Fast PACES

2021

Symptoms
2nd Edition

By Dr. Muhammad Imran Babar

MRCP (UK)
__________________________________________________________________________________

List of symptoms

_________________________________________________

1. How to introduce in station 2 and 5, 2

2. ODPARA, 3

3. LOQIRAA, 4

4. General Questions, 5

5. Central Nervous system, 6

6. Endocrinology, 7

7. Pituitary adenoma, 8

8. GIT, 9

9. Vomiting, 10

10. Jaunice risk factors assessment, 11

11. Shortness of breath, 12

12. Chest, 13

13. Cardiovascular system, 14

14. Kidneys and BPH, 15

15. Obs. And Gynecological system, 16

16. Joints (Connective tissue disorders), 17

17. Autoimmune conditions, 18

18. Rash or Ulcer, 19

19. Allergy related questions, 20

20. Diabetes Mellitus, 21

21. Social history, 22

22. Male sexual history, 23

1
 Chapter 1 How to introduce in station 2 and 5

Introduction in station 2

Hello! Good morning (Good evening)

My name is Dr. Babar.

I am one of the Doctors in this clinic.

You must be Mr./Mrs. XYZ? (Wait for patient's acknowledgment)

Right, (Short pause)

Nice to meet you

Well,

I have been asked to speak to you about your health problem - Is that fine with you? (Wait for patient's verbal or non-

verbal acknowledgment) Thanks - and is that all right if I take a few notes during our conversation if required?

Well,

I gathered from your notes that you have. (Headache e.g.)

Is that so? (Wait for patient's acknowledgment)

Right,

Could you please tell me more about it in your own words?

Introduction in station 5

Hello, Good morning!

My name is Dr. Babar.

Are you Mr./Mrs. XYZ?

Nice to meet you!

Well,

I have been asked to speak to you and do your examination. Is that fine? (Wait for patient's acknowledgment) Moreover,

is that fine if I take a few notes during our chat? (Wait for patient's acknowledgment)

Right,

I understand that you have a headache? Is that correct?

Could you please tell me more about it?

2
 Chapter 2 ODPARA (History of present illness)

Onset • How did it come on, suddenly or gradually?

• What were you doing at that time? (Especially if sudden)
• Did anything happen prior to it?

Duration • For how long you have this problem?

Progression • Has it been getting worse, better or staying the same?

Aggravating factors • Have you noticed what makes it worse?

Relieving factors • What makes it better?

Associated system • Ask about relevant questions from CNS, CVS, Chest, Renal, or Joints, etc.

3
 Chapter 3 LOQIRAA. (Use this pneumonic if pain is the presenting complaint)

Location • Where precisely do you fell the pain most?

• Could you please show me?

Onset, Duration and • Did it come on, suddenly or gradually?

Progression
• What were you doing at that time? (If sudden)

• For how long you have this pain? (Usually mentioned in the notes)

• Is the pain present all the time or does it come and go?

• How long does each episode last? How many episodes are there, and how frequent are

the attacks? (If intermittent)

Quality • What sort of pain is it, could you please describe it for me?

Intensity • How intense is it on a scale of 1 to 10?

Radiation • Does this pain go any whererelse?

Aggravating factors • Does anything make it worse?

Alleviating factors • Does anything make it better?

Associated system • E.g., Heart, chest, GIT, CNS and renal etc. depending upon the scenario

4
 Chapter 4 General questions

Have you noticed any fever?

• Fatigue

• Sweating (Night sweats means infective endocarditis, lymphoma or Tuberculosis etc.)

• Changes in appetite

• Changes in weight

• Rash on skin and

• Lumps or bumps

5
 Chapter 5 Central Nervous System

• Are you right or left-handed?

• Did you sustain a head injury before you get this problem?

• Have you noticed any headache, facial pain, neck or back pain?

• Any problem with mood or memory?

• Did you ever suffer from fits, faints, or funny turns?

• Do you feel dizzy or have a spinning sensation?

• Have you noticed trouble with your speech?

• Any problem with your vision, hearing, sense of smell, and taste?

• Any difficulty in swallowing?

• Any facial weakness and sensory loss?

• Any problem with your arms or legs? If the answer is yes, ask the patient to describe the issue by using the word

"like"

• Any weakness? (If yes, how quickly did it come on? And how long ago? Has it improved or gone away now?)

• Any stiffness?

• Any numbness, tingling, or other abnormal sensations?

• Any shaking in arms, legs, or other body parts?

• Any problem with the control of waterworks or bowel works? (Distal spinal cord problem)

• Any problem with walking?

• Any problem with balance, especially when you walk on a straight line? (Cerebellum)

• Do you feel like walking on cotton wool?

• Any balance problem in a dark room or when you close your eyes? (Dorsal column)

• Do you feel dizzy when you stand up quickly? (Autonomic neuropathy)

• Note: Any unusual complaints before this? (Concentrate on complaints suggestive of aura, especially if sudden

onset problem, e.g., epilepsy or migraine)

6
 Chapter 6 Endocrinology

General questions • Did you sustain a head injury before you get this problem?

• Any headache, especially on the front?

• Have you noticed any changes in your appearance?

• Have you noticed any problem with your hair?

• Have you noticed issues with your skin like dryness or color changes?

• Any changes in your voice?

• Any problem with bowel works like constipation or loose motion?

• Any problem with monthly periods? (Female)

• Is your health affecting your relationship in any way? (Androgens)

• Any fever, fatigue and lethargy, sweating, appetite changes, weight changes, sleep

problems, lumps, or bumps? (General questions)

Specific questions • Any problem in adjusting to the extremes of temperature? (Thyroid)

• Have you felt increased thirst recently? (DM)

• Any problem with waterworks, especially an increased frequency or quantity? (DM, DI,

and Hyper-calcemia)

• Any abnormal discharge from your breast? (Prolactinoma)

• Do you feel racing of your heart? (Thyrotoxicosis, pheochromocytoma etc.)

• Have you noticed a sudden shaking of your hands with headache, sweating & flushing of

the face? (Pheochromocytoma)

• Do you feel dizzy when you stand up from sitting position? (Adrenal Insufficiency)

• Any changes in hand and feet size? (Acromegaly)

• Have you noticed any thinning of the skin or bluish spots even after a minor injury?

(Cushing syndrome)

7
 Other specific questions that can be asked during history of endocrine problems

• Do you use any medicines like anti-thyroid drugs, hormonal preparation, steroids, etc.?

• Any health problem that runs in the family, especially related to the defense system, gland problem, procedures

done on the neck, kidney stones (MEN-1 and MEN-2)?

• Have you ever had a surgery or radiation treatment for your head or neck?

Chapter 7 Pituitary adenoma

Consider MEN-1, MEN-2a, Cushing disease, and Non-functioning pituitary adenoma.
• Do you have any feeling of being unwell? Are you losing your muscle bulk? (Growth hormone)

• Is your health affecting your relationship in any way? Have you noticed loss of body hair? (Male androgens)

• Any problem with monthly periods? Have you noticed hot flushes? (Decreased female androgens and

hypothyroidism may cause secondary amenorrhea, oligo-menorrhea, and menorrhagia)

• Any problem adjusting to temperature? (Secondary hypothyroid but weight gain and myxedema may be absent)

• Do you feel dizzy when you stand up from the sitting position? (Secondary adrenal insufficiency but pigmentation

may be absent, may also have nausea, vomiting and weight loss if acute ACTH deficiency)

• Problem to feed the baby after birth? (Prolactin deficiency, If applicable)

• Have you noticed an abnormal discharge from your nipples? (Pituitary adenoma causing hyper-prolactinemia,

both male and female may be affected)

• Question-related to an underlying condition, e.g. (Acromegaly, etc.)

Note:

• Frontal headache is always suggestive of macro-adenoma

• Clue of bi-temporal hemianopia may be bumping into the objects on both sides?

• Always ask the patient about symptoms consistent with pan-hypopituitarism if an associated condition is present

like acromegaly, features of prolactinoma or symptoms suggestive of secondary hormonal deficiency etc.

8
 Chapter 8 GIT

• Any yellowness of your eyes? (If yes) Any itching on the skin, pale-colored bowel works, and dark-colored

waterworks. (For obstructive jaundice)

• Do you ever wake up with an acid taste in your mouth in the mornings? Have you had any heart burn recently or at

night? (GERD)

• Any difficulty in swallowing?

• Any nausea or vomiting? (Also ask) Have you ever had vomiting containing blood?

• Any early fullness after meals?

• Any tummy pain or discomfort?

• Any tummy swelling?

• Any changes in bowel habits? If yes, what have you noticed, loose bowel works or constipation?

• Did you ever notice blood through the back passage?

• Any black-colored bowel motions?

• Any changes in your diet since the problem started?

9
 Chapter 9 Vomiting

• Could you please describe what happens?

• Do you get any cough with vomiting? Are there any phlegm or food particles mixed in it?

ODPAR (A)

• For how long?

• How frequent?

• What makes it worse?

• What makes it better?

• What does vomit look like?

• Any blood mixed in it?

• Any nausea before vomiting or not? (With or without warning)

• Do you get vomiting at any specific time of the day? (Vomiting early in the morning is related to alcohol,

pregnancy, raised intracranial pressure, etc.)

• Do you have any vomiting free periods before you have this problem again? (Cyclical vomiting syndrome)

• Do you get vomiting just after meals or hours after meals? (Gastro-paresis or Gastric outlet obstruction if more

than one hour later.)

10
 Chapter 10 Jaundice risk factors assessment

• How much alcohol do you drink in an average weekend?

1. Alcohol • What type?

• CAGE Questions may be required

• Any piercings or tattoos on your skin?

2. Viral • Have you ever had a blood transfusion?

• Have you ever had any medical or surgical procedures?

• Have you ever-injected drugs in your blood channels? And any sharing of needles?

• Have you had any contact recently with someone having jaundice? (Hepatitis A or E)

• Did you travel somewhere in the last 6 months? (Hepatitis A or E)

• Sexual history (After taking permission)

• Have you had vaccinations for hepatitis A and B?

3. Autoimmune • Medications

(The clue may be in • Past medical history

medicines.) • Family history

• Do you have any difficulty in breathing with wheezy noise from your chest?
4. Metabolic
(Emphysema especially in young)

• Any shaking of your limbs and stiffness? (Parkinsonism especially in young)

• Any color changes in skin and knee pains? (Hemochromatosis)

5. Vascular • Have you ever had clotting in blood channels anywhere?

• Methotrexate, Amiodarone, Phenytoin, INH, Co-amoxiclav, and others

6. Medicine • Recent use of other immunosuppression medicines (May flare up Hepatitis B

infection)

11
 Chapter 11 Shortness of breath

• Any difficulty in breathing?

• How far can you walk before you get difficulty in breathing?

• How many flights of stairs can you manage without getting breathless?

• What was your breathing like before this?

• Which other activities are affected because of a breathing problem?

ODPARA • How did it develop, suddenly or gradually?

• For how long you have this problem? And is your breathing problem constant or comes

and goes? How frequently you get breathing problem? (If intermittent)

• How has it changed over time?

• What makes it worse?

• What makes it better?

12
 Chapter 12 Chest

• Any cough? (Nighttime dry cough means Heart failure, GERD or asthma)

• Is this dry or contains phlegm? (If patient brings out sputum then following questions)

o How much at a time? What is the color? Thick or thin? Any blood mixed in phlegm?

• Did you ever cough up blood? (PE or Cancer)

• Any chest pain on taking a deep breath? (PE or Pleurisy due to acute infection)

• Any whistling sound or noise from your chest? (Asthma or COPD)

• Any difficulty in breathing?

Note: Detailed questioning of SOB is not required if it is not a presenting a complaint, however always ask few
questions to sort it out whether problem is related to heart or not like; PND, orthopnea etc.
If the patient has noted a whistling sound in his chest, ask few more questions given below to differentiate
asthma from COPD

• Do you have an allergy to any Food, Medicines, Pets, Pollens, house dust mites, fragrance, certain fumes, etc.?
• Do you get these complaints at any specific time, especially early in the morning?
• Any effect of seasonal changes on your cough?
• (Beta-blockers can potentially worsen asthma.)

Associations General Fever, fatigue, weight and appetite changes, lumps or bumps

Connective tissue Ask about joint pain, color changes of fingers, tightening of the skin, etc.
disorders
Sarcoidosis Any problem with eyes like redness and grittiness? Any painful bumps on
the skin?

Did anyone at home complain that you snore loudly? Do you fall asleep
OSA easily during the day? Have you ever fallen asleep during driving? Etc.

History Past history, especially any lung or heart disease

Medicines ACE inhibitors, beta-blockers, amiodarone, methotrexate, and

nitrofurantoin, etc.

13
 Job especially the exact nature of work, the timing of symptoms onset at

Social history the workplace, wearing of mask or not, does anyone else have similar

complaints in the job area, the impact of holidays, and the nature of

previous jobs?

Smoking in detail, including previous smoking and passive smoking?

If the patient has extensive travel history, rule out TB and HIV, etc.

(Social Hx.to rule out occupational lung disease and others)

14
 Chapter 13 Cardiovascular system

• Do you ever wake up at night feeling breathless?

• How many pillows do you sleep on at night?

• Do you get a dry cough, especially when you lie flat? (Chronic pulmonary edema)

• Any racing of your heart?

• Any chest pain or chest tightness on walking?

• Do you feel dizzy? Did you ever collapse, especially during exercise?

• Any swelling around the ankles?

• Any pain in the legs, especially on walking? (Claudication)

Note: Any health problem in the past related to heart, e.g., rheumatic fever, DM, high blood pressure, fat problems in
the blood, etc.

Always ask questions of • Any cough?

CHEST in cases of SOB • Any phlegm?

o How much at a time?

o What is the color

o Thick or thin

o Any blood mixed in phlegm

• Did you ever cough up blood? (PE or cancer)

• Any chest pain on taking a deep breath? (PE or pleurisy)

• Any whistling sound or noise from your chest? (Asthma or COPD)

• Also, ask the following questions if there is wheeze:

o Any effect of weather changes on your breathing?

o Do you get difficulty in breathing at any particular time of the day or night?

o Do you have an allergy to anything? (Like pets, pollens, house dust mite, etc.)

o Any difficulty in breathing? (Detailed questioning if this is the presenting

complaint)

15
 Chapter 14 Kidneys and BPH

I. Renal system

• Any problem with waterworks? Like;

• Pain or burning while passing waterworks?

• Do you need to rush to pass water work? (Urgency)

• Changes in frequency?

• Any changes in the color of waterworks? (Frothy, pink, brown or bright red)

• Any blood in the waterworks? (If yes ask; before, during, or after waterworks, also colors discussed above)

• Ever passed a stone in waterworks?

• Do you get double voiding? (Incomplete emptying)

• Do you feel d sometimes? (Incontinence)

• Any swelling around your ankles or eyes? (Nephrotic)

• Any bone pain or itching on the skin? (CRF)

• Ask questions related to BPH. If required, the same questions may also help to rule out obstructive uropathy.

• Any backache or tummy pain?

• Changes in the quantity of waterworks? (Increased or decreased)

II. BPH

• Do you need to rush for waterworks? (Urgency)

• Do you need to pass waterworks frequently at night? (Nocturia)

• Any difficulty at the start to pass urine?

• Do you feel a poor stream of waterworks?

• Any dribbling after waterworks?

16
 Chapter 15 Obs. and gynecological system (Always ask 3 P’s)

• When did you start having periods?

• Have you faced any problem with your monthly periods recently? If yes: Ask about the kind of problem i.e., pain,

regular or irregular, more, less, or none at all?

• Are you taking any pills?

• Any possibility of pregnancy at the moment? If no: Any previous pregnancy? If yes: Any problem with pregnancy in

the past?

17
 Chapter 16 Joints (Connective tissue disorder)

Sequence of questions Skin> Nails> Joints> Blood channels> Nerves> Muscles> Functional capacity>
Associations

• Any tightening of skin at the back of your hands? (Scleroderma)

• Any ulcers on your fingertips?

• Any problem with your nails?

• Any pain in joints? Any swelling? Any redness? Any stiffness? If yes: For how long the stiffness remains? When do

you get more symptoms? Any deformities of your joints?

• Any color change of your fingers? (Raynaud’s)

• Any numbness or tingling in your hands? (Sensory → entrapment neuropathy, e.g., carpal tunnel syndrome)

• Any weakness of hands? (Muscles wasting and neuropathy)

• Any weakness in shoulders or thighs? (Polymyositis or dermatomyositis)

• Any dryness of eyes or mouth? (Sicca syndrome)

• How does your skin react to sunlight? - Photosensitivity (SLE)

• Any dry cough and difficulty in breathing, especially on walking? (ILD)

• Any burning in the chest?

• Any swallowing problem? (Motility disorder)

• Any problem with waterworks? Any swelling around the eyes or feet? (Renal involvement)

• Any neck pain or backache?

• General questions (Fever, fatigue, appetite, etc.)

Extra-articular questions and • Any rashes? If yes; where and which type?

associations • Any other problem with your eyes like redness? (With or without pain)

• Any nasal stuffiness?

• Any ulcer in your mouth or your private areas?

• Any problem with bowel works like loose motion.

18
 Chapter 17 Autoimmune conditions

• Any white patches on your skin? (Vitiligo)

• Any yellowness of your eyes? (Autoimmune Hepatitis, PBC, PSC)

• Any problem adjusting to the temperature? (Thyroid)

• Excessive thirst and increased frequency of waterworks? (Type-I DM)

• Do you feel dizzy when you stand up from sitting position? (Addison’s disease)

• Any problem with bowel works? (Celiac disease)

• Any tummy pain, soreness of tongue or numbness & tingling in feet? (Autoimmune gastritis)

Others Hypoparathyroidism (Any cramps in your feet or hands)

Connective tissue disorders e.g.

• SLE

• RA

• Sicca Syndrome etc. (Joint Pains etc.)

• Mixed connective tissue disorders

19
 Chapter 18 Rash or ulcer

• Where exactly is the rash?

• Do you have a rash anywhere else?

• How does it look like?

• Can you feel it? (If yes, vasculitis otherwise purpura.)

• Does it disappear when you press it? (If no, Vasculitis otherwise, purpura)

• Any pain, itching, bleeding, or discharge from it?

• ODPARA

• History of atopy

Important associated questions in case of rash • History of medicine

• Systemic disease

20
 Chapter 19 Allergy related questions

Important to ask in cases of SOB, asthma, anaphylaxis and hypersensitivity reaction, etc.

• Do you have an allergy to anything?

• Do you have any pets at home? Any allergy to their hair or saliva?

• Any allergy to pollens or house dust mite?

• Any allergy to specific food or medicine (NSAIDs, opioid, Penicillin, etc.)

• Allergy to metals, pressure, heat, or cold?

• Allergy to any kind of stress?

• Have you ever had a problem related to an insect bite?

21
 Chapter 20 Diabetes mellitus

• Do you have diabetes?

1. DM
• For how long?

• Do you monitor your blood glucose at home regularly? If yes; what are your blood

glucose ranges? (Both fasting and in relation to meals)

• Do you know about your previous three months record of diabetes called HbA1C?

• Are you taking any medicine for DM?

2. Medicine
• Which medicine? (Duration, dose, compliance and side effects)

• Did you ever use Insulin? (Duration, type, frequency, dosing, compliance, which site

and associated skin problems)

• Any particular side effects to medicine? Like;

o Ever had low blood glucose level and what symptoms you had?

o How often do these occur?

o Have you noticed any reason for such episodes?

o Do you know what to do when this happens?

• Have you had dietetic consultations previously? If yes, do you follow this regularly or

not?

• Do you undertake a regular exercise to control your blood glucose levels?

• Have you ever had a sudden weakness of body limbs? (TIA/ Stroke)
3. Complications
• Any problem with vision? (If yes, what type of problem)

(Macro and micro • Any chest pain? (IHD)

vascular) • Any difficulty in breathing? (IHD, LVF)

• Any problem with waterworks?

• Any pain in legs on walking? (Intermittent claudication)

• Any numbness or tingling in your feet? (Peripheral sensory neuropathy)

• Any weakness or any cramps in feet? (Peripheral motor neuropathy)

22
 • Any problem with balance, especially when you close your eyes? (Dorsal column)

• Do you feel dizzy when you stand up? Any problem with bowel works? Is your health

affecting your relationship in any way? (Autonomic neuropathy)

• Have you ever had any hospital admission for uncontrolled Diabetes? (DKA and HONK)

• Any problem with your feet like wounds? Do you take care of your feet? Do your shoes

fit properly?

4. Checkups • Do you get regular checkups for eyes, kidney, feet, and blood pressure?

23
 Chapter 21 Social history
(SAJID – LT)

• How many cigarettes?

• For how long? Did you ever try to quit?

• Did you ever smoke previously? (Ask if patient negates, especially if a case of the chest)

• Does anyone in the family smoke? (Passive smoking)

• Do you drink alcohol? How much? Do you know the recommended limits?

• Do you use any other recreational drugs? If yes, in which form?

• What do you do for a living? Any previous job? (If chest problem)
• How is your job affected and daily activities affected?
• How are your family and hobbies affected because of your health problem? (Impact)
• Do you drive? Private or public vehicle?

• Where do you live? In a house, bungalow, or flat?

Details of living in case of: • At which story?

• Joint pain • Any stairs at home?
• Backache • Who lives with you? Spouse/partner/others?
• Disability • What about the health of your partner?
• SOB etc.

• Any recent travel?

CAGE questions if required e.g.
Jaundice
Deranged LFTs etc.
• Recently or in the past, did you ever try to cut down your drinking habits?
• Do you feel annoyed by the people?
• Do you feel guilty about your drinking habits?
• Do you need to use alcohol early in the morning to steady your nerves when
you wake up?

• Do you exercise regularly?

Others • Do you take a balanced diet?

24
 Chapter 22 Male sexual history

• Is that all right if I ask you some personal questions? Let me assure you whatever
Take permission and proceed.
we talk about will stay confidential.

• Could you tell me about your close relationships?

• Regular partner or casual?

• How many partners? Men, women, or both?

If casual, then ask
• When did you have last intercourse with your casual partner? (Within 3 to 6

months)

• Did you use any protective measures?

• Did it remain intact throughout the intercourse?

• Did you know the health status of your partner?

• Do you know the contact details of your partner?

• Does your current (regular) partner know about your problem?

• Is she with you today? Have you both ever visited sexual health clinic? If yes, Ask

If ever got tested?

• Have both of you been tested for sexually transmitted infections in the past?

• Were both of you ever vaccinated against the Hepatitis-B virus?

25