1 - chest pain (SOCRATES)

1 SR - cvs questions 2 - palpitations (uncomfortable sensation of your

heart beating in your chest)
3 - claudication (pain on walking a certain
distance that will get better if you rest for a few
minutes)
4 - shortness of breath
5 - paroxysmal nocturnal dyspnoea (wake up
breathless)
6 - perpheral oedema

2 SR - rs questions 1 - cough
2 - sputum
3 - haemoptysis
4 - wheeze
5 - exercise tolerance
6 - chest pain (always pain for any system)

1 - appetite change
3 SR - Gi questions 2 - vomiting
3 - haematemesis
4 - malaena
5 - rectal bleeding (in/around stool or on wiping)
6 - change in bowel habit
7 - abdominal pain (socrates)

1 - headaches
4 SR - CNS questions 2 - visual disturbances
3 - syncope or presyncope (black out or light
headed)
4 - weakness
5 - paraesthesia
6 - fits/ siezures
7 - smell/hearing/ taste changes
8 - balance problems

1
5 SR - locomotor 1 - joint or bone pain inc back
questions 2 - stiffness
3 - swelling
4 - is it worst in the morning when you wake up or
after a long day. (inflame vs mech)
5 - rashes
6 - hair loss
7 - eye problems (epi/scleritis)
8 - mouth problems (ulcers)
9 - breathing problems (pleuritis)
10 - chest pain/heart problems (pericarditis)
11 - raynaud's
12 - haematuria
13 - muscle pain or weakness
14 - sphincter control
15 - previous episode
16 - recent infections

1 - haematuria (blood in urine)

6 SR - genitourinary 2 - dysuria (pain on urination)
questions 3 - frequency
4 - voiding difficulty
5 - any strange discharges or pus
6 - any chance of pregnancy? when was your last
period.

1 - weight loss
7 SR - general questions 2 - night sweats (wake up drenched)
to ALWAYS ask 3 - fevers
4 - rashes
5 - name, age and occupation
6 - whether they've had similar episodes before
7- ICE at the end (and reassure)
8 - risk factors for the system affected
9 - allergies!

2
 1- ask their age
8 abbreviated mental 2 - date of birth
test score - questions if 3 - what year is it
you are concerned the 4 - what time is it
patient is confused 5 - where are you
6 - what is your home address
7 - recall identity of 2 people present
8 - who the current monarch or prime minister is
9 - when was world war 2
10 - count back from 20 to 1

a score of less than or equal to 8 suggests

confusion.

1 - smoking status
9 things to ask in social 2 - ETOH consumption
history 3 - recent foreign travel if relevant
4 - housing type/ stairs/ with whom/ pets
5 - community support
6 - mobility
7 - activities of daily living
8 - urinary/bowel continence

WIPER
10 things to do at the intro = your full name and role
very start of the HX name, age and occupation
Be explicit in getting consent (the purpose of this
interview is... so is it ok if i ask you some
questions?)
start with a broad question (so tell me about what
has brought you in today)

1 - full clinical examination

11 general format of 2 - DRABCDE
answer when asked how 3 - blood tests
to manage a PT 4 - imaging
5 - medical and surgical interventions.

3
 1 - other medical conditions
12 PMSH - questions to 2 - anything else you see your GP regularly for
ask (now screen for relevant risk factors e.g.
cholesterol, bp, diabetes, clotting problems,
thyroid problems, asthma, COPD...)
3 - any previous operations
4 - anything else you've been into hospital for

1 - ask a few open questions at the start and the

13 some general actor will give you everything you need.
principles for Hx taking in - what's brought you in today
the OSCE - what concerns you most about this
- is there anything else you've noticed
- how have these things affected your life.

2 - ask what they're concerned about at the

start to build rapport and get ICE out of the
way.

3 - for the PC/hpc/ as SOCRATES, do the red

flag checks, systemic symptoms, and flair
questions to show you know what it is

Abbreviation:
SOCRATES
ICE ~ In Case of Emergency
ETOH ~ EtOH stands for ethyl alcohol, or ethanol
WIPER ~ Wash hands; Introduce; Permission; Expose Patient Appropriately; Recline/Position
Patient
PT ~ Physical Therapy
DRABCDE ~ Danger, Response, Airway, Breathing, Circulation, Deformity,
Environment/Expose/Everything els
PMSH ~ Past Medical History
OSCE ~ Objective Structured Clinical Examination

4
The mnemonic acronym SOCRATES summarises the questions that should be put about most
symptoms.

* Site
* Onset
* Character
* Radiation (if the symptom is discomfort or pain)
* Alleviating factors
* Timing
* Exacerbating Factors
* Severity

1. Site
Ask:
* Where is the symptom exactly?
* Whether it is localised (concentrated in a small area) or diffuse (spread out over a wide area)?
* Ask the patient to point to the actual site on the body
Bear in mind:
* Some symptoms are not localised.
- Patients who complain of dizziness do not localise this to a specific site
- Vertigo occasionally involves a feeling of movement within the head, and to that extent is
localised
- Other symptoms that are not localised include cough, dyspnoea (shortness of breath), and weight
change.

2. Onset (pattern and mode of onset)

Ask:
* Did the symptom come on rapidly, gradually, or instantaneously? (Certain cardiac arrythmias are of
instantaneous onset and offset. Sudden loss of consciousness (LOC, syncope) with immediate
recovery occurs with cardiac but not neurological disease)
* Has the symptom been present continuously or intermittently (does it come and go)?
* Is the symptom getting worse or better? If so, when did the change occur? (For example,
exertational breathlessness of COPD may come on with less and less activity as it worsens?)
* What was the patient doing at the time the symptom began (For example, severe breathlessness
that wakes a patient from sleep is very suggestive of cardiac failure.

3. Character
Ask the patient to describe what they mean by the symptom; to describe it's character.
For example:
* If the patient complains of dizziness, does this mean the room spins around (vertigo), or is it more
a feeling of impending loss of consciousness
* Does indigestion mean abdominal pain, heartburn, fullness after eating, excess wind, or a change
in bowel habit.
* If there is pain, is it stabbing, dull, sharp, boring, cramp-like, or burning.

4. Radiation of pain or discomfort

Determine if the symptom (if localised) radiates (spreads to a specific location, or in a specific
direction). This mainly applies if the symptom is pain.

Certain radiation patterns are typical of certain conditions, or even diagnostic (.eg the nerve root
distribution od pain associated with herpes zoster [shingles])

5
5. Alleviating Factors
Ask:
* Whether anything makes the symptom better? (For example, the pain of pericarditis may be
relieved when a patient sits up ,while heartburn from acid reflux may be relieved by drinking milk or
taking antacids)
* Have analgesic medications been used to control the pain?
* Have narcotics been required?

6. Timing
Ask:
* When they symptom first began? Try and date this as accurately as possible. (for example, ask the
patient what the first think was that they noticed was "wrong" or "unusual"
* Whether they've had a similar illness in the past?
* When was the last time they felt entirely well?
* (For patients with long-standing symptoms), ask why they decided to see the doctor at this time.

7. Exacerbating Factors
Ask:
* Whether anything makes they symptom worse? The slightest movement may exacerbate the
abdominal pain of peritonitis, or the pain in the big toe caused by gout.

8. Severity
Severity is subjective. The best way to assess severity is to ask the patient whether the symptom
interferes with normal activities or sleep.
Severity can be graded from mild to very severe.
* A mild symptom is one the patient can ignore
* A moderate symptom cannot be ignored, but doesn't interfere with daily activities
* A severe symptom interferes with daily activities
* A very severe symptom markedly interferes with daily activities

Alternatively, pain or discomfort can be graded on a 10-point scale from 0 (no discomfort) to 10
(unbearable), However, this shouldn't be used for patients in obvious severe pain - a face scale
using pictures of different faces representing pain severity from absence of pain (0) to severe pain
(10) is more useful in practice. Another method of quantifying pain is the the visual analogue scale,
where the patient is asked to mark the severity of the pain on a 10cm horizontal line.
Note that all of these scales are more useful for comparing the subjective severity of pain over time
than for absolute severity (for example, comparing before and after certain treatment has been
started).
Severity for other symptoms can be quantified more precisely. For example, shortness of breath on
exertion occurring after 20 metres walking on flat ground is more severe than shortness of breath
occurring after walking 180 metres up a hill. Central chest pain from angina occurring at rest is more
significant than angina occurring while running 100 metres to catch a bus.
It is always relevant to quantify symptom severity, but also to remember that symptoms a patient
may consider mild might be very significant.