History – Systems Review

A thorough systems review is a key part of medical history taking. Starting with general, endocrine, skin and haematologic (GESH) allows us to progress from head to tail. Here is a systematic approach to systems review. To cover off on some basics here are some scripts:

1. General: “Have you had any fatigue/tiredness? change of weight? shivers/shakes? fevers/sweats/night sweats? sleep problems? If I asked RUOK, what would you say?”
2. Endocrine/Skin/Haematologic: “Have you noticed any tremors? hot/cold weather preference? changes in urination? thirst? changes in skin? lumps or bumps? itch? rash? easy bruising?”

Systems Review

1. General:
   1. fatigue/tiredness
   2. weight loss/gain
   3. shivers/shakes
   4. fevers/sweats/night sweats
   5. sleep/daytime somnolence
   6. mental health “If I asked RUOK, what would you say?”
2. Endocrine:
   1. tremor
   2. hot/cold weather preference
   3. polyuria/polydypsia
   4. changes in hair or nails
   5. PHx/FHx endocrine disease
3. Skin:
   1. lumps
   2. rashes/sores
   3. itching
   4. changes in colour
   5. PHx skin cancer
4. Hematologic:
   1. easy bruising
   2. easy bleeding
   3. lymphadenopathy
   4. PHx/FHx DVT, PE
5. Head (Neurological):
   1. headaches
   2. dizziness
   3. fits/faints/funny turns
   4. numbness/tingling
   5. weakness/paralysis
   6. tremor/clumsiness
   7. PHx HI, CVA, MS
6. Head (Psychiatric):
   1. depression
   2. anxiety
   3. hallucinations
   4. memory problems
   5. suicidal thoughts
   6. domestic violence
   7. PHx/FHx nerves
7. Eyes:
   1. pain
   2. redness
   3. discharge
   4. visual acuity changes
   5. double vision
8. Ears:
   1. pain
   2. discharge
   3. hearing loss
   4. tinnitus
9. Nose:
   1. sinus pain
   2. discharge,
   3. congestion
   4. epistaxis
10. Mouth/Throat:
    1. tooth pain
    2. ulcers
    3. gum problems
    4. sore throat
11. Neck:
    1. lumps
    2. hoarseness
12. Respiratory:
    1. pleuritic pain
    2. cough/dry/productive/haemoptysis
    3. wheeze
    4. SOB
    5. snoring/daytime somnolence
    6. SHx/PHx/FHx: occupation, smoking, pneumonia, TB, CXR
13. Cardiovascular:
    1. chest pain
    2. palpitations
    3. pre-syncope/syncope
    4. SOBOE
    5. orthopnoea/PND
    6. claudication/peripheral circulation
    7. varicose veins
    8. SOA
    9. PHx RhF, H/T, heart murmurs
14. Breast:
    1. pain
    2. lumps
    3. skin changes
    4. nipple discharge
    5. PHx/FHx Breast/ovarian cancer
15. Gastrointestinal:
    1. abdominal pain
    2. diet and appetite changes
    3. nausea and vomiting
    4. dysphagia
    5. heartburn
    6. bloating
    7. jaundice
    8. bowel habit change
    9. diarrhea/constipation/incontinence
    10. melena/hematochezia
    11. PHx/SHx alcohol, surgery, hepatitis, ulcers, colitis, bowel cancer
16. Urinary:
    1. pain on urination
    2. frequency/urgency
    3. steam/delay/dribble
    4. nocturia
    5. incontinence
    6. urine color/haematuria
    7. PHx of UTI, kidney stone
17. Genital:
    1. menstrual history
    2. dyspareunia
    3. genital rash
    4. sexual dysfunction
    5. PHx STI
18. Musculoskeletal:
    1. pain (joints)
    2. pain (muscles)
    3. pain (back)
    4. stiffness
    5. weakness

Systems Review Flashcards

The Talley and O’Connor Systems Review

Enquire about common symptoms and three or four of the common disorders in each major system listed below. Not all of these questions should be asked of every patient. Adjust the detail of questions based on the presenting problem, the patient’s age and the answers to the preliminary questions.

1. General
   1. Have you had problems with tiredness? (Many physical and psychological causes)
   2. Do you sleep well? (Insomnia and poor ‘sleep hygiene’, sleep apnoea)
   3. Have you had fevers?
   4. Do you have night sweats?
   5. Have you lost weight recently without dieting? (Malignancy)
2. Endocrine system
   1. Have you noticed any swelling in your neck?
   2. Do your hands tremble?
   3. Do you prefer hot or cold weather?
   4. Have you had a thyroid problem or diabetes?
   5. Have you noticed increased sweating?
   6. Have you been troubled by fatigue?
   7. Have you noticed any change in your appearance, hair, skin or voice
   8. Have you been unusually thirsty lately? Or lost weight? (New onset of diabetes)
3. Haematological system
   1. Do you bruise easily?
   2. Have you had fevers, or shivers and shakes (rigors)?
   3. Do you have difficulty stopping a small cut from bleeding? (Bleeding disorder)
   4. Have you noticed any lumps under your arms, or in your neck or groin? (Haematological malignancy)
   5. Have you ever had blood clots in your legs or in the lungs?
4. Neurological system and mental state
   1. Do you get headaches?
   2. Is your headache very severe and did it begin very suddenly? (Subarachnoid haemorrhage)
   3. Have you had fainting episodes, fits or blackouts?
   4. Do you have trouble seeing or hearing?
   5. Are you dizzy?
   6. Have you had weakness, numbness or clumsiness in your arms or legs?
   7. Have you ever had a stroke or head injury?
   8. Do you feel sad or depressed, or have problems with your ‘nerves’?
   9. Have you ever been sexually or physically abused?
5. Respiratory system
   1. Are you ever short of breath? Has this come on suddenly? (Pulmonary embolism)
   2. Have you had any cough?
   3. Is your cough associated with shivers and shakes (rigors) and breathlessness and chest pain? (Pneumonia)
   4. Have you coughed up blood? (Bronchial carcinoma)
   5. What type of work have you done? (Occupational lung disease)
   6. Obtain a sleep history. Do you snore loudly? Do you fall asleep easily during the day? When? Have you fallen asleep while driving?
   7. Do you cough up anything?
   8. Do you ever have wheezing when you are short of breath?
   9. Have you ever had pneumonia or tuberculosis?
   10. Have you had a recent chest X-ray?
6. Cardiovascular system
   1. Have you had any pain or pressure in your chest, neck or arm? (Myocardial ischaemia)
   2. Are you short of breath on exertion? How much exertion is necessary?
   3. Have you ever woken up at night short of breath? (Cardiac failure)
   4. Can you lie flat without feeling breathless?
   5. Have you had swelling of your ankles?
   6. Have you noticed your heart racing or beating irregularly?
   7. Have you had blackouts without warning? (Stokes–Adams attacks)
   8. Have you felt dizzy or blacked out when exercising? (Severe aortic stenosis or hypertrophic cardiomyopathy)
   9. Do you have pain in your legs on exercise?
   10. Do you have cold or blue hands or feet?
   11. Have you ever had rheumatic fever, a heart attack or high blood pressure
7. Gastrointestinal System
   1. Are you troubled by indigestion? What do you mean by indigestion?
   2. Do you have heartburn?
   3. Have you had any difficulty swallowing? (Oesophageal cancer)
   4. Have you had vomiting, or vomited blood? (Gastrointestinal bleeding)
   5. Have you had pain or discomfort in your abdomen?
   6. Have you had any abdominal bloating or distension?
   7. Has your bowel habit changed recently? (Carcinoma of the colon)
   8. How many bowel motions a week do you usually pass?
   9. Have you lost control of your bowels or had accidents? (Faecal incontinence)
   10. Have you seen blood in your motions? (Gastrointestinal bleeding)
   11. Have your bowel motions been black? (Gastrointestinal bleeding)
   12.  Have your eyes or skin ever been yellow?
   13. Have you ever had hepatitis, peptic ulceration, colitis or bowel cancer?
   14. Tell me (briefly) about your diet recently.
8. Reproductive and breast history (women)
   1. Are your periods regular?
   2. Do you have excessive pain or bleeding with your periods?
   3. How many pregnancies have you had?
   4. Have you had any miscarriages?
   5. Have you had high blood pressure or diabetes in pregnancy?
   6. Were there any other complications during your pregnancies or deliveries?
   7. Have you had a Caesarean section?
   8. Have you had any bleeding or discharge from your breasts or felt any lumps there? (Carcinoma of the breast)
9. Genitourinary System
   1. Do you have difficulty or pain on passing urine?
   2. Is your urine stream as good as it used to be?
   3. Is there a delay before you start to pass urine? (Applies mostly to men)
   4. Is there dribbling at the end?
   5. Do you have to get up at night to pass urine?
   6. Are you passing larger or smaller amounts of urine?
   7. Has the urine colour changed?
   8. Have you seen blood in your urine? (Urinary tract malignancy)
   9. Have you had any problems with your sex life? Difficulty obtaining or maintaining an erection?
   10. Have you noticed any rashes or lumps on your genitals?
   11. Have you ever had a sexually transmitted disease?
   12. Have you ever had a urinary tract infection or kidney stone
10. Musculoskeletal System
    1. Do you have painful or stiff joints?
    2. Are any of your joints red, swollen and painful?
    3. Have you had a skin rash recently?
    4. Do you have any back or neck pain?
    5. Have your eyes been dry or red?
    6. Have you ever had a dry mouth or mouth ulcers?
    7. Have you been diagnosed as having rheumatoid arthritis or gout?
    8. Do your fingers ever become painful and become white and blue in the cold? (Raynaud’s)
11. The elderly patient
    1. Have you had problems with falls or loss of balance? (High fracture risk)
    2. Do you walk with a frame or stick?
    3. Do you take sleeping tablets or sedatives? (Falls risk)
    4. Do you take blood pressure tablets? (Postural hypotension and falls risk)
    5. Have you been tested for osteoporosis?
    6. Can you manage at home without help?
    7. Are you affected by arthritis?
    8. Have you had problems with your memory or with managing things like paying bills? (Cognitive decline)
    9. How do you manage your various tablets? (Risk of polypharmacy and confusion of doses)
12. Concluding the interview
    1. Is there anything else you’d like to talk about?