ask about color during syncope and during recovery Ask about symptoms before, during and after attackAsk about if he seat down, and what is the responseAsk about the bite his tongue and pass urine, or injured him selfAsk about alcohol and drug intakeAsk about the driving( most important question )Ask about consciousness, what is the time he taken to regain consciousdrsaied78@yahoo.comShortness of breathing and chest pain

Shortness of breathing and chest pain-cardiac 1-ACS2-Constrictive pericardities3-Valve lesion-Chest1- pleurisy2- Pnumothorax3- Pleural effusion4-pnumonia5- Bronchial asthma exacerbation, occupation, exercise, cold, home pets and history of allergy6- Pulmonary embolism7- Interstitial lung diseases ask about collagen specially scleroderma8- Pulmonary hypertension primary or secondary, ask about HIV and appetite suppression drugs9- Drugs -GIT GERD

Joint pain with fever

Still diseaseRheumatic heart diseaseSarcodosisSLECrystal arthropathy

Ask about traumaAsk if pain affection joint and surrounding tissueAsk about deformity and swellingAsk if there is sign of inflammationAsk about hair, muscle, skin, Reynauds, nails, bowel habit, eye and orogental ulcerAsk about relation to alcohol or drugs as in goutAsk about diet history if suspect gout

Headache

Acute as SAH, Meningitis, GCA, carotid dissection, pituitary apoplexy, acute angel glaucoma and cerebral vein thrombosis

Intermittent migraine, cluster. Trigeminal neuralgia, tension, paroxysmal hemicrania

Chronic analgesic misuse headache, space occupying lesion, BIH, pituitary affection, normal pressure hydrocephalus and co poisoning

Ask about affection of sleepAsk about effect of cough, sneezingAsk about head traumaAsk about eye, teeth, ear, and nose symptomsAsk about facial painAsk about relation to work, stress, and foodAsk about photophobia, neck pain, feverAsk about pain at tempomandibular joint pain with eating or aloneAsk about visual filed and galactorrhea Ask about HIVAsk about psychiatric historyAsk about APCKDAsk about bleeding disorderAsk about family history for thrombosis, migraine, and SAH

Hirsutism

Cushing disease and Cushing syndromePCOSimple obesityPregnancyOvarian and androgen secreting neoplasmDrugs as phynetoin and steroid, OCP

Ask about manifestation of pituitary tumor as headache and vision affection and manifestation of other hormone deficitAsk about manifestation of Cushing as skin bruises, recurrent infection Ask about drug historyAsk about malignancyAsk about sexual lifeAsk about skin rash and darkening of skin specially areola and axillaAsk about BpPolyuria

1-DM-2--DI A- Neurogenic as trauma, infection HIV TB, infiltrations as Sarcodosis, hemochromatosis, histocytosis and malignancy post surgery, post radiotherapy and head trauma

B-Nephrogenic as hereditary, hypokalemia, hypercalcemia or drugs as lithium

C-Psychogenic Polyuria polydepsia-

D-Paraneoplastic syndrome- Ask about amount of urine, colour, and nocturiaAsk about muscle cramps duo to electrolyte disturbanceAsk about dry eye, dry mouthAsk about polydepsia and how much fluid intakeAsk about pituitary dysfunction symptomsAsk about weight and galactorrhea

Bloody diarrhea InfectionUCCronhsHIVBehcetMalignancyIschemic colitisSuperior mesenteric artery occlusionVascular malformationLocal anal causes as piles, fissureDiverticulitisTBCollagen disorder leads to Vasculitis

Purpuric rash

Increase destruction ITP history of URTI in last 10 days Hypersplenism

Bone marrow suppressionInfection as CMV, EBVDrugs as methotrexate Aplastic anemiaMegaloplastic anemiaMetastases

VascularSLE HSP HCV Cryoglobulinemia

Drugs as anticoagulant, thiazids, penicillinVitamin c deficiencyBlood transfusionHIVTTPHUSDIC

ASK ABOUT BLANCHINGAbdominal pain, joint pain, renal colicSkin rashLNDiet and fruitsAlcoholTrauma and bleeding related to itAsk about family history

PREPARATION FOR PACES

HISTORY

BY

Dr: AHMED MAHER ELIWA

-My role-Pt name-Problem of pt DD risk factor, association and complication

-Take consent to start the consultation-Tell him, your GP has written to me explaining that you have some trouble with youre ., I would like to ask you some question, so I can decide the plan of management

-Tell him I need to write few notes in may paper, so if I am writing thing down, I still will be listening to you-Complain -ROS GGG CCC HELS

ROS

-General Weight, any recent change in your weight, how many Kg, over how many days . Appetite, any change in your appetite . Fever any change in body temp. . Fatigue, any undue fatigue .Swelling, any lump or bumps in your body .Sleep any change in sleeping hours

-Gastroenterology

. Are you have any mouth sore, it is painful, any problem with teeth.There is any difficult of swallowing, sensation of food sticking in your throat, where does it seems to stick, and it worse by fluid or solid.Any pain during swallowing.Any feeling sick, retching or regurgitation of clear tasteless fluid.Did you getting sick, it is color, how many time, related to pain. Related to food, what relive, what exacerbate, does it contain any trace of blood, any indigestion, can you describe your indigestion to me, any heart burn, can you describe to me..Did you have any tummy pain and analysis pain.Did you have any wind, does it pass downward or upward.Ask about normal bowel habit , how many times in normal, and now how many times, what color , there is blood , slime, what is about odor, associated with abdominal pain, it is difficult to flush away, does it smell or float, there is incontinent of stool, when you try to opening bowels, you have sensation of needing to go without evacuation-Did you have any discolorations of your eyeball or skin?

-Genitourinary

.Any problem with your water work.Any pain during or immediately after passing urine.Strangury, inability to pass urine with suprapubic pain and repeated desire to micturation.Pain in the side of back.Frequency, pass the urine with repeated time without no change in volume.Urgency, sudden need to pass urine. Urge incontinence, involuntary to pass urine when an urgent need to micturate cannot be resistant.Stress incontinence, leakage of urine in response to increase intra abdominal pressure.Hesitancy delay in initiation of urine flow.Poor urinary stream and dribbling of urine after micturation.Polyuria, pass amount of urine more than normal, it is associated with increase drink of water, passes urine at night.Coloure of urine

.I want to ask you some rather personal questions is that ok?.Have you a regular sexual partner, male or female, are you practicing safe sex, are you worried about that you might have picked anything from sexual intercourse.Any change in sexual desire or abilityAsk about scrotal pain, swellingAsk about anal discharge, rectal bleedingAsk about ulcer at penis, rash, wart.Ask about menses, purities valve, sores, dysparunia, post coital bleeding

Cardiovascular system- Chest pain, shortness of breath, orthopnea, paroxysmal dyspnea-Ankle swelling-Awareness of heart beat-Blackout-Leg pain (Claudiacation)

Chest-Cough, phlegm, haemoptysis-Shortness of breath-Noisy chest-Chest pain-Sleep affection, snore during sleep-Change the voice character

Neurological

-Headache, eye affection, photophobia, neck pain, confusion, fever and drowsiness-Faint or blackout-Funny turns or fits-Weakness or numbness, tingling sensation (pin and needle in limbs)Special sense, smell, hearing, taste, eye, and swallowing-Unsteadiness, in the dark and during walk-Gait-Water work and back passage-Did you have any change in your mood, concentration, memory or behaviors?

Hematology

-Any bleeding spot under skin, from teeth, gums or from nose

LocomotorsJoint pain, stiffness, swelling and deformity

SkinSkin rash, colour, size, shape, itching, discharge, Hair loss of hair or abnormal growth of hairSweating

Past medical history (PATMIS)-Procedure, admission and blood transfusion-Medical examination for check up-ImmunizationSerious illnessAllergyDrugs

Family history

-Similar condition-Any illness runs in your family

Social-Alcohol, smoking and recreational drugs-Marital status-Sexual history-Job and finance-Lives with -Travel, vaccination and diet history-Daily activity

-After end of consultation tell the pt is there is anything that we have not discussed and you are worried about it-From what we have discussed, it is possible your symptoms could be duo to . After I examine you, we might consider doing

- During discussion

I will request Basic investigation Confirm diagnosis Search for aetiology and complication

Management plan-Symptoms control-managed underling disease process-General management

Abdominal swelling

-DD 1- Ascites 2- Obesity 3-pregnancy 4-flatus

-Causes of Ascites -Liver diseases Viral hepatitis, alcoholic, drugs, biliary, autoimmune, metabolic, malignancy (asbestosis) and vascular

- Non hepatic causes Heart failureNephritic syndrome and renal failure Constrictive pericarditiesLocal abdominal causes as infection, malignancy, pancreatitis

Shortness of breathing and chest pain

-cardiac 1-ACS 2-Constrictive pericardities 3-Vave lesion-Chest 1- pleurisy 2- Pnumothorax 3- Pleural effusion 4-pnumonia 5- Bronchial asthma exacerbation, occupation, exercise, cold, home pets and history of allergy 6- Pulmonary embolism 7- Interstitial lung diseases ask about collagen specially scleroderma 8- Pulmonary hypertension primary or secondary, ask about HIV and appetite suppression drugs 9- Drugs -GIT GERD

Asymptomatic hypertension

-Essential HTN- Secondary HTN Renal APCKD, RAS, CKD, GN, interstitial nephritis Endocrine as cons, Cushing, pheochromocytoma, MENS 2, ACROMEGALY Anxiety and panic disorder Pregnancy induced HTN Drugs as steroids and liquorices OCP Coarctation of aorta

Ask if previous pregnancy induced HTNDiscus other risk factors of vascular affection-Discus the life style change as alcohol, smoking, diet, exercise, coffee and tea -Plan as blood test including renal profile and electrolyte and image on heat - Check for complications eye, heart, and kidney

Back pain

Causes Mechanical as lumber disc Trauma Infection as TB, Brucellosis, and osteomylitis Inflammatory as seronegative arthropathy Tumor primary or secondary specially MM Osteoporosis, osteomalicia Renal colic Pancreatitis

Ask about the neurological manifestation and pathological fractureAsk about refer of pain to lower limb and at any levelAsk about the relation of pain to walk and what is about affection of rest on itAsk if pain relived by sitting forward (spinal canal stenosis)Ask about night pain, gait affection, sphincter affection

Any join affection; ask about skin rash, hair, eye, proximal muscle, and nail. Raynaudes, bowel change, STDs and diet history for celiac and osteomalicia

Ask if there is change in weight or height Ask about relation of pain with cough and sneezingAsk about risk factors of osteoporosis as early menopause, oophorectomy, smoking, nutrition, family history, corticosteroids therapy, HRT, OCP, Thyrotoxicosis and collagen disorder

Drug history and HRT-Plan of care Basic investigation like CBC, LFT, RFT, electrolytes and x ray of spine DEXA, isotopic bone scan for metastases and MRIJoint pain with fever

Still diseaseRheumatic heart diseaseSarcodosisSLECrystal arthropathy

Ask about traumaAsk if pain affection joint and surrounding tissueAsk about deformity and swellingAsk if there is sign of inflammationAsk about hair, muscle, skin, Reynauds, nails, bowel habit, eye and orogental ulcerAsk about relation to alcohol or drugs as in goutAsk about diet history if suspect gout

Fever with headache

Meningitis viral as HIV, HS Bacterial as TB, meningococcal, pneumococcal, listeria Fungal as cryptococcalSLE

Ask about skin rash Ask about neck pain photophobiaAsk about head traumaAsk about traveler historyAsk about vaccinationAsk about splenectomyAsk about diet as unpasteurized milk that leads to neurobrucellosis and listeriaAsk about vaccination historyAsk about HIV, TB history

Bronchial asthma with increase symptoms

- Search about the trigger factors as pollen, dust mite, cat dander, cold air, smoke, exercise, pets, aspirin and occupational (isocynate, platinum)-History of allergic rhinitis and topic eczema-History of drug allergy-Inhaler technique and embarrassment of using inhaler -Previous use predisolone-GERD-Post nasal discharge-Allergic pulmonary aspergillus's-Carcinoid -charge Strauss, GPS, and WG

Ask about day symptoms, affection of sleep, interfere with daily activityAsk about relation with exercise, and cold exposureAsk if there is other medication than used for treatment of asthmaAsk about did he use salbutamol more than beforeAsk about there is previous anesthesiaTell plan for annually influenza vaccine and 5 years pneumococcal vaccine

Abdominal pain

Postprandial pain, GB, DU, mesenteric ischemiaAIPFMFPANDKAMIRenal failureAdrenal insufficiencyLead poisingDrugsPancreatitisIBSMalingering

Any pain should be scoreAsk about alarm signAsk about diet history in details for celiacAsk about bowelAsk about other symptoms suggestive IBS as anxiety, coffee and teaAsk about HIVAsk about IBDAsk about previous surgeryAsk about tingling and numbness during attack of painAsk what increase pain as alcohol?Ask about psychtic illnessAsk about drugs for depression, Ask about skin rash and sensitivity to rashBurning of the feet

Causes -Alcoholic and amylodosis - Vitamin b12 deficiency and folic acid deficiency -Paraneoplastic syndrome - Vasculities -Drugs as INH, amiodarone -infection as HIV and syphilis -Diabetes mellitus -Trauma -Endocrinal as hypothyroidism, acromegaly, pregnancy - ask about renal failure - Collagen disorder

Ask about back painAsk about history of peripheral vascular disease Ask about foot ulcerAsk about the autonomic dysfunction as impotence, arrhythmia, and hypotensionAsk about sensation and history of falls in the dark areaAsk about gait

In the plan of care should treat the other risk factors

Cold and painful finger

Causes Collagen disorder as scleroderma, SLE, dermatomyositis, Peripheral vascular diseases Drugs as BB Job Trauma Cervical disc and syringomyelia Blood diseases as polythycemia, waldenstorm, vasculities, cryoglobulinemia, myloproliferative disorder Primary

Ask about family historyAsk about same change in hand, feet and hair lobulesAsk about smokingAsk about history of trauma

Causes of collapse

CNS as stroke, Parkinson, epilepsy, and disequilibrium, CVS as ACS, valve stenosis, arrhythmia, vasovagal, carotid hypersensitivity syndrome, HOCMHypotension (especially with autonomic neuropathy) and hypoglycemiaSituational syncopeAlcohol related fallsDrugsAddisonDehydrationHemorrhageHyperventilation and anxiety

Ask if attack happened during supine Ask about color during syncope and during recovery Ask about symptoms before, during and after attackAsk about if he seat down, and what is the responseAsk about the bite his tongue and pass urine, or injured him selfAsk about alcohol and drug intakeAsk about the drivingAsk about consciousness, what is the time he taken to regain conscious

Causes of dizzy spell

CNS Parkinson plus syndrome, epilepsy, ataxia, stroke and vestibular neuritisCVS carotid hypersensitivity syndrome, valve lesion, arrhythmia,Hypoglycemia ask about diet, exercise, injection technique and any lumps also search about other causes of hypoglycemia as hypopiutarism, Addison, sarcoma liver and renal diseasePostural hypotensionSituational syncope as micturation, cough, vasovagal syncopeOsteoarthritisDrugs like diuretics and antihypertensive medicationAnemiaEar disease, BBVMultiple sclerosis, relation of vertigo with hot bath

Ask about attack what happened before, during and after

Ask if attack occurred while sitting or lying downAsk about history of fallsAsk about loudness, facial pain

Confusion

Causes -Dementia as Alzheimer disease Lowey body dementia Multi infarction dementia Parkinson and Parkinson related syndrome Picks dementia Hydrocephalus Hypothyroidism and vit. B12 deficiency Creutzfeldt jakobe and syphilis Wernicks encephalopathy Post trauma HIV Syphilis Subdural hematoma Hydrocephalus Brain tumor

-Acute confusion

Infection Hepatic encephalopathy Uremia Drugs Alcohol, Wernicks and delirium tremens Polypharmacy Subdural hematoma Fecal impaction Urinary retention Electrolyte disturbance MI and PE HIV

Ask about the fluctuation of consciousAsk about if he easily distractedAsk if the pt has insight to his symptomsAsk about memory recent ant retrogradeAsk about behaviorAsk about languageAsk about he can make planAsk about hallucination Ask about problem in concentrationAsk about the personal hygiene, incontinence Ask about trauma, drug intake and alcohol historyAsk about depressionAsk about social risk as driving, cooking alone, boiling waterAsk about gaitAsk about abnormal movement, Ask about moodRheumatoid arthritis

Ask about bone protection from long use of steroidAsk about contraindication of infliximab and methotrexateAsk about carpal tunnel syndrome Ask about affection of daily activity and jobAsk about weakness and sensory affectionAsk about skin nodules, nail, hair, eye, bowel, stiffness, Ask about traumaAsk drug history as thiazids, hydralazine, and procainamid

Diabetes mellitus

Check eye, heart, stroke, peripheral vascular disease, renal, foots, peripheral nerve, NASH, impotence, unsteadiness and autonomic dysfunction

Ask about job specially drivingAsk about other risk factors of cardiovascular diseaseAsk about life style

Ataxia and difficult to walk

AlcoholVascularCongenitalParaneoplasticMalignantSpace occupying lesionDrugsHypothyroidismTraumaDemylinated disorderMiller fisher syndrome

Ask about history of falls

Risk factors for DVT and PE

Long flightOCPFamily historyMalignancySLEAntiphospholipidLife styleBed ridden

SLE

Non specific symptoms as fever, skin rash, LN, chest pain, Reynauds and polyartharalgia

Bloody diarrhea InfectionUCCronhsHIVBehcetMalignancyIschemic colitisSuperior mesenteric artery occlusionVascular malformationLocal anal causes as piles, fissureDiverticulitisTBCollagen disorder leads to Vasculitis

Ask if mixed with stoolAsk about tensmus, urgency, and pain during defecationAsk if mass protruded from the anusAsk about bowel habitAsk about if fresh blood, dark red, mixed with stool, or present in toilet paperAsk about nocturnal diarrheaAsk about alarm signAsk about drug as anticoagulant and NSAIDAsk about family history of cancerAsk about skin papules after taking blood sampleAsk about fever, rigors, and sweatingAsk about serositis as pleurisyAsk about oral, genital ulcerAsk about family history

Jaundice

Hemolytic as sickle cell, thalassemia, and G6PD deficiency and autoimmune specially drug inducedCholestasisMedically as PBC, PSC, autoimmune liver disease, drugs, OCP, hepatitis A B C , alcohol, anesthesia and vascularObstructionPancreatitis

Painful jaundice as, alcohol, infection, drugs, budd chiari, Wilson, pancreatitisPainless as hemolysis, gilberts, pancreatic malignancy, cirrhosis, primary biliary cirrhosis

Ask about risk for hepatitis as blood contact, sharing needle, sex, and for hepatitis A ask about exposure to sewage or food intake or waterAsk about drugs and alcoholAsk about herbal medication Ask about pain, fever, loss of weight, anorexia, colour of urine and stool, itching, vomiting, abdominal swelling, confusion and sleep affectionAsk about other autoimmune diseaseAsk about liptospirosisAsk about recent anaesthesiaAsk about history of preeclampsia in women

Amenorrhea

Pregnancy and OCPAnorexia nervosaHyperthyroidism and hypothyroidAddison Pituitary causesHysterectomy

ASK about headache, vision affection, galactorrhea and libidoAsk about hypercalcemia, gastric ulcerAsk about family historyAsk about diet and exercise

Cough, no sputum

Bronchial asthma and precipitating factorsGERD and relation to foodILD and causes including collagen and drugsDrugsPostnasal discharge, allergic rhinitis, sinusitisInfection including TBJobForeign bodyExternisc allergic alvolitis

Ask about URT symptoms as nasal discharge, nasal congestionAsk about hoarseness of voiceAsk about complication of cough as hernia, incontinence of urine, syncopeAsk about exposure to animalAsk about exposure to asbestoses

double vision

Multiple sclerosisMyasthenia gravisBotulismMiller fisherGravesMitochondria dystrophyProgressive external ophthalmoplegiaIncrease ICTWernicks encephalopathyPituitary apoplexy

Ask about it unilateral, bilateralAsk about what site of diplopia is worseAsk about two images site by site or above each otherAsk if double vision always same or variableRelation of diplopia to fatigueAsk about drug history specially penicillamine and aminoglycosidAsk about visual acuity, night vision, headache, ptosis, diplopia, sequint, and filed of visionAsk about bulbar symptoms and respiratory affectionAsk about other autoimmune diseasesAsk about history of APCKD Dysphagia

Neurological causes bulbar and psudobalbarLocal as FB, GERD, drugs, infection as fungus, scleroderma, cancer and achalasiaDrugs as nitrate CCB, bisphosphonateHIV

Globus hystericus

Ask if there is pain between mealsAsk if swallowing easier with different positionAsk about cough, choking when pt lying flatAsk about recurrent chest infectionAsk about type of foodAsk about nocturnal symptoms

Facial swelling

Angioneuretic edemaSystemic illness as thyrotoxicosis, lymphoma, SLEHereditaryDrugs as ACEi

Ask about the precipitating factors as trauma, stress, pollen, food as peanut, extreme cold or hot, jeweler or contact with animalAsk about history of atopy or bronchial asthmaAsk about skin rash, itching, abdominal pain and skin after resolution of attackAsk about symptoms suggestive laryngeal edema

Hypoglycemia

Iatrogenic as hypoglycemic drugs and quninAddisonPanhypopitutarismRenal and hepatic failureMalignancyInsulinomaReactive hypoglycemiaLack of food intake, injection site, exerciseSurgery as gastric bypass surgeryAlcohol excessive intake

Ask about awareness if he is unaware, no driving

Haemoptysis

CancerBronchiactesisPEInfection as TB or pneumoniaABPSMSCarcinoidHIV Kaposi sarcomaLaryngeal causesDrugs as anticoagulantVasculitis as WG, GPS, MPHereditary hemorrhagic telangecetesiaBleeding disorderThoracic endometriosis

Ask to DD between hematemesis and hemoptysisAsk about asbestosisAsk about TBExplain need for bronchoscope

Headache

Acute as SAH, Meningitis, GCA, carotid dissection, pituitary apoplexy, acute angel glaucoma and cerebral vein thrombosis

Intermittent migraine, cluster. Trigeminal neuralgia, tension, paroxysmal hemicrania

Chronic analgesic misuse headache, space occupying lesion, BIH, pituitary affection, normal pressure hydrocephalus and co poisoning

Ask about affection of sleepAsk about effect of cough, sneezingAsk about head traumaAsk about eye, teeth, ear, and nose symptomsAsk about facial painAsk about relation to work, stress, and foodAsk about photophobia, neck pain, feverAsk about pain at tempomandibular joint pain with eating or aloneAsk about visual filed and galactorrhea Ask about HIVAsk about psychiatric historyAsk about APCKDAsk about bleeding disorderAsk about family history for thrombosis, migraine, and SAH

Hoarseness of voice

Overuse voiceLaryngitisFungal infection in pt use steroid inhalationUpper respiratory tract infectionGERDInhalation of smokeLung cancerLaryngeal cancerBulbar palsyOrtener syndrome from mitral stenosisThyroid enlarged

Tell pt, you will refer him to ENT

Hypercalcemia

HyperparathyroidismMEN 1and MEN 2AcromegalyThyrotoxicosisAddisonFamilial hypercalcemia hypocalceuriaSarcodosisMilk alkali syndromeMalignancy as multiple myelomaDrugs as thiazids diuretics and lithiumVitamin D over doseImmobility

Hypercalcemia with increase PTH, 1ry and tertiary hyperparathyroidism, lithium and hypocalceuria hypercalcemia

Hypercalcemia symptoms as fatigue, depression, anorexia, nausea, vomiting, constipation, renal colic and peptic ulcer

Weight loss

Intentional as diet, anorexia nervosa, exercise, drugs as laxative, diuretics, eltorexineEndocrinal as Thyrotoxicosis, and diabetes mellitus (patient has good appetite) Poor appetiteAnxiety and depressionGastrointestinal as malabsorption, celiac, and cancerAddison, MalignancyAs lymphoma, Myloproliferative disorder Chronic illness and infection as TB, HIVIBD

Ask about the weight before and similar attackAsk about diet historyAsk about any teeth problemAsk about travel historyAsk about drugs that lead to weight loss as SSRIs, metformin and illicit drugs

Macrocytic anemia

Megaloplastic Vitamin B 12 deficiency ask about diet and celiac disease other autoimmune diseaseFolic acid deficiency other iliocecal disease like Whipple, Cronhs, and cancer Non MegaloplasticDrugs as phynetoin, methotrexate and trimethprimMDSAlcoholHypothyroidismLiver disease

Ask about symptoms of anemia as fatigue daily activity and mental statusAsk about other causes of vit B12 deficiency as celiac, ileal disease and bacterial overgrowthAsk about manifestation of vit B 12 deficiency as neuropathy and glossiestAsk about past history of surgeryAsk about steatorrheaAsk about other autoimmune disease

Neck lump

Infection as TB, CMV, IMN and HIVSarcodosisLymphomaMetastasesMyloproliferative disorderDrugs as phynetoin, allopurinolCollagen as SLE, still disease

Ask about the contact at workAsk about contact with animal cat scratch diseaseAsk about toxoplasmosisAsk about relation with alcohol

Painful shoulder with proximal muscle weakness

Inflammatory as polymyositis and dermatomyositisPMRGCAFibromyalgiaEndocrine as Cushing, acromegaly, thyrotoxicosisCollagen as rheumatoidDrugs as steroid and statinElectrolyte disturbanceParaneoplastic syndrome

Ask about tiredness, joint pain, and headache, tenderness over head, jaw claudicating and blurring of visionAsk about morning stiffnessAsk about tendernessAsk about muscle weakness, sensation and muscle wastingAsk about fever weight lossAsk about pain or weakness, stiffnessAsk if pain at shoulder or armAsk about sensory affectionAsk about history of trauma

Palpitation

Ask about anxiety disorderAsk about caffeine and teaAsk about drugs ask salbutamol inhaler Ask about illicit drugsAsk about hyperthyroidismAsk about trigger factors as stress, coffee, tea and emotion changeAsk about what is mean by palpitation, it is slow or fast,Ask if any things can terminate itAsk about systemic causes as Thyrotoxicosis, pheochromocytoma, anemiaAsk about family history or sudden cardiac death

Personality change

Hepatic encephalopathy ask about precipitating factorsAcute alcohol intoxicationWernicks encephalopathySubdural hematomaHypoglycemiaMeningitis

Polyuria

DM--DI Neurogenic as trauma, infection HIV TB, infiltrations as Sarcodosis, hemochromatosis, histocytosis and malignancy post surgery, post radiotherapy and head trauma Nephrogenic as hereditary, hypokalemia, hypercalcemia or drugs as lithiumPsychogenic Polyuria polydepsia-

Paraneoplastic syndrome Ask about amount of urine, colour, and nocturiaAsk about muscle cramps duo to electrolyte disturbanceAsk about dry eye, dry mouthAsk about polydepsia and how much fluid intakeAsk about pituitary dysfunction symptomsAsk about weight and galactorrhea

Lower limb edema

Heart failureCor pulmonalPPH and secondary PHLiver cell failureRenal failureHypoalbuminemiaHypothyroidismDrugs as OCP, ca channel blocker and steroidLymphoedema

Ask about bite of stingAsk about trophic change of skin

Pruritus

ScabiesPBCThyrotoxicosisLymphomaRenal failureLiver cell failureExposure to fiberglass, washing powderHemochromatosisDMHIVPolycythemiaPsychological historyDrugs as phynetoinMalignancy

Ask about other member of familyAsk if Pruritus affected by food, drugs, and stressAsk about skin rashAsk about skin injury and bleedingAsk about eye sore and mouth affectionAsk about Pruritus of vulvae

Purpuric rash

Increase destruction ITP history of URTI in last 10 days Hypersplenism

Bone marrow suppression Infection as CMV, EBVDrugs as methotrexate Aplastic anemia Megaloplastic anemia Metastases Vascular SLE HSP HCV Cryoglobulinemia

Drugs as anticoagulant, thiazids, penicillinVitamin c deficiencyBlood transfusionHIVTTPHUSDIC

ASK ABOUT BLANCHING Abdominal pain, joint pain, renal colic Skin rash LN Diet and fruits Alcohol Trauma and bleeding related to it Ask about family history

Pyrexia

Infection as hepatitis, TB, HIV, malaria, brucellosis, infective endocardites CollagenDrugsMalignancyIBDFactiousIBSThyrotoxicosis

Ask about Fever, weight loss, sweating, drench bed sheetAsk about diet intake for HAV, brucellosisAsk about sexual historyRisk for hepatitis specially HAVAsk about backache, depression, joint pain, fever, night sweat

Haematuria

Trauma and vigorous exerciseAPCKDRenal stoneRenal cystSickle cell diseaseHydronephrosisInfection as TBBPHIgA nephropathy, post strep. GN, alportDrug as anticoagulant, cyclophosphamidBlood disease as hemolysis, congenital or acquired or thrombocytopeniaVasculitis as HCP, PAN, WG, GPS, MP

Ask about at start, at end or allAsk about catheter insertionAsk about job as working in dye, rubber, benzeneAsk about history of biliharzasisAsk about nocturia, frothy urine, and stone passage

Tiredness

Fibromyalgia Chronic fatigue syndromeMyasthenia gravisHypothyroidismPsychiatric illnessDrugs like anexiolyticsAlcoholAnemia OSA asks about snoring, nocturia, restlessness at night, morning headache, and reduced libido

Ask about sleep in front of TV, or at workAsk about accident by carAsk about chronic diseasesAsk about history of URTI,Ask about coffee, tea, alcohol

Tremors

Parkinson and Parkinson plus syndrome and causes, dementia and control of urineBenign essential tremorsIntention tremorsAnxietyDrugs as lithium, B2 agonistAlcoholThrotoxicosisPheochromocytoma

Ask about shaking of handUnilateral or bilateral, symmetrical or asymmetricalDuring rest or during all movemoment or during intention to touch subject or sustained postureAsk about symptoms of Parkinson as tingling, coldness, and rigidity, and slow movement, inability to roll over bed, dribbling of saliva or blepharospasmAsk about tremors at head and legs and if affect elbow or wristAsk about voice changeAsk about effect of alcohol on tremor Ask about thyrotoxicosisAsk about respiratory, liver failure

Treatment of BET is BB, thalamotomy, deep brain stimulation

Visual disturbance

DMGCACRAOCRVOTIAsMigraineHypoglycemiaPostural hypotensionMSMacular degeneration

Ask about headache, pain, filed, acuity, movement, ptosis, colour vision, night vision,

Weight gain

Simple obesityPCOCushing, psudocushingHypothyroidismAcromegalyInsulinomaHypothalamus disorder as Sarcodosis, neoplasmDrugs like steroid, OCP, antiepileptic, HRT, atypical antipsychotic, anabolic steroidNicotine withdrawalPregnancyFluid as in RF, LCF, HF, nephritic syndrome

ask about central obesity, straia, hair growth, thinning of skin, easy bruising, low mood, recurrent infection, facial acne, back pain, proximal muscle weakness and period change and ask about alcoholAsk about diet historyAsk about at any site there obesityAsk about trials of weight lossAsk about complication of obesity as IHD, DM, OSA, HTN,Ask about symptoms of hypothalamus disorder as headache, vomiting, Polyuria

Seizure

Congenital as tuberous sclerosisInfection as TB, meningitisSpace occupying lesionVascular as AVM, strokeMetabolic as hypoglycemia, hypokalemia, hyponatermia, hypocalcemiaTraumaDrug withdrawal as benzodiazepineAlcohol withdrawalDrugs as lithium, ciprofloxacin

Ask about strange sensation, abd pain, fatigue, sleep deprivation, pallor, sweaty, and hallucination

Ask about past history of trauma, febrile convulsion, and birth injuryAsk to differentiate epilepsy from psudoepilepsy

AnemiaTell that sometimes of anemia is settle, decrease daily activity, lack of concentration, headache, and palpitation

Explore about BM failureExplore of hemolytic anemia, pain and attack of jaundiceAsk about mensesAsk about dietAsk drugsAsk about family history of cancerAsk about malignancyAsk about bleeding from orifice or under skinAsk about chronic illness, CKD and collagenPast history of operationAsk about sinster symptoms and signs

Night sweat

TBHIVThyrotoxicosisBrucellosisLymphomaMalariaHypoglycemiasarcodosis

Ask about frequency, feels hot or coldAsk about appetite, thrush in mouth, dyspahgia, loss of weightAsk about skin rashAsk about travel historyDid you feels any flushing pain with alcoholAsk about intimated relationship

TIAsCardiac, AF, MS, cardiomyopathy and paradoxical embolismVasculitisBlood disease as thyrombocytosis, polycythemia, PAN

Ask about past history of rheumatoidFamily history of strokeFamily history of death by strokeFamily history of APCKD

Risk of blood clots

Long flightPregnancyDrugs as tamoxifineAfter surgeryLong immobilityFamily history

All of above should be assessed in pt complain from Dyspnea, collapse, chest pain, hemoptysis, stroke, pain at lower limbs and collapse

Constipation

HypercalcemiaHypothyroidismDepressionParkinsonDiverticulitisSpinal surgerySexual abuseLocal anal causesCancer bowel

Ask about normal bowel habitAsk about character of stoolAsk about strainingAsk about if he hart himself during defecation Ask about blood in stoolAsk about flatus or windDid you need to evacuate the rectum by your hand?There is any over flow diarrheaAsk about diet history

Diarrhea

InfectionCeliacBacterial overgrowthTropical sprueCrohnsUCHIVTumorDM autonomicThrotoxicosisCarcinoidVIPOmaDrugs as laxative and thyroxinRadiation

Ask about night diarrheaAsk about oral ulcerAsk about history of antibiotic in last 2 months or hospital admissionAsk about history of bowel surgeryAsk if stool float in the pan

Inability to walk with sensory affection

HSMNGBSMFSLocal spinal causes as malignancy, TB, disc prolapsedMSBotulismCIPD

Ask about traumaAsk about sphincter affectionAsk about recent vaccination, TB and surgeryAsk about recent URTI, or gastroenteritisAsk about breathing in pt suspected be GBSAsk about family historyAsk about travel, vaccination and sexual history

Bone pain and pathological fracture

Multiple myelomaOsteoporosisOsteomaliciaPrimary hyperparathyroidismTertiary hyperparathyroidismPaget diseaseBone neoplasm either primary or secondaryOsteoarthritis

Ask about Reynauds phenomenonAsk about hypercalcemia symptomsAsk about risk of osteoporosis and osteomaliciaAsk about height and weight

Hirsutism

Cushing disease and Cushing syndromePCOSimple obesityPregnancyOvarian and androgen secreting neoplasmDrugs as phynetoin and steroidOCP

Ask about manifestation of pituitary tumor as headache and vision affection and manifestation of other hormone deficitAsk about manifestation of Cushing as skin bruises, recurrent infection Ask about drug historyAsk about malignancyAsk about sexual lifeAsk about skin rash and darkening of skin specially areola and axillaAsk about Bp

Uncontrolled DM

Ask about hemochromatosisAcromegalyIncompliant to medicationIncompliant with life style

Ask about skin rash, erectile dysfunction, bony pain, cardiomyopathy, darkening of skin, hypogonadal dysfunction as hair loss, loss of libido

Sweating and anxiety

HypoglycemiaHyperthyroidismPheochromocytomaMenopausal symptomsPsychological condition

Ask about period and OCPAsk about HRTAsk about blood pressureAsk about heart rateAsk about drugsAsk about menopausal symptomsAsk about relation of sweating to weatherAsk about feeling cold during sweatingAsk about temperature at this time

Intermittent episode of inability to move

Hypokalemia periodic paralysisThyrotoxicosis associated with hypokalemia periodic paralysisMyasthenia gravesNarcolepsy and cataplexyPsychologically stressProximal muscle weakness

Ask about fatigueAsk what relation to exercise isAsk about relation to foodAsk about symptoms related to MGAsk about variability of symptomsAsk about Thyrotoxicosis symptoms