History Taking

in Medicine and Surgery

Third Edition

Jonathan M. Fishman
BM BCh (Oxon.), MA (Cantab.), BA (Hons.) MRCS (Eng.), DOHNS (RCS Eng.), PhD
Graduate of Oxford and Cambridge
Medical Schools

Laura M. Cullen
MB BS, BSc. (Hons.), nMRCGP, DFSRH
Graduate of Imperial College, London

Edited by Ashley Grossman

FmedSci
BA, BSc, MD,
FRCP
Professor of
Endocrinology
University of
Oxford
Contents
Forewords to third and previous editions v
About the authors ix
Introduction and how to use this book x
Abbreviations xii
The structural basis of history taking 1
How to present the history 13
Abdominal masses and distension 16
Acute abdominal pain 22
Alcohol-related problems 33
Ano-rectal pain 42
Back pain 46
Breast lump 54
Change in bowel habit 59
Chest pain 63
Collapse, syncope and blackouts 71
Confusion 78
Constipation 85
Cough 91
Depression and anxiety 98
Diabetes 108
Diarrhoea 117
Dizziness and vertigo 125
Double vision (diplopia) 132
Dyspepsia and indigestion 137
Dysphagia 142
Dysuria 149
Earache (otalgia) 154
Facial pain 159
Faecal incontinence 165
Falls and gait abnormalities 170
Fatigue and lethargy 178

<< iii >>

 Haematuria 185
Haemoptysis 193
Headaches 200
Hearing loss 208
Hoarseness and voice disorders 212
Jaundice 218
Joint disorders (mono/polyarthritis) 225
Leg pain 233
Leg ulcers 242
Lower gastrointestinal bleeding 249
Lumps (general) 256
Lymphadenopathy (general) 261
Multiply injured patient 268
Neck lumps 278
Nipple discharge 285
Overdose 290
Palpitations 295
Pruritus 304
Pyrexia of unknown origin and fever 311
Rashes 319
Red eye 328
Scrotal pain and swellings 332
Shortness of breath 338
Swollen legs 350
Tinnitus 356
Tremor and movement disorders 361
Upper gastrointestinal bleeding 370
Vaginal bleeding 376
Visual loss (acute and chronic) 384
Vomiting 390
Weight loss 397
Asking difficult questions 403
Case scenarios 407
Index 447

<< iv >>
 Abdominal masses and
distension

> History of presenting complaint

When did the lump appear?

SOCRATES

Site
Where is the lump?

O nset
Duration?
How was it noticed and by whom? (suddenly appeared,
painful). Have your clothes become tighter recently?
Abdominalmassesanddistension

C haracter
Is it focal or generalised?

A ssociated symptoms
Is it producing local
symptoms? Is there pain or
discomfort?
Are there any other lumps?
Are there any systemic symptoms (weight loss, malaise, change in
bowel habit, anorexia, fever?).

<< 16 >>
> The 7 F’s
Are there any symptoms of bowel obstruction (Flatus)? – colicky
abdominal pain, vomiting, absolute constipation, abdominal
distension. Are there any changes in bowel habit or rectal
bleeding? (think about the causes of bowel obstruction).
Is there any shortness of breath due to Fluid accumulation, or
ascites, (causing splintage of the diaphragm)? Are there any
features suggesting liver disease and in particular portal
hypertension eg jaundice, haematemesis (varices), dilated veins
on abdomen, rectal bleeding (haemorrhoids). Are there any signs of
jaundice or symptoms of anaemia?
Are you constipated? (Faeces)
Have you put on weight recently? (Fat)
Is there any chance that you could be pregnant? (Fetus)
Are there any symptoms of malabsorption eg steatorrhoea (Are
your stools pale, bulky, offensive? Do your stools float? Are they
difficult to flush away?) (Food – coeliac disease causes
abdominal distension).
Are there any Gynaecological/Genitourinary symptoms? – dysuria,
frequency, urgency, urge incontinence, haematuria, vaginal bleeding
(Flipping Great Masses). Is there any associated leg swelling/ DVTs/
varicosities (extrinsic venous compression)?

T iming/duration
Is it enlarging/staying the same/getting smaller? Over what
time course?

A
What do you think is wrong? b
d
Is there anything that you are worried this might be due o
m
in
to? Ask about treatment, if any, already received? al
m
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<< 17 >>
 > Past medical history
MITJTHREADS
Is there any history of previous hospital admissions/operations/illnesses,
especially abdominal disorders or operations?
Is so when (year), why, how was the diagnosis made, where
(which hospital?), who were you under?
Is there a history of IBD?
Is there a history of any gynaecological problems (flipping great
masses) such as fibroids, ovarian cysts etc.
Is there any history of known hernias, maldescended testes, or AAA?

> Drug history

What medications are you currently taking?
What dose?
Why are you on that?
Compliance, side-effect(s) of medication, OTC/herbal remedies,
allergies. (What happens?)
Abdominalmassesanddistension

> Social history

To focus on:
● Smoking
● Alcohol
● Recreational drugs
● Overseas travel history such as hydatid cysts
● Occupation (heavy lifting →
hernias) Lifestyle limitations due to
disease.
Has patient taken time off work? How
much? What are your hobbies?
How do the symptoms interfere with your life (walking, working,
sleeping)?

<< 18 >>
> Family history
Are there any diseases or illnesses that ‘run in the family’?
Is there a FHx of malignancy, especially bowel
carcinoma? Has there been any contact with TB or
other infections? Is there a FHx of polycystic kidney
disease?
Is there any consanguinity? Draw a family tree.

> Differential diagnosis

● Fat (Obesity)
● Fetus (Pregnancy)
● Flatus (Air)
● Bowel Obstruction
● Aerophagy (air swallowing) eg IBS
● Fluid (Ascites)
● Chronic peritonitis (eg TB, missed appendicitis)
● Carcinomatosis (malignant deposits especially
ovarian, stomach)
● Chronic liver disease (cirrhosis, secondary deposits, portal
or hepatic vein obstruction, parasitic infections)
● Congestive heart failure (right-sided)
● Chronic renal failure (nephrotic syndrome)
● Chyle (lymphatic duct disruption)
● Constrictive pericarditis
● Faeces A
b
● Chronic constipation d
o
● Chronic intestinal obstruction m
● Hirschsprung’s disease in
al
● Acquired megacolon m
a
● Flipping great masses s
s
● Uterine fibroids e
● Giant Hepatomegaly/splenomegaly s
a
● Giant renal cell carcinoma n
d
● Polycystic kidneys di
● Lymph nodes st
e
● Abdominal aortic aneurysm n
si
o
<< 19 >>
 ● Abdominal cysts – renal, pancreatic, ovarian,
pancreatic pseudocyst, mesenteric, hydatid
● Desmoid tumour
● Bladder (retention)
● Food
● Malabsorption syndromes eg coeliac disease

> Investigations
B lood tests
● Haematology – FBC, ESR, blood film
● Anaemia (anaemia of chronic disease)
● Polycythaemia (RCC)
● Raised WCC (blood dyscrasias, diverticular disease,
renal infections, empyema gall bladder etc)
● ESR (malignancy, chronic inflammation)
● Blood film (blood dyscrasias and hepatosplenomegaly)
● Biochemistry
● U+Es (vomiting and dehydration eg gallbladder and
bowel lesions, ureteric obstruction, renal lesions)
Abdominalmassesanddistension

● Ca2+ (carcinoma)
● Glucose (pancreatitis, pancreatic carcinoma)
● CRP (infection)
● LFTs (liver lesions, metastases, low albumin in ascites)
● Amylase (pancreatic pseudocyst)
● PSA (prostate carcinoma)

U r ine (M,C& S)
● Haematuria (RCC, bladder tumours)
● Pus cells
● Organisms
● Malignant cells
● β-hCG (pregnancy)

<< 20 >>
R adiology
● CXR
● Congestive cardiac failure
● Metastases
● AXR
● Bowel obstruction
● Constipation
● Large spleen/liver
● Renal/ureteric calculi
● Transabdominal/transvaginal USS
● Organomegaly
● AAA
● Cysts/collections
● Enlarged bladder
● Ovarian/uterine lesions
● CT abdomen ± guided biopsy
● Carcinoma
● Collection/cyst

Further investigations
● OGD (carcinoma stomach, pyloric stenosis)
● Small bowel enema (Crohn’s, carcinoma)
● Barium enema (carcinoma bowel, diverticular)
● Colonoscopy (carcinoma colon, diverticular)
● Cystoscopy (bladder tumour)
● Paracentesis – If ascites for cytology, culture (microbiology) A
b
and protein content (biochemistry) d
o
● Diagnostic laparoscopy ± biopsy m
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<< 21 >>
 Acute abdominal pain

> History of presenting complaint

Site
Can you point with a finger to the location of the pain?

O nset
When did the pain start? Where did it
start? Has it moved since?
What were you doing when the pain started?
How quickly did it come on? (Suddenly, over seconds, minutes,
gradually)

C haracter
Where is the pain worst?
What is the pain like – aching, sharp/stabbing/like a knife,
burning? Is it constant or variable? Is it colicky?

R adiation
Does the pain radiate? (To the back – AAA, pancreatitis; down
into the groin/genitals – renal/ureteric colic, testicular torsion; to
the shoulders
– gallbladder; loin – pyelonephritis; chest – MI)
Acuteabdominalpain

A ssociations
What else did you
notice? General
● Sweating/fever
● Rigors
● Shortness of breath
● Dizziness on standing (Concealed/covert haemorrhage)
<< 22 >>
Gastrointestinal – Have you had any
● Acid reflux, waterbrash?
● Pain during swallowing? (Odynophagia) Difficulty swallowing?
(Dysphagia)
● Nausea or vomiting? (Onset, duration, persistence, how
much, frequency, composition – blood, bile, small-bowel
contents, coffee-grounds)
● What came first, the vomiting or the pain? (NB:
Classically, if pain comes on first, followed by vomiting,
this suggests a
surgical cause. If vomiting comes on first, followed by pain,
this suggests a medical cause for the pain)
● What effect did vomiting have on the pain?
● Is there diarrhoea (frequency, consistency, blood/mucus/
pus), constipation, haematemesis/melaena/PR bleeding, painful
defecation? Is there any recent change in bowel habit? Are
there any symptoms of indigestion, steatorrhoea, or weight
loss?
● Are there any features of bowel obstruction?
● When were your bowels last open?
● When was flatus last passed?
● Are you able to pass flatus at the moment?
● Is there any distension or vomiting?
● Are there any current hernias?
Genitourinary – Are there urinary symptoms? (Suggestive of UTI or
acute retention: ask about frequency, dysuria, urgency, haematuria,
nocturia, hesitancy, poor stream, terminal dribbling, etc)
Gynaecology
● Have you had previous gynaecological problems?
● Do you mind me asking if you are sexually active?
● At what stage are you at in your menstrual cycle at the
moment? Are there any problems with menstruation?
● Is there per vaginal bleeding, PID/inflammation of the tubes, A
ovarian cysts? c
ut
● When was the first day of your last menstrual period? e
(Menses – duration, regular, heavy, painful; PV discharge; PV a
b
bleeding; IMB, PCB, PMB; fibroids; endometriosis; relation of d
pain to menstrual cycle (mittelschmerz)) o
m
● Is it possible you could be pregnant? (Ectopic) in
al
● Has there been recent trauma? (Delayed rupture of spleen!) p
ai
n
<< 23 >>
 T iming
What is the duration? (> 6 hours of unremitting pain is likely to
be surgical rather than medical)
Have you had it before? If so, how was it
different? When does the pain occur and how
frequently?

E xacerbating/relieving factors
What brings it on/what made the pain worse?
What relieves the pain (What takes the pain away)? (Rest, posture/
movement/lying flat, analgesia, antacids, milk, defecation)
What brings on the pain?
● Does breathing affect the pain?
● Does breathing deeply make it worse?
● How about coughing, movement, hot drinks, alcohol?
(Gastritis, pancreatitis)
● Food? (Fatty foods – the pain of gallbladder pathology,
acute pancreatitis, mesenteric ischaemia, PUD and GORD
can all be precipitated by food)
● Exercise/exertion?

S everity
Is it the worst pain you have ever experienced? Score out of 10
compared with childbirth or 10 being severe enough to take your
own life.
Have you taken time off work or been away from school because of
the pain?
Acuteabdominalpain

Is your sleep affected?

<< 24 >>
R isk factors
Risk factors for AAA
Hypertension
Smoking Advancing age
Family history of AAA COPD
Cardiac disease Previous stroke

Risk factors for pancreati ti s (GET SMASHED)

Gallstones and Ethanol – two commonest causes of pancreatitis
Trauma Steroids Mumps
Autoimmune (PAN)
Scorpion bites
Hypothermia, Hypercalcaemia, Hypertriglyceridaemia ERCP, Emboli
Drugs – thiazides, azathioprine

What do you think is wrong?

A
Ask about treatment already received (eg NSAIDs). c
ut
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<< 25 >>
 > Past medical history
Is there history of previous GI disease? (Indigestion, abdominal pain)
Do you suffer from gallstones?
Have you had an AAA, peptic ulcer, diverticular disease or
pancreatitis before?
Have you had abdominal surgery previously (adhesions)?
Have you had previous gynaecological problems?
Have you had a previous appendicectomy?
Consider the patient’s fitness for general anaesthesia – Have you
had any reactions to general anaesthetics in the past?

> Drug history

Are you taking any medications, especially:
● Anti-inflammatories? (Cause PUD)
● Steroids? (Mask abdominal signs)
● The pill or HRT? (Need to be stopped prior to surgery
due to increased thromboembolic risk)
Compliance, side-effect(s) of medication, OTC/herbal remedies,
allergies. (What happens?)

> Social history

Do you smoke? (Important to stop pre-operatively because of
Acuteabdominalpain

increased risk of thrombosis)

Do you drink alcohol? (Gastritis, acute/chronic pancreatitis)
Do you use recreational drugs?
Sexual history – I need to ask you some important though
rather personal questions, if I may, which may or may not
relate to the symptoms you’ve been having. Have you had
recent unprotected intercourse with a new partner?
(PID/salpingitis)
How would you manage at home after a possible operation? Who
is at home to look after you on discharge? (The situation at home
is very important if considering surgery.)
<< 26 >>
> Family history
Is there a family history of any GI conditions, eg IBD (UC/Crohn’s
disease)?
Is there a family history of rare metabolic causes of abdominal
pain, eg porphyria, familial Mediterranean fever?
Do any anaesthetic reactions run in the family? (Malignant hyperpyrexia
syndrome)
 A
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ut
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<< 27 b
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 > Differential diagnosis
Right hypochondrium Epigastric Left hypochondrium
Basal pneumonia Oesophagitis/gastritis Basal pneumonia
Hepatitis Peptic ulcer disease Ruptured spleen
Gallbladder pathology Gallbladder pathology Splenomegaly
(biliary colic, acute/ Acute pancreatitis Splenic infarction
chronic cholecystitis, Myocardial infarct Subphrenic abscess
cholangitis) Perforated oesophagus
Congestive (Boerhaave’s)
hepatomegaly Abdominal aortic
aneurysm

Right loin/flank Central/periumbilical Left loin/flank

Pyelonephritis Abdominal aortic Pyelonephritis
Renal/ureteric colic aneurysm Renal/ureteric colic
Renal infarct Acute pancreatitis Renal infarct
Gastroenteritis
Bowel obstruction
Early appendicitis
Ischaemic bowel
(mesenteric
thrombosis)
Testicular torsion

Right iliac fossa Suprapubic Left iliac fossa

Appendicitis Cystitis/UTI Diverticulitis
Meckel’s diverticulitis Urinary retention Constipation
Mesenteric adenitis Uterine fibroid (red Renal/ureteric colic
Perforated caecal degeneration) Sigmoid volvulus
carcinoma Colitis (ischaemic,
Crohn’s disease infective, ulcerative)
Terminal ileitis Ovarian cyst accident
Renal/ureteric colic (rupture, haemorrhage,
Acuteabdominalpain

Ovarian cyst accident torsion)

(rupture, haemorrhage, Ectopic pregnancy
torsion) Salpingitis
Ectopic pregnancy Testicular torsion
Salpingitis
Testicular torsion

<< 28 >>
Medical causes of abdominal pain

C ardiovascular
● Myocardial infarction
● Aortic dissection
● Bornholm’s disease (Coxsackie B)

R espirator y
● Basal pneumonia

M etabolic
● Diabetic ketoacidosis
● Addisonian crisis
● Sickle cell crisis
● Hypercalcaemia
● Uraemia
● Phaeochromocytoma
● Acute intermittent porphyria
● Lead poisoning

I nfections
● Gastroenteritis
● Tuberculosis
● Typhoid fever
● Malaria
● Cholera
● Yersinia enterocolitica
● Urinary tract infection

N eurological A
● Herpes zoster/shingles (NB: dermatomal) c
ut
● Tabes dorsalis e
a
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<< 29 >>
 I nflammator y
● Vasculitis
● HSP
● PAN
● Familial Mediterranean fever

P sychogenic
● Narcotic addiction
● Irritable bowel syndrome

> Investigations
B lood tests
● Haematology – FBC, ESR, clotting, cross-match/G+S
● Anaemia (bleeding, anaemia of chronic disease)
● Raised WCC (infection, inflammation)
● ESR (infection, inflammation, malignancy)
● Clotting (pre-op prep)
● Cross-match/G+S (AAA, ectopic, pre-op prep)
● Biochemistry
● U+Es (vomiting and diarrhoea, renal lesions)
● CRP (infection)
● Glucose (DKA, pancreatitis)
● LFTs (hepatitis, gallstones)
● Ca2+ (pancreatitis, renal colic, hypercalcaemia as a
primary cause)
Acuteabdominalpain

● Amylase (pancreatitis, ischaemic bowel)

● Lipids (pancreatitis)
● β-hCG (ectopic)
● Microbiology
● Blood cultures (Gram-negative sepsis)
● Arterial blood gases (pancreatitis, metabolic acidosis)

<< 30 >>
U r inalysis (M,C+S)
● Pus cells, nitrites, protein, organisms (pyelonephritis, UTI)
● Blood (renal colic)
● β-hCG (ectopic)
● Glucose, ketones (DKA)

E CG
● Exclude MI
● Pre-op preparation for anaesthetic
● Arrhythmias (eg AF) leading to emboli (acutely ischaemic bowel)

R adiology
● Erect CXR
● Perforated viscus
● Basal pneumonia
● Pneumomediastinum (Boerhaave’s syndrome)
● AXR (± lateral decubitus)
● Bowel obstruction
● Constipation
● AAA
● Renal calculi
● Thumbprinting of bowel wall (bowel ischaemia)
● Transabdominal/transvaginal USS
● Exclude gynaecological pathology
● Collection/cyst
● Free fluid (peritonitis, ascites)
● AAA
● Gallstones
● Renal stones
● CT abdomen/pelvis A
● Collections c
ut
● Anastomotic leak e
a
● Diverticulitis b
● Renal colic (CTU) d
o
● Tumours m
in
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p
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<< 31 >>
 Further investigations
● OGD ± biopsy and Helicobacter pylori testing (peptic
ulcer, malignancy)
● Large-bowel enema/Gastrografin (‘instant’) enema (cause
for large-bowel obstruction)
● Small-bowel enema/follow-through (Crohn’s disease)
● Duplex Doppler/angiography (mesenteric thrombosis)
● Diagnostic laparoscopy
● Vaginal/endocervical swabs (PID)
● Blood film/Hb electrophoresis (sickle cell crisis)
● VDRL (tabes dorsalis)
● Urinary porphobilinogens (acute intermittent porphyria)
● Short synacthen test (Addison’s disease)
Acuteabdominalpain

<< 32 >>
 Alcohol- related problems

> History of presenting complaint

How much do you drink? How much do you drink on each occasion?
How often do you drink?
What do you drink?
How many units do you drink in a week? (1 unit = 1 small (125-ml)
glass wine, 1 shot (25 ml) whisky, 0.5 pint beer (standard 3.5%))
How long does it take you to finish a bottle of whisky/vodka?
CAGE questi onnaire
Have you ever thought that you ought to cut down on your drinking?
Have people annoyed you by criticising your drinking? Have you ever felt guilty about your drinking?
Have you ever had a drink first thing in the morning to overcome a hangover? (An eye opener)

Two or more positive replies identifies problem drinkers; one

is an indication for further enquiry about the person’s drinking.
Do you find that you tend to drink more than your friends around
you when you are out socialising? Do they ever comment on how
much you drink, or ask you to reduce your intake?
How often during the past year have you been unable to
remember what happened the night before because you had A
been drinking? lc
o
h
H istor y ol
-r
el
If intake is low risk, ask about any previous history of heavy drinking or at
dependence. e
d
Age of onset of regular drinking/alcohol misuse/harmful drinking. p
r
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<< 33 >>
 A mount
Are you a binge drinker, or do you drink consistently? (If the
former is true, ask for how long, how much consumed, how long
in between binges and precipitating factors for binges)
How much money do you spend on alcohol?

Place of drinking
Do you drink alone or with other people?

O ther
What is the purpose of your drinking?
What is your attitude towards alcohol?
Do you take any drugs as well?

Conditions associated with drinking

● CNS:Wernicke–Korsakoff syndrome, polyneuropathy
● Gastrointestinal: gastritis, pancreatitis, liver disease, carcinoma
of oesophagus
● Endocrine: cushingoid face
● Cardiovascular: hypertension, cardiac
arrhythmias, cardiomyopathy
● Metabolism: gout
● Musculoskeletal: myopathies
Alcohol-relatedproblems

D ependency
What happens when you go without alcohol for long periods of time?
(Manifestations of dependency)
Are you aware of your compulsion to drink?

Tolerance
Is your tolerance increasing? Are you able to drink more now
than you used to before getting drunk?

<< 34 >>
W ithdrawal symptoms
Do you get withdrawal symptoms if you go without a drink for a
long period of time?
When – first thing in the morning?
Do you get shaking, agitation, nausea, retching, sweating?
Are your symptoms relieved by drinking alcohol?
Do you get hallucinations, or altered perceptions?

Counselling/advice/treatments
Ask about previous advice, counselling and treatments received for
alcohol problems.

> Past medical history

Have you ever had to detoxify?
Were you admitted to hospital or managed at home?
Establish the history and current situation with regard to the following
systems:

G astrointestinal
● Liver disease
● Jaundice
● Pancreatitis
● Abdominal pain
● Gastritis
● GI haemorrhage
● Carcinoma of mouth, oesophagus, liver A
lc
o
C ardiovascular h
ol
● Hypertension -r
el
● Cardiomyopathy at
e
● Arrhythmias d
p
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<< 35 >>
 N eurological
● Neuropathy
● Psychosis
● Memory difficulties
● Hallucinations
● Cognitive impairment
● Blackouts
● Fits
● Accidents
● Anxiety

R espirator y
● Chest infections

M etabolic
● Gout

R eproductive
● Sexual dysfunction
● Fetal alcohol syndrome (in women of reproductive age)

> Drug history

Do you take any medications?
Alcohol-relatedproblems

Do you take any drugs that may interact with alcohol, eg

warfarin, anticonvulsants, disulfiram, metronidazole?

> Social history

Do you smoke? (Reinforces drinking behaviour and vice versa)
Do you use recreational drugs?
Have there been any requests for medical certificates?
Has there been any absenteeism at work?
Do you have any marital or family problems and has there been
any domestic violence?

<< 36 >>
 Has alcohol ever led you to neglect yourself, your family or
work? Do you have any financial difficulties?
Have you had any prosecutions for violent behaviour or driving
offences? Have you ever been done for drink/drunk driving?
Have you or someone else been injured as a result of your
drinking?
Have you ever had your driving licence taken away or penalty
points awarded relating to alcohol misuse?
Family, housing, social and employment situations and the
effect of alcohol misuse on these.
Do you receive any state benefits – unemployment,
incapacity, disability?
Have you made any attempts to stop drinking? What? When
was the last time? How? Why did you fail?
Do you presently attend or have you ever been to Alcoholics
Anonymous? Have you heard of it? Have you thought before
about going?

> Complications of alcohol misuse

G astrointestinal
● Oesophagus
● Gastro-oesophageal reflux
● Oesophageal carcinoma
● Oesophageal varices
● Mallory–Weiss syndrome
● Stomach
● Gastritis
A
● Peptic ulcer disease lc
o
● Small intestine h
ol
● Malabsorption and malnutrition -r
● Altered motor activity (diarrhoea) el
at
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<< 37 >>
 ● Liver
● Fatty liver (steatosis)
● Alcoholic hepatitis
● Liver cirrhosis and its complications
> Ascites
> Spontaneous bacterial peritonitis
> Portal hypertension

> Hepatocellular carcinoma

● Spleen
● Splenomegaly (portal hypertension)
● Pancreas
● Pancreatitis (acute and chronic)
● Pancreatic carcinoma

C ardiovascular
● Coronary heart disease
● Dilated cardiomyopathy
● Hypertension
● Cardiac arrhythmias

R espirator y
● Aspiration pneumonia

N eurological
● Seizures/uncontrolled epilepsy
Alcohol-relatedproblems

● Cerebrovascular accidents
● Cerebellar degeneration (ataxia)
● Wernicke–Korsakoff syndrome (thiamine deficiency)
● Peripheral polyneuropathy (mainly sensory)
● Hypoglycaemic coma
● Hepatic encephalopathy
● Alcoholic dementia
● Marchiafava–Bignami syndrome (corpus callosum atrophy)
● Central pontine myelinolysis
● Myopathy (acute/chronic)
● Rhabdomyolysis
● Neuropraxia

<< 38 >>
 H aematological
● Haemolysis (Zieve’s syndrome)
● Impaired erythropoiesis
● Macrocytosis
● Alcoholism-associated folate deficiency
● Sideroblastic anaemia
● Neutropenia
● Thrombocytopenia
● Clotting factor deficiency (liver failure)
● Warfarin and other drug interactions (liver failure)

E ndocrine/metabolic
● Hypoalbuminaemic state
● Hypoglycaemia
● Hypogonadism/infertility
● Hyperoestrogenaemia/gynaecomastia
● Pseudo-Cushing’s syndrome
● Ketoacidosis
● Gout
● Osteopenia/osteoporosis/fractures

D ermatological
● Facial flushing
● Palmar erythema
● Spider naevi
● Linear telangiectasia
● Dupuytren’s contracture
● Caput medusae (portal hypertension)
● Parotid enlargement A
lc
o
P regnancy h
ol
● Infertility -r
el
● Fetal alcohol syndrome at
e
● Intrauterine growth retardation d
p
● Increased risk of abortion/stillbirth r
o
bl
e
m
s

<< 39 >>
 P sychiatric
● Alcohol dependency/addiction/misuse
● Alcohol withdrawal
● Acute confusional state
● Alcohol intoxication (falls/blackouts/accidents/injuries,
dangerous driving, violence, criminal behaviour)
● Alcoholic hallucinosis
● Delirium tremens
● Depression and anxiety
● Suicide
● Alcoholic dementia

S ocial
● Job loss
● Marital/relationship difficulties
● Criminal activity
● Violence
● Driving offences and RTAs

> Investigations
B lood tests
● Haematology – FBC, clotting, haematinics
● Anaemia (multifactorial)
Alcohol-relatedproblems

● Thrombocytopenia (multifactorial)
● MCV (macrocytosis)
● Clotting (liver disease)
● Haematinics (vitamin 12 B , red cell folate)
● Biochemistry
● LFTs including GGT (cirrhosis)
● U+Es (hepatorenal syndrome)
● Glucose (liver disease, pancreatic failure)
● Albumin (liver failure)
● Lipids (secondary hyperlipidaemia)
● Blood ethanol levels (intoxication)

<< 40 >>
R adiology
● CXR
● Large heart (dilated cardiomyopathy)
● Aspiration
● USS
● Fatty liver
● Hepatitis
● Cirrhosis
● Evidence of portal hypertension

Further investigations
● Carbohydrate-deficient transferrin (alcoholism)
● Red cell transketolase (Wernicke’s)
● Echocardiography (dilated cardiomyopathy)
● OGD (varices, PUD)
● Liver biopsy (liver disease)
● EEG (hepatic encephalopathy)
● Nerve conduction studies (neuropathy)

A
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<< 41 >>
 Ano- rectal pain

> History of presenting complaint

Site
Where do you feel the pain? (in the skin or deep inside?)

O nset
Sudden vs gradual
Is it there the whole time or precipitated by something, eg
passing stool?
Duration?

C haracter
Is the pain spasmodic? (proctalgia)
Is it worse during or after defecation (anal
fissure)? Does it persist after defecation?

A ssociated symptoms
● Are there any other pains, such as abdominal pain?
● Is there any bleeding from the back passage?
● Are there any changes in bowel habit? Is there tenesmus?
● Is there passage of mucus/pus/blood?
● Are there any lumps, or the sensation of something coming
down when you pass stools?
● Are you still able to reduce your piles?
Ano-rectalpain

● Is there a history of trauma?

● Are you able to pass urine, or is there any back pain or
weakness of your legs? (rarely cauda equina lesions present
this way).
● Are there any systemic features – weight loss, fever,
malaise, anorexia, rigors?

<< 42 >>
Case scenarios

> Case 1
You are the surgical SHO on call. It is midnight. You have accepted a
referral from a GP for a 35-year-old woman who has pain in the
right iliac fossa.
Please take a detailed history from her to determine the cause
of her problem.
What questions would you like to ask the patient?

PC
When you ask the patient what is wrong, she explains that she
has had right iliac fossa pain since lunchtime that day. She was
out at a restaurant with her best friend and just as she got up
from her chair at
lunch the pain came on. But she tells you nothing much else until direct
questions are asked.

H PC
ODQ the pain came on suddenly.
ODQ the pain has been constant and severe.
ODQ about radiation – The location of the pain is vague and
she is unsure whether the pain initially started around the
umbilicus but she thinks it may well have. There is no radiation
down to the groin.
However, ODQ about shoulder-tip pain she agrees that there is
radiation to the right shoulder, although she puts this down to a
recent shoulder injury that she sustained while playing netball.
ODQ there is no history of trauma to the abdomen.
Associated symptoms:
● Bit of nausea, no vomiting
● No fever
C
● No distension a
s
● Loss of appetite e
s
● No urinary symptoms (dysuria, urgency, frequency) c
e
n
a
ri
<< 407 >>
 ● ODQ she has noticed she has passed some vaginal
discharge which is dark red and possibly blood but she
suspects this is a withdrawal bleed/breakthrough bleeding
from the OCP.
Exacerbating factors – Walking around makes the pain worse.
Relieving factors – Lying/sitting still relieves it.
She took ibuprofen earlier but that has not helped.
Severity – The worst pain she has ever had, 9/10. She could never
sleep with this pain.
ODQ about her LMP, her last withdrawal bleed (from being on the
OCP) was 6 weeks ago.

PMHx
Nil. Has not had her appendix out. No past operations.
No gynaecological history apart from suffering from painful
heavy periods as a teenager.

D Hx
OCP – No allergies.
ODQ about compliance, she admits that a few weeks ago while
on holiday and because of the excitement of being away from
home she forgot to take her pill for two consecutive days.

S Hx
Functionally independent. Has no children. Shares a flat with a
woman friend.
ODQ about travel she recently went on holiday to Ibiza with six
other friends, including her boyfriend.
ODQ – Nothing significant about her holiday but she did have a
D+V illness from sampling the local delicacies.
Casescenarios

Smokes 10 a day and has done since the age of 15.

Drinks about 10 units alcohol a week (ODQ five large glasses of
wine a week on average).
ODQ sexual history – She has been going out with her
boyfriend for 3 years now. No other sexual partners. ODQ no
‘one night stands’ on holiday in Ibiza.

<< 408 >>

FHx
Grandmother diagnosed with bowel cancer at age of 80.
Grandfather died of MI at age of 72.
Mother diabetic (insulin-controlled). Father alive and well.
One brother and one sister, alive and well.

SE
Nil. No weight loss.

What is your differential diagnosis?

What investigations would you like to carry out?

Case discussion
This case illustrates well the importance of taking a structured and
accurate history in any patient presenting with acute abdominal
pain. In this case it would be easy to assume, early on, that the
diagnosis is acute appendicitis.
However, further questioning revealed that the patient forgot to
take her pill while on holiday in Ibiza with her friends (who
included her boyfriend). This, together with the fact that she has
also noticed some dark-red vaginal discharge and her last
withdrawal bleed is late, puts a
ruptured ectopic pregnancy at the top of the differential diagnosis.
The inefficacy of the OCP due to patient non-compliance was
compounded further by a D+V illness while on holiday, which
reduces absorption of the drug.
Other diagnoses that would also feature in the differential diagnosis
are PID, an ovarian accident (rupture, torsion, haemorrhage),
appendicitis, miscarriage, Crohn’s disease, etc. However, these are all
less likely and this case is an ectopic pregnancy until proved
otherwise because of its severity and the consequences of missing
such a diagnosis.
This young lady indeed turned out to have an ectopic pregnancy
which had ruptured into the peritoneal cavity. Blood within the
C
peritoneal cavity results in chemical peritonitis and irritates the a
diaphragm, causing referred pain to the shoulder (because the s
diaphragm is innervated by C3–5). An ectopic pregnancy was e
s
confirmed from a positive β-hCG urine test and by transvaginal USS c
which showed an anembryonic uterus and blood in the cul-de-sac e
n
(but no adnexal mass). At laparoscopy she was a
ri
<< 409 >>
 found to have a ruptured ectopic pregnancy within the right
fallopian tube. This was surgically managed and she subsequently
made a full recovery.
This case illustrates well the fundamental point of never forgetting to
take a full gynaecological history for all women presenting with
either acute abdominal pain, amenorrhoea and/or vaginal bleeding.
For all women of child-bearing age presenting with such symptoms,
always think at the back of your mind – Could this lady be pregnant
and now be presenting with a complication of pregnancy?
Casescenarios

<< 410 >>

> Case 2
You are the GP of a 39-year-old postman who comes to your practice
complaining of a painful red eye.
Please take a history from him to try and determine what is
wrong. What questions would you like to ask the patient?

PC
When you ask the patient what the trouble has been he explains
that he has had a three-day history of a painful, left eye.

H PC
Site – Is is truly unilateral and has not had any problems with
the contralateral (right) eye.
Onset – It came on quite acutely over a day or so. ODQ no
history trauma/foreign bodies to eye.
Character – ODQ it is actual pain rather than
discomfort/irritation/ itching/dryness or a gritty eye. No obvious
diurnal variation in symptoms.
Radiation – No headache, no radiation.
Associated symptoms:
● ODQ he has noticed vision has become more blurred in that
eye when he covers up the other eye.
● ODQ no changes to colour vision.
● ODQ parts of the visual field are not obviously missing.
● ODQ no eye discharge or stickiness.
● ODQ no nausea/vomiting.
● ODQ eye has been watering.
● ODQ no rhinorrhoea.
Timing – It has been getting worse over the past few days.
Exacerbating factors – Light (photophobia).
C
No Relieving factors. a
s
Severity – Pain 8–9/10. He normally wears disposable contact e
s
lenses but has been unable to do so over the last few days c
because the pain is so bad. e
n
a
ri

<< 411 >>

 ODQ the patient also has noticed that over the past six months, or
so, he has had generalised aches and pains in his joints but
particularly his lower back. He attributes this to his job.
ODQ he describes a bit of loose stools (on and off for the last few
months), ODQ with slime and mucus but no blood. No fever. ODQ
mild abdominal tenderness but nothing compared to his eye pain.
ODQ no urethral discharge. No other urogenital
symptoms. No contacts with a similar problem. No SOB
or skin changes.

PMHx
ODQ no history of glaucoma.
No history of previous eye problems. Contact lens hygiene is good.
Only history of note is a meniscal tear ten years previously
sustained whilst playing football.
ODQ no history of headaches or migraines. ODQ no history of
psoriasis. ODQ no history of ankylosing spondylitis.

D Hx
● Paracetamol for pain.
● NKDA

S Hx
Smokes 10 a day for 20 years. Drinks 15 units alcohol a
week. Lives with his girlfriend. Functionally independent.
ODQ no new sexual partners recently.
ODQ not IVDU.

FHx
Casescenarios

Nil. ODQ he thinks his grandfather (maternal side) had glaucoma.

SE
Nil. No weight change.
<< 412 >>
 What is your differential diagnosis?
What investigations would you like to carry out?

Case discussion
The history is fairly vague but indicates favourably a diagnosis of an
acute iritis (anterior uveitis). The features that fit with this are a
unilateral, painful, watering red eye of relatively acute onset, that is
exacerbated by light and is associated with a loss of visual acuity.
Having said that, the diagnosis of an acute angle-closure
glaucoma presenting in this way should always be at the back of
one’s mind and can present in a similar fashion, although there
are no systemic symptoms here (such as nausea and vomiting)
which usually
accompanies acute angle-closure glaucoma. The pre-test probability
of glaucoma is increased further in this case by the presence of a
positive family history. Tonometry should be a mandatory part of the
examination in all such cases where a patient presents with a
unilateral painful red
eye and should never be forgotten as the condition is potentially
sight- threatening. Never forget that missing a diagnosis of acute
angle- closure glaucoma may result in permanent visual loss.
The other differential that should also feature high up in the
differential diagnosis is an infectious process in view of the fact that
the patient is normally a contact lenses wearer, although he wears
disposable lenses and hygiene is good so this makes an infection
due to contact lenses less likely. However, it does not rule out the
possibility of an inflammatory process within the cornea (keratitis,
corneal abrasion, corneal ulceration, dendritic ulcer etc.).
Having considered the possibility that this may be an iritis the
astute clinician should try to find out the possible cause for such
a process. The fact that ODQ the patient describes what sounds
like sacro-iliitis makes the possibility of an HLA-B27 associated
disease more likely for the cause for his iritis. There is no history
of psoriasis or ankylosing spondylitis, or nothing from the sexual
history to indicate a possible
Reiter’s syndrome (no urethral discharge). In view of the loose
stools and associated mucus this makes the possibility of an
enteropathic arthritis associated with inflammatory bowel disease,
C
or a reactive arthritis associated with infective diarrhoea, more a
likely. Indeed this patient turned out to be within the 10% of patients s
e
with inflammatory bowel disease that initially present with extra- s
intestinal manifestations of the disease as their main presenting c
problem (in this case an acutely painful red eye as an extra- e
n
intestinal manifestation of ulcerative colitis). a
<< 413 >>