NEURO ILLNESS SCRIPTS K.

Stone, GEMP II 2020

HEADACHES
Type Symptoms/ risk factors
Classic Unilateral
migraine Pounding
Disabling (severe; cannot carry out daily activities)
Photophobia
N&V
Duration: 4-72 hours
Stress
Preceded by aura (visual disturbances; unusual sounds/ smells)
Common As above but no aura
migraine
Cluster Unilateral – one eye or temple
headache Stabbing/ severe pain
Lacrimation
Rhinorrhea
Flushing of face
Duration: minutes to hours
Stress
Chronicity: bouts lasting several weeks/ few times a year (NB: history of episodes)
Tension Bilateral
headache ‘Band around the head’
Recurrent
Mild (does not preclude daily activities)
No associated symptoms
Does not wake px at night
Temporal Unilateral – temporal area
arteritis Visual disturbances (diplopia/ blurred vision/ monocular blindness)
Jaw pain + temporal tenderness
Age
Acute sinusitis Pressure over cheek bones or forehead
Tenderness of sinuses
URTI symptoms – cough/ sore throat/ fever/ fatigue/ rhinorrhea etc.
Subarachnoid Instantaneous onset
Hemorrhage Very severe – ‘thunderclap’ headache
Initially localized à then generalized
Neck stiffness
NB: history of trauma?
Medications – anticoagulants/ antiplatelets?
Seizures?
Meningitis Generalized headache
Photophobia
N&V
Fever
Neck stiffness
Raised Generalized headache
Intracranial Worse in the morning
Pressure Drowsiness
N&V (worse in morning)
Visual disturbances (e.g. CN III fallout)

NB: Always rule out potentially dangerous causes (in red) by asking about:
• Fever
• Neck stiffness
• History of trauma
• Photophobia
• N&V
FAINTS & FITS

Condition Symptoms/ risk factors

Vasovagal Brief LOC; no neurological signs upon awakening
syncope Younger px - teens or 20s
Emotional distress – unexpected pain, unpleasant sight, sound or smell
Nausea and clamminess

Orthostatic Brief LOC; no neurological signs upon awakening

hypotension Sudden drop in BP when changing body position (e.g. standing up)
Known low BP
Use of anti-hypertensives / hypovolemia
(NB: ask about medical history)

Cardiac Brief LOC; no neurological signs upon awakening

arrhythmia History of palpitations
e.g. Ventricular Family history of sudden death
Tachycardia Anti-arrhythmic medications
History of cardiac disease
(NB: ask about family and medical history)

Hypoglycemia Sweating
Weakness & confusion
May be seen in diabetics
Hypoglycaemic agents
Low blood glucose

Generalized Abrupt
tonic-clonic Preceded by aura (smell, taste, auditory, déjà vu)
seizure Tongue biting (blood in mouth)
Urinary incontinence
Jerking limb movements witnessed
Evidence of injury
Post-ictal drowsiness, confusion, muscle pain
Absence Children
seizure Loss of awareness
(petit mal) “Staring”
Hysteria Bizarre attacks
Fluctuating levels of consciousness
Transient Transient “blackout”
Ischemic Weakness, numbness or paralysis – face, arm or leg (typically one-sided)
Attack (TIA) Slurred/ speech
Blindness (one/ both eyes) / double vision
Vertigo/ loss of balance/ coordination
Hypertension

Ask about:
• When does it occur?
• What were the preceding circumstances (aura/ position/ cough/ micturition/ vertigo etc.)
• Were there any warning signs?
• Was there an actual loss of consciousness?
• How did you recover?
• How did you feel afterwards?
• Chronic illness – DM, epilepsy, CVS, arrhythmias, hypertension
• Medication - anti-hypertensives, anti-arrhythmics
• Family history – arrhythmias, sudden death, cardiac disease
• NB: seizure may result from SAH – rule out: instant onset thunderclap headache..
DIZZINESS

Condition Symptoms/ risk factors

Benign positional Brief episodes (intermittent)
vertigo) Precipitated by change in head position (crystals move in utricle & saccule)

Vestibular neuritis Persistent

(vestibular branch of Non-positional
CN VIII only) Normal hearing
Labyrinthitis Persistent
(vestibular & cochlear Non-positional
branches of CN VIII) Hearing loss
Meniere’s disease Intermittent vertigo
Hearing loss
Tinnitus

Associated features:
• Nausea
• Vomiting
• Pallor
• Sweating
• Headache

CEREBELLAR DISEASE

Condition Symptoms/ risk factors

Cerebellar damage • Vertigo
e.g. alcoholic • Loss of balance/ coordination
cerebellar • Ataxic gait
degeneration • Dysdiadochokinesia
• Dysmetria
• Nystagmus
• Titubation
• Hypotonia
• Stuttering/ staccato speech
MSK ILLNESS SCRIPTS

Condition Symptoms/ risk factors

Osteoarthritis Asymmetrical polyarthritis esp. knees, spine, hips
Morning stiffness < 30 mins
Swollen finger joints (Heberden’s distal IP/ Bouchard’s proximal IP joints)
Joint pain worsens with use/ during the day
Peri/postmenopausal females
Obesity
Repetitive trauma/ overuse (e.g. sports people, physical labour)
Rheumatoid Symmetrical polyarthropathy esp. small joints e.g. hands, feet
Arthritis Morning stiffness > 30 mins
Joint pain after inactivity
Male smokers & perimenopausal females
Finger deformities - Swan neck, Boutonniere, ulnar deviation, Z deformities
Subcutaneous nodules
Systemic symptoms – fever, fatigue, loss of appetite
Acute gout Monoarthritis esp. podagra (big toe)
Acute onset
Obesity
Hypertension
Beer drinkers
Diuretics
Males
Chronic – tophaceous skin deposits e.g. around elbows
Septic Arthritis Monoarthritis (adults: knee; babies: hips)
Severe pain – constant, throbbing/ dull, worse @ night
(NB to rule out – Swelling
dangerous) Non-weight bearing on affected joint
Fever
Erythema/ warmth/ bogginess
Babies/ children: not eating/ playing, crying
Risk factors: age, DM, HIV/AIDS, RA, preceding infection, trauma/ surgery (esp.
joint/ prosthesis)
Osteomyelitis Pain
Swelling
Warmth, erythema
Fever
Draining pus through the skin
Loss of range of motion/ weight bearing
History of surgery/ infection/ trauma
Prosthetic joints
Haemarthrosis Monoarthritis
Pain
Swelling
Warmth & erythema
Bleeding – epistaxis, gums, bruising etc.
Family history of bleeding disorders (haemophilia)
Drugs e.g. warfarin
Mechanical Back pain
back pain Onset associated with: trauma/ activity..
Worse with activity
Relieved by rest
Relieved by NSAIDs
Ankylosing M>F
Spondylitis Lower back/ buttock/ thigh pain - over SI joints (may spread to knees/ shoulders)
Worse at night
Wake up with morning stiffness
+- Scoliosis
Improves with activity
 Potts Disease Back pain
History of TB infection
Weight loss
Fever
+- chest symptoms – cough, shortness of breath
Systemic Symmetrical polyarthritis
Lupus Females (20s to 40s)
Erythematosus Fatigue
Weight loss
Malar/ discoid rash
Fever
Ulcers
Dactylitis
Psoriatic Asymmetric polyarthritis
Arthritis Early morning stiffness
Nail pitting/ ridging
Psoriasis plaques

NB: Always rule out life-threatening causes e.g. Septic arthritis or neurological or cancer
Always ask about warning signs:
• Fever
• Swelling
• Redness/ warmth
• Weight loss
• Trauma/ previous surgery
• Back pain
• Bladder/ bowel dysfunction (neurological)
GIT ILLNESS SCRIPTS

Condition Symptoms/ risk factors

Peptic Ulcer Epigastric pain – dull/ burning/ gnawing
Disease Pain relieved by antacids/ food/ vomiting
(emergency if Episodic pain/ wakes patient at night
perforated) Vomiting (+- blood i.e. ‘coffee ground vomitus’)/ melaena (dark) stool/ frank,
massive bleeding à perforation
Risk factors: NSAIDs, Smoking
GORD Burning epigastric pain or chest/ retrosternal pain/ discomfort
Worse when bending forward or lying down (+- positional cough when lying)
Worse after eating
Antacids/ vomiting – transient relief
Difficulty swallowing
Bitter taste in mouth
Aggravated by – alcohol, caffeine, fatty meals, CCBs, theophylline
Eosinophilic Dysphagia
esophagitis N&V
Weight loss/ loss of appetite/ malnutrition
Stomach pain
History of hayfever or asthma
Gastroenteritis N&V
Diarrhoea – +- pus/ blood (depending on agent); no fat
Abdominal pain
+- fever
Hepatitis Jaundice – sclera/ skin
RUQ abdominal pain
Abdominal distension
Dark urine/ pale stools
Pruritis
Change in appetite/ weight
Risk factors: Alcohol, IV drug use, tattoos, blood transfusion, sexual behaviour
Surgical history – pancreatic/ biliary
Family Hx of liver disease; immunized vs Hep B?
Acute RUQ/ Rt hypochondriac pain – severe – starts in epigastric region, localizes to
Cholecystitis RUQ; radiates to right shoulder/ scapula
May be colicky at first – but almost always becomes constant
N&V
+- Fever
Risk factors: ‘Female, Fat, Forties, Fertile’
Cystic duct Epigastric pain – severe, constant
obstruction Previous episodes of similar pain
Sometimes following fatty meals
Pale stools
Steatorrhea
Pancreatitis Steady epigastric pain - radiates to the back
Relieved by sitting up or leaning forward
Vomiting
Fever
Steatorrhoea – fatty & smelly stools
Alcohol binge drinking
Hx of gallstones
Pancreatic Weight loss
cancer Fatigue/ malaise
Fever
Chronic onset
Epigastric pain (later onset)
Family history of malignancy
Hepatocellular RUQ/ Rt hypochondriac pain (late presentation)
carcinoma Abdominal bloating
LoA/ feeling of satiety
Weight loss
N&V
Yellow eyes/ skin (jaundice)
Risk factors: history of hepatitis infection/ anabolic steroid use/ heavy alcohol use/
obesity/ diabetes
Kidney Colicky, severe pain – comes in waves; superimposed on constant pain
infection Renal angle tenderness
Radiates to groin (‘loin to groin’ pain)
Haematuria
+- Fever
Bowel Small bowel – periumbilical region; more frequent, colicky (every 2-3 mins)
obstruction Large bowel – anywhere; less frequent, colicky (every 10-15 mins)
(potential Vomiting
emergency) Constipation/ obstipation/ ‘overflow’ diarrhoea
No gas
Abdominal distension
Colon cancer Diarrhoea – intermittent, chronic diarrhoea / ‘overflow’ diarrhoea
+- Fecal incontinence/ urgency
Bloody stools (bright red)
Tenesmus
Weight loss/ LoA
Family history of malignancy
Older age
Appendicitis Acute
(potential Initially periumbilical à migrate to RLQ / R iliac fossa
emergency if Nausea & vomiting
perforated) Fever
Anorexia
Crohn’s Diarrhoea (bloody)
Disease Abdominal pain
Weight loss
Abdominal mass
Failure to thrive
Fistulae/ perianal abscesses
Extra-intestinal: mouth ulcers, osteoporosis, arthritis, peripheral neuropathy
Ulcerative ++ Diarrhoea (bloody) à more severe vs CD; often nocturnal
Colitis Urgency
Tenesmus
Weight loss
Severe: fever, tachycardia, abdominal pain & distension
Primary Sclerosing Cholangitis, skin conditions e.g. erythema nodosum
Family hx
Irritable Bowel Abdominal distension
Syndrome Alternating diarrhoea + constipation (or one predominant over the other)
(IBS) Abdominal pain – relieved by defecation
Looser/ more frequent stool with onset of abdo pain
Mucus in stool
Tenesmus (feeling of incomplete rectal emptying)
Triggers/ exacerbating factors: gastroenteritis, food intolerance, stress, surgery
Coeliac Diarrhoea
Disease Bloating/ distension
Flatulence
Weight loss
Intolerance to gluten-containing foods
Fatigue
Family hx
 Diverticulitis LLQ pain – cramping/ constant
N&V
Fever
Constipation
LoA
Indigestion, flatulence
Ruptured AAA Sudden onset abdo/ back pain (first pulsing then boring/ stabbing)
Spreads to: back, pelvis, legs or buttocks
Sweating/ clammy skin
Tachycardia
N&V
Hypotension
Shock/ loss of consciousness

NB questions for all GIT complaints:

• Abdominal pain
• Vomiting
• Diarrhoea/ constipation
• Fever & weight loss
• Abdominal distension
• Family hx of malignancy
• Diet/ appetite changes

QUESTIONS TO EXPLORE MAIN COMPLAINT:

Pain
Use SOCRATES

Vomiting
• Duration – acute or chronic?
• Preceded by nausea or no warning (e.g. bowel obstruction)?
• Immediately after eating (e.g. gastric outlet obstruction) or delayed (e.g. gastroenteritis)?
• Timing – morning (pregnancy, alcoholism, raised ICP) or evening?
• Volume and contents?
- Bloodstained? (e.g. ulceration)
- Bile stained?
- Feculent?
- Old food?
• Ask about:
- Abdominal pain
- Weight loss
- Medications
- Headaches

Diarrhoea
• Frequency
• Consistency
• Acute vs chronic?
• Urgency? (colonic disease)
• Blood/ mucus/ pus?
• Volume
• Pale/ greasy/ smelly/ difficult to flush (steatorrhoea)
• Faecal incontinence? (‘does stool sometimes come out unexpectedly?)
• Tenesmus? (‘does it feel like you still need to go to the toilet even after you’ve been?’)
• Weight loss? (cancer, malabsorption)
• Passing gas? (obstructive)
• Medication? (antibiotics/ laxatives)
• Travel (infectious cause?)
• Previous illness/ surgery (IBS/ GIT surgery e.g. gastric bypass)
• Family hx (malignancy, IBD, coeliac disease)
• Fever/ rigors/ chills (infective, lymphoma)
• Diet changes

Constipation
• Medication: opioids, anti-depressants, calcium/ aluminium antacids
• Frequency of bowel movements
• Passing gas?
• Consistency of stool
• Fever?
• Abdo distension?
• Weight loss?
• Stool consistency/ form/ colour/ blood?
• Feeling of incomplete evacuation
• Diet changes
• Pregnancy
• Family hx e.g. colon ca.

Bleeding
• Nature (haematemesis, melaena, haematochezia)
• Character – e.g. bright red blood vs tarry black stools; massive/ mixed into stool; small amounts/ on top
of stool/ on toilet paper/ in bowl?
• Bleeding disorders?
• Medications – NSAIDS (PUD)
• Weight loss?
• Coagulopathy?

Heartburn/ GORD
• Frequency?
• Relation to meals?
• Position?
• Radiation? (left arm, jaw à MI?)
• Relieving factors e.g. antacids?
• Bitter taste in mouth?
• Positional cough?
• Difficulty swallowing?

Dysphagia
• Solids and/or liquids? (if both – motor disorder e.g. achalasia, esophageal spasm)
• Location of obstruction?
• Intermittent/ persistent/ progressive (e.g. stricture, carcinoma, achalasia)?
• Coughing/ choking?
• Steady or progressive (worse with time)?
• Pain
• Heartburn
• Weight loss
• Asthma/ hayfever (eosinophilic esophagitis?)

Jaundice
• Onset and duration?
• Dark urine/ pale stools? (obstructive jaundice)
• Fever? (cholangitis)
• Change in appetite/ weight? (malignancy)
• Alcohol use (how much/ binge?)
• Medication – halothane, rifampicin, OCP, steroids, alcohol, tetracycline, paracetamol overdose
• Risk factors for hepatitis? (IVDU, tattoos, blood transfusion, sexual behaviour)
• Hep B immunization?
• Family hx of liver disease
ENDO ILLNESS SCRIPTS

Condition Symptoms/ risk factors

Diabetes Polyuria
(acute) Polydipsia
Weight loss
Weakness/ fatigue/ lethargy
Complications:
Blurred vision
Peripheral neuropathy (pain/ numbness/ pins & needles)
Chest pain/ angina
Diabetes Structure history-taking around the 4 C’s:
(chronic/
follow-up)

Q’s to ask:
Complaints: Have you noticed any new symptoms/ issues?
Compliance: How regularly are you taking your medication? How are you
managing your lifestyle factors e.g. diet/ exercise/ weight etc?
Control: How regularly are you monitoring your blood sugar?
Complications: Have you noticed any complications e.g.
Macrovascular – angina/ chest pain, TIAs (transient loss of consciousness/
headache), ulcers/ sores that won’t heal etc?
Microvascular – blurred vision
Neuropathy – e.g. claudication - pain/ numbness/ pins and needles in legs or feet;
autonomic e.g. changes in bowel habits – e.g. diarrhoea
Hyper- Increased appetite
thyroidism Weight loss
Palpitations
Sweating
Tremor
Heat intolerance
Diarrhoea
Irritability/ hyperactivity/ ‘jittery’
Insomnia
Muscle weakness
Neck swelling
Medication (e.g. amiodarone for arrhythmia or thyroxine for weight loss)
Family history of thyroid problems

Hypo- Decreased appetite

thyroidism Weight gain
Lethargy
Swelling of eyelids, legs
Constipation
Menstrual changes e.g. oligomenorrhoea
Coarse, pale, dry, thick skin
Brittle nails/ hair
Voice or speech change/ hoarseness
Cold intolerance
Family history of thyroid problems
 Condition Symptoms/ risk factors
Acromegaly Enlarged hands & feet
Enlarged, coarsened facial features
(increased GH) Fatigue & weakness
Weight gain
Sweating
Headaches
Heat intolerance
Decreased vision (bitemporal hemianopia)
Decreased libido/ erectile dysfunction
Increased pigmentation
Addison’s Fatigue
disease LoA, LoW
Postural hypotension
(adrenal N, V, abdo pain
insufficiency à Diarrhoea
reduced gluco- Hyperpigmentation, Vitiligo
and mineralo- Nocturia
corticoids) Seizures
Cushing’s Fat deposition – moon facies, buffalo hump, central obesity
syndrome Weight gain
Striae
(increased Easy bruising
cortisol; if d/t Thinned skin
pituitary ACTH Hyperpigmentation
overproduction Insomnia
= Cushing’s Erectile dysfunction/ irregular menses
disease) Diabetes
Hyperpara- Stones: Renal stones
thyroidism Bones: Bony tenderness (osteopenia, pseudogout)
(++ PTH = ++ Abdo groans: Constipation, peptic ulcer, pancreatitis
calcium + Vit D) Psych moans: Confusion, convulsions, coma
Prolactinoma Galactorrhea – white, milky fluid (no blood); increasing volume
(d/t pituitary Visual disturbances (bitemporal hemianopia)
adenoma) Breast enlargement/ swelling
NB to rule out: Headaches
pregnant, breast Reduced libido
ca (family hx) Erectile dysfunction / menstrual changes (amenorrhoea/ oligomenorrhoea)

General Health Status for Endocrine

• Thirst/ drinking more fluids
• Sweating?
• F: Menstruation – is it happening; how many days; regular/ same time each month?
• Sexually active/ libido/ M: Erections?
• Fertility?

Past Medical History for Endocrine

• Hypertension (esp. in young patient – possible phaeochromocytoma, Cushing’s, Conn’s)
• Known chronic endocrine conditions e.g. Diabetes, Thyroid
• Previous surgery – thyroidectomy (full/partial – may also damage parathyroids); pituitary, adrenal (e.g.
nephrectomy)/ procedures/ admissions – radio ablation, head injury
• Chronic meds – thyroid replacement, diabetes (4 Cs)
• Growth and development in childhood (if relevant)

Family History for Endocrine

• Thyroid disorders
• Autoimmune conditions
• Diabetes mellitus
• Multiple Endocrine Neoplasia
REPRO ILLNESS SCRIPTS

Condition Symptoms/ risk factors

Pregnancy Amenorrhoea (check LNMP)
(not an illness Abdominal distension
but should rule N&V (morning sickness)
out in all Breast tenderness/ paresthesia/ enlargement/ enlarged, darkened areolae
females of Leucorrhoea – thick, mucus discharge
reproductive Fatigue
age) Heart burn/ indigestion
Later: +- back pain, pedal/ hand oedema à CTS, constipation, shortness of
breath, pruritis, nipple discharge (colostrum)
Primary Central/ cramping abdominal pain
dysmenorrhea Occurs in alignment with ovulatory cycles
(normal period +- vomiting & diarrhoea
pain) Onset typically from menarche
Relieved with OTC analgesia

Ectopic LAP, unilateral à L/R iliac fossa – constant, sharp

pregnancy +- vaginal bleeding/ spotting (+- clots)/ discharge
Amenorrhoea – onset usually 6-8 wks post LNMP
Dizziness/ fatigue
Risk factors: previous PID/ STIs, pelvic surgery, endometriosis, previous ectopic,
smoking
If ruptured: (acute abdomen/ surgical emergency)
Worsening pain - may radiate to shoulder (diaphragmatic irritation)
Abdominal rigidity/ involuntary guarding
Tachycardia/ orthostatic hypotension from blood loss
Rule out: appendicitis (fever, N&V), UTI (dysuria, frequency), bowel obstruction
Miscarriage Known pregnancy OR hx of amenorrhoea
Central LAP
Bleeding +- clots
Risk factors: previous miscarriages, older maternal age, drug use
If septic miscarriage: painful, foul-smelling vaginal bleeding +- fever

Pelvic Lower abdominal pain – usually bilateral

Inflammatory Abnormal vaginal discharge (mucopurulent)
Disease (PID) Abnormal bleeding – post coital, intermenstrual, menorrhagia
Fever & chills
Dysuria
Dyspareunia – deep
If + RUQ tenderness – consider Fitz-Hugh-Curtis syndrome
Risk factors: multiple partners/ recent new partner, no barrier contraception,
previous STIs, gynae procedures, ectopic pregnancy,
Endometriosis LAP – unilateral, severe, longer lasting & associated with menstruation
Irregular menses à Menorrhagia +- prolonged bleeding (>7 days); shorter
menstrual cycles (< 27 days)
Dysmenorrhoea
Dysuria
Dyschezia
Dyspareunia
+- Infertility
Risk factors: family history, early menarche, uterine/ Fallopian tube defects
Fibroids Abnormal bleeding – intermenstrual spotting, post-coital, menorrhagia
(leiomyomata) LAP – vague, crampy
Abdominal distension
Irregular menstrual cycle
Dyspareunia
+- infertility
+- hx of miscarriage/ premature birth
Condition Symptoms/ risk factors
STI Vaginal discharge – green/ yellow/ foul smelling/ blood stained..
Dysuria (burning)
Urinary frequency & urgency
Pruritis
Genital ulcers/ sores/ skin changes
+- Fever
Dyspareunia
Risk factors: unprotected sex, multiple sexual partners
Vulvovaginal Vaginal discharge – thick, white, curd/ ‘cottage cheese’-like, odourless
Candidiasis Swollen/ red/ tender labia
Pruritis
Dysuria
Dyspareunia (superficial)
Risk factors: Recent broad-spectrum antibiotics, DM (poor control), unprotected
sex, corticosteroids, oral contraceptives, pregnancy, HIV
PCOS Amenorrhoea/ oligomenorrhoea
Hirsutism
Obesity
Alopecia (male pattern/ frontal balding)
+- infertility
Insulin resistance
Muscle bulking & deepening voice
Cliteromegaly
Cervical +- LAP (may or may not be present)
cancer Abnormal vaginal bleeding – doesn’t follow menstrual cycle e.g. post-coital
Abnormal menses - menorrhagia/ amenorrhea/ oligomenorrhoea
Dyspareunia
+- vaginal discharge (+- foul smell)
Constitutional sx – weight loss, fatigue, N&V, decreased appetite
Risk factors: Family hx of cancer, HIV, smoking, OCC use (> 5 years), multiple
births (>3 3), multiple sexual partners, early onset sexual activity, STIs
Ovarian cancer Abdominal distension/ bloating (+- peripheral wasting)
Discomfort
Weight loss
Early satiety/ decreased appetite
+- LAP (usually only later)
Fatigue
Shortness of breath
Constipation/ indigestion
Urinary frequency/ urgency
+- vaginal bleeding
Family hx of cancer
Breast cancer Breast lump/s (usually painless, firm, non-mobile, solitary à bilateral/ multicentric)
Nipple changes (e.g. inversion)
Nipple discharge (esp. bloody)
Skin changes (e.g. tethering, ulceration, peau d’orange)
Breast size/ shape change (e.g. tethering, asymmetry)
Risk factors: Family hx of cancer, age >50, alcohol use, nulliparity/ > 30 at first
delivery, no breast-feeding, early menarche, late menopause, obesity, sedentary
lifestyle, combined OCP, increasing age
Breast abscess Breast pain
Erythema & swelling
+- Fever
Risk factor: breast feeding (1st month)
Fibroadenoma Breast lumps – solitary or multiple/ bilateral
Painless
Well circumscribed, smooth, mobile (‘breast mouse’)
Age: 20s-40s
May be more prominent during pregnancy/ menses (high estrogen states)
 Condition Symptoms/ risk factors
Fat necrosis Breast lump – solitary
Painless
Skin retraction/ tethering
+- Hx of trauma
(Resembles breast ca. à rule out)
Duct ectasia Intermittent nipple discharge – yellow/ green/ black/ thick white +- blood-stained
Burning pain – areolar region
Unilateral/ bilateral
+- nipple retraction
+- subareolar mass/ swelling
+- redness/ inflammation
Risk factors: Smoking, hypothyroidism
Paget’s Nipple changes – crusted, scaly, eczematous, flaking, flattened
disease Itching/ tingling nipple/ areola
+- Nipple discharge – yellow/ bloody
Redness/ erythema of surrounding skin
Menopause Irregular menstrual cycles – oligo-/amenorrhoea & cycle length changes
Hot flushes
Night sweats
Vaginal dryness
Dyspareunia
Low libido
Insomnia
Hair loss
Mood/ cognition changes – depression, forgetfulness
Perimenopausal age c. 45-55 yrs (unless early onset)

Menstrual history questions:

• When was your last normal menstrual period? (first day of bleeding)
• How long is your menstrual cycle usually? (normal: 26-32)
• How regular is your menstrual cycle? (same duration every month?)
• How long do you bleed for? (normal: 4-7 days)
• Have you noticed a change in blood loss? (amount/ increased use of sanitary products/ clots)
• Do you bleed between periods? (spotting, post-coital etc.)
• Do you have painful periods?
• At what age did your periods start? (menarche)
• If menopausal:
- At what age did your periods stop? (cessation for at least 12 months)
- What other symptoms did you have when your periods stopped?

Sexual history questions: (NB: remember to ‘signpost’: “I am going to ask you some personal questions..”
• Are you sexually active?
• How many sexual partners do you have? And your partner?
• Do you practice safe sex all the time?
• Are you using any contraceptives? Which one/s?
• Do you know your HIV status? And your partner’s?
• Have any of your recent sexual partners had any STI symptoms?
• What kind of sexual activity do you practice? (e.g. vaginal, anal, oral sex)
• When was the last time you had sex?