2

Systematic direct questions

The alimentary system
Appetite Has the appetite increased, decreased, or
remained unchanged? If it has decreased, is this
caused by a lack of desire to eat, or is it because of
apprehension as eating always causes pain?
Diet What type of food does the patient eat? Are
they vegetarian? When do they eat their meals?

Weight Has the patient’s weight changed? By how

much? Over how long a time? Many patients never
weigh themselves, but they usually notice if their
clothes have got tighter or looser and friends may
have told them of a change in physical appearance.
Teeth and taste Can they chew their food? Do they
have their own teeth? Do they get odd tastes and sensations
in their mouth? Are there any symptoms of
water brash or acid brash? (This is sudden filling of the mouth with watery or acid-tasting fluid – saliva
and gastric acid respectively.)


Swallowing If they complain of difficulty in swallowing
(dysphagia), ask about the type of food that
causes difficulty, the level at which the food sticks, and
the duration and progression of these symptoms. Is
swallowing painful?
Regurgitation This is the effortless return of food
into the mouth. It is quite different from vomiting,
which is associated with a powerful involuntary contraction
of the abdominal wall. Do they regurgitate?
What comes up? If food, is it digested or recognizable
and undigested? How often does it occur and does
anything, such as stooping or straining, precipitate it?

Flatulence Does the patient belch frequently? Does

this relate to any other symptoms?
Heartburn Patients may not realize that this symptom
comes from the alimentary tract and they may have
to be asked about it directly. It is a burning sensation
behind the sternum caused by the reflux of acid into
the oesophagus. How often does it occur and what
makes it happen, e.g. lying flat or bending over?


Vomiting How often do they vomit? Is the vomiting
preceded by nausea? What is the nature and volume
of the vomitus? Is it recognizable food from previous
meals, digested food, clear acidic fluid or bilestained
fluid? Is the vomiting preceded by another
symptom such as indigestion pain, headache or giddiness?
Does it follow eating

Haematemesis Always ask if they have ever vomited

blood because it is such an important symptom.
Old, altered blood looks like ‘coffee grounds’. Some
patients have difficulty in differentiating between
vomited or regurgitated blood and coughed-up blood (haemoptysis). The latter is usually pale pink and
frothy. When patients have had a haematemesis,
always ask if they have had a recent nose bleed. (They
may be vomiting up swallowed blood.)

Indigestion or abdominal pain Some people call all

abdominal pains indigestion; the difference between
a discomfort after eating and a pain after eating may
be very small. Concentrate on the features of the
pain, its site, time of onset, severity, nature, progression,
duration, radiation, course, precipitating, exacerbating
and relieving factors


Abdominal distension Have they noticed any abdominal
distension? What brought this to their attention?
When did it begin and how has it progressed?
Is it constant or variable? What factors are associated
with any variations? Is it painful? Does it affect
their breathing? Is it relieved by belching, vomiting
or defaecation?

Defaecation How often does the patient defaecate?

What are the physical characteristics of the stool?
■ Colour: brown, black, pale, white or silver?
■ Consistence: hard, soft or watery?
■ Size: bulky, pellets, string or tape like?
■ Specific gravity: does it float or sink?
■ Smell?

Rectal bleeding Has the patient ever passed any

blood in the stool? Was it bright or dark? How much?
Was it mixed in with or on the surface of the stool, or
did it only appear after the stool had been passed?
Flatus, mucus, slime Is the patient passing more gas
than usual? Has the patient ever passed mucus or
pus? Is defaecation painful? When does the pain
begin – before, during, after, or at times unrelated to
defaecation?


Prolapse and incontinence Does anything come out
of the anus on straining? Does it return spontaneously
or have to be pushed back? Is the patient continent
of faeces and flatus? Have they had any injuries
or anal operations in the past?
Tenesmus Do they experience any urgent, painful
but unproductive desire to pass stool? This is called
tenesmus.
Change of skin colour Have the patient’s skin or eyes
ever turned yellow (jaundiced)? When? How long
did it last? Were there any other accompanying symptoms
such as abdominal pain or loss of appetite?
Did the skin itch?

The respiratory system

Cough How often does the patient cough? Does the
coughing come in bouts? Does anything, such as a change of posture, precipitate or relieve the coughing?
Is it a dry or a productive cough?
Sputum What is the quantity (teaspoon, dessertspoon,
etc.) and colour (white, clear or yellow) of the
sputum? Some patients only produce sputum in the
morning or when they are in a particular position.


Haemoptysis Has the patient ever coughed up blood?
Was it frothy and pink? Were there red streaks in the
mucus, or clots of blood? What quantity was produced?
How often does the haemoptysis occur?

Dyspnoea Does the patient wheeze? Does he get

breathless? How many stairs can he climb? How far
can he walk on a level surface before the dyspnoea
interferes with the exercise? Can he walk and talk
at the same time? Is the dyspnoea present at rest?
Is it present when sitting or made worse by lying
down? (Dyspnoea on lying flat is called orthopnoea.)
How many pillows does the patient need
at night? Does the breathlessness wake them up at
night – paroxysmal nocturnal dyspnoea – or get
worse if they slip off their pillows? There are classifications
that grade dyspnoea numerically, but it is
better to describe the causative conditions rather
than write down a number.
Is the dyspnoea induced or exacerbated by external
factors such as allergy to animals, pollen or dust?
Does the difficulty with breathing occur with both
phases of respiration or on expiration?


Pain in the chest Ascertain the site, severity and
nature of the pain. Chest pains can be continuous,
pleuritic (made worse by inspiration), constricting
or stabbing.

The cardiovascular system

Cardiac symptoms
Breathlessness Ask the same questions as those
described above under ‘Respiratory system’.
Orthopnoea and paroxysmal nocturnal dyspnoea
Orthopnoea and paroxysmal nocturnal dyspnoea
are the forms of dyspnoea especially associated with
heart disease.

Pain Cardiac pain begins in the mid-line and is

usually retrosternal but may be epigastric. It is often
described as constricting or band-like. It is usually
brought on by exercise or excitement. The patient should be asked if the pain radiates to the neck or to
the left arm and whether it is relieved by rest.
Palpitations These are episodes of tachycardia which
the patient notices as a sudden fluttering or thumping
of the heart in the chest.


Ankle swelling Do the ankles or legs swell? When do
they swell? What is the effect on the swelling of bedrest
and/or elevation of the leg?
Dizziness, headache and blurred vision These are
some of the symptoms associated with hypertension
and postural hypotension.

Peripheral vascular symptoms

Does the patient get pain in the leg muscles on exercise
(intermittent claudication)? Which muscles are
involved? How far can the patient walk before the
pain begins? Is the pain so bad that he has to stop
walking? How long does the pain take to wear off?
Can the same distance be walked again? Is there any
pain in the limb at rest? Which part of the limb is
painful? Does the pain interfere with sleep? What
positions relieve the pain? What analgesic drugs give
relief? Are the extremities of the limbs cold? Are
there colour changes in the skin, particularly in
response to a cold environment? Does the patient
experience any paraesthesiae in the limb, such as
tingling or numbness?


The urogenital system
Urinary tract symptoms
Pain Has there been any pain in the loin, groin or
suprapubic region? What is its nature and severity?
Does it radiate to the groin or scrotum?
Oedema Do any parts of the body other than the
ankles swell?
Thirst Is the patient thirsty? Do they drink excessive
volumes of water?

Micturition How often does the patient pass urine?

Express this as a day/night ratio. How much urine
is passed? Is the volume and frequency excessive
(polyuria)? Is micturition painful? What is the
nature and site of the pain? Is there any difficulty
with micturition, such as a need to strain or to wait?
Is the stream good? Can it be stopped at will? Is
there any dribbling at the end of micturition? Does the bladder feel empty at the end of micturition or
do they have to pass urine a second time?

Urine Has the patient ever passed blood in the

urine? When and how often? Have they ever passed
gas bubbles with the urine (pneumaturia)?
Symptoms of uraemia These include headache,
drowsiness, visual disturbance, fits and vomiting.


Genital tract symptoms
MALE
Scrotum, penis and urethra Has the patient any
pain in the penis or urethra during micturition or
intercourse? Is there any difficulty with retraction of
the prepuce or any urethral discharge? Has the patient
noticed any swelling of the scrotum? Can he achieve
an erection and ejaculation?

FEMALE

Menstruation When did menstruation begin (menarche)?
When did it end (menopause)? What is the
duration and quantity of the menses? Is menstruation
associated with pain (dysmenorrhoea)? What is
the nature and severity of the pain? Is there any
abdominal pain mid-way between the periods (mittelschmerz)?
Has the patient had any vaginal discharge?
What is its character and amount? Has she
noticed any prolapse of the vaginal wall or cervix or
any urinary incontinence, especially when straining
or coughing (stress incontinence)?


Pregnancies Record details of the patient’s pregnancies
– number, dates and complications.
Dyspareunia Is intercourse painful?
Breasts Do the breasts change during the menstrual
cycle? Are they ever painful or tender? Has the
patient noticed any swellings or lumps in the breasts?
Did she breast-feed her children? Has there been
any nipple discharge or bleeding? Has she noticed
any skin changes over the breasts?
Secondary sex characteristics When did these
appear?

The nervous system

Mental state Is the patient placid or nervous? Has
the patient noticed any changes in their behaviour
or reactions to others? Patients will often not appreciate
such changes themselves and these questions
may have to be asked of close relatives. Does the patient get depressed and withdrawn, or are they
excitable and extroverted?

Brain and cranial nerves Does the patient ever

become unconscious or have fits? What happens
during a fit? It is often necessary to ask a relative or
a bystander to describe the fit. Did the patient lie
still or jerk about, bite their tongue, pass urine? Was
the patient sleepy after the fit? Was there any warning
(an aura) that the fit was about to develop? Has there
been any subsequent change in the senses of smell,
vision and hearing?


Is there a history of headache? Where is it experienced?
When does it occur? Are the headaches associated
with any visual symptoms?
Has the face ever become weak or paralysed? Have
any of the limbs been paralysed or had pins and
needles? Has there ever been any buzzing in the ears,
dizziness or loss of speech? Can the patient speak
clearly and use words properly?

Peripheral nerves Are any limbs or part of a limb

weak or paralysed? Is there ever any loss of cutaneous
sensation (anaesthesia)? Does the patient experience
any paraesthesiae (tingling, ‘pins and needles’) in
the limbs?

Musculoskeletal system

Ask if the patient suffers from pain, swelling or limitation
of the movement of any joint.What precipitates
or relieves these symptoms? What time of day
do they occur? Are any limbs or groups of muscles
weak or painful? Can he walk normally? Has he any
congenital musculoskeletal deformities?


Previous history of other illnesses,
accidents or operations
Record the history of those conditions which are not
directly related to the present complaint.Ask specifically
about tuberculosis, diabetes, rheumatic fever,
allergies, asthma, tropical diseases, bleeding tendencies,
diphtheria, gonorrhoea, syphilis, and the likelihood
of intimate contact with carriers of the human
immunodeficiency virus (HIV)

Drug history

Ask if the patient is taking any drugs. Specifically,
enquire about steroids, anti-depressants, insulin, diuretics, anti-hypertensives, hormone replacement
therapy and the contraceptive pill. Patients usually
remember about drugs prescribed by a doctor but
often forget about self-prescribed drugs they have
bought at a pharmacy. Is the patient sensitive to any
drugs or any topical applications such as adhesive
plaster? If they are, write it in large letters on the
front of the notes.


Immunizations
Most children are immunized against diphtheria,
tetanus, whooping cough, measles, mumps, rubella
and poliomyelitis. Ask about these, and smallpox,
typhoid and tuberculosis vaccination.

Family history

Enquire about the health and age, or cause of death,
of the patient’s parents, grandparents, brothers and
sisters, and ask about any children who have died.
Draw a family tree if there is obvious familial disorder
(e.g. lymphoedema). If the patient is a child,
you will need information about the mother’s pregnancy.
Did she take any drugs during pregnancy?
What was the patient’s birth weight? Were there any
difficulties during delivery? What was the rate of
physical and mental development in early life?

Social history

Record the marital status and the type and place of
dwelling. Ask about the patient’s sexual life, the sex
and sexual behaviour of their sexual partners and
the nature of their physical relationships. Ask about
the patient’s occupation, paying special regard to contact with hazards such as dusts and chemicals.
What are the patient’s leisure activities? Has the patient travelled abroad? List the countries visited
and the dates of the visits if these appear to be relevant.


Habits
Does the patient smoke? If so what – cigarettes, cigar
or pipe? Record the frequency, quantity and duration
of their smoking habit. Does the patient drink alcohol?
Record the type and quantity consumed and the duration of the habit. Does the patient have any
unusual eating habits?