Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.


Covered in greater details under the Integumentary System History

Ask about:

  • Colour
  • Texture/thickness
  • Change in hair distribution
    • Hirsutism: excess facial hair in women (increased androgen production)
    • Alopecia
  • Changes in hair
    • Fine hair (hyperthyroidism)
    • Coarse hair (hypothyroidism)
    • Flakes of dandruff or redness and scaling (seborrheic dermatitis, psoriasis)
    • Increased itching (if particularly at night: nits or lice)
  • Rashes
  • Lesions - Onset, location, duration, evolution, aggravating and alleviating factors
    • Size
    • Shape
    • Colour
    • Bleeding
    • Pain
    • Scaling
  • Lumps
  • Moles: change in colour or size
  • Dryness or itching
  • Associated Symptoms: Nausea, Vomiting, anorexia, malaise, weight loss, fever, chills, pain, pruritus
  • Red flags: fever, weight loss, malaise and arthralgias


  • Trauma
  • Headache
    • Onset and frequency
      • Early morning (increased intra-cranial pressure, depression headache)
      • Changing pattern from acute to chronic headache or progressively severe headaches increase likelihood of tumour, abscess or other mass lesion(s)
    • Location
    • Associated nausea
      • Could signify brain tumour(s) or subarachnoid haemorrhage
    • Chronic use of analgesics
      • Analgesic rebound headaches: 50% of patients with chronic daily headaches
    • Dizziness: light-headedness or vertigo
    • Loss of balance
      • Does the patient mean syncope or pre-syncope?
      • Is it associated with positional change (as in orthostatic hypotension)
      • Stressful precipitating events (as in vasovagal syncope)
    • Tinnitus

    Specific Types of Headaches

    • Tension headache
      • Occipital or temporal
      • Unilateral or bilateral
    • Cluster headache
      • Usually unilateral
      • Periorbital
      • Occur daily
      • Usually at night for several weeks
      • Often present with ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of eye and ptosis
      • Lasts between 15 min and 3 h
    • Migraine
      • Unilateral (sensitivity: 66%, specificity: 78%)
      • Nausea and/or vomiting (sensitivity: 82%, specificity 96%)
      • Aura
      • Visual changes: visual aura, scintillating scotomas (sensitivity: 43%, specificity: 74%)
    • Temporal/giant cell arteritis
      • Tenderness of the adjacent scalp
      • > 50 yo (99%)
      • Fever (50%)
      • New headache (60%)
      • Jaw claudication (50%)
      • Visual loss or blindness (15-20%)
      • Polymyalgia rheumatica (50%)
      • Fatigue
      • Anorexia
      • Weight loss
      • Nausea and/or vomiting specificity: 74%)
      Common Headaches
      Primary Secondary Intracranial Secondary
      -Withdrawal (analgesic over use, caffeine, alcohol)
      -Electrolyte disturbances
      -Structures of skull (ears, eyes, sinuses and teeth)
      -Cerebrovascular disorder
      -Pressure changes in cerebrospinal fluid
      -Vascular (stroke, temporal arthritis, intracranial, hematoma)
      -Non-vascular (mass lesion, abscess)
      -Optic neuritis
      -Co poisoning


Covered in greater detail under the Ophthalmological History

Ask about:

  • Use of corrective lenses
  • Date of last eye examination
  • Vision changes (hyperopia, myopia, presbyopia, astigmatism)
  • Visual loss: gradual vs. sudden
    • Sudden: retinal detachment, vitreous haemorrhage, occlusion of the central retinal artery
    • Location of loss
  • Diplopia: horizontal vs. vertical
  • Blurred vision
  • Floaters, flashing lights or a curtain/veil over vision
  • Location of blurred vision
    • Moving specks or strands suggest vitreous floaters
    • Fixed defects suggests lesions in the retina or visual pathway
    • May indicate detached retina (an ophthalmologic emergency)
  • Eye pain
    • Narrow-angle glaucoma: eye pain, seeing halos around lights, nausea/vomiting and sudden change in vision
  • Redness and discharge
    • Subconjunctival haemorrhage: sharply demarcated red area without pain, visual changes, discharge, change in pupil, and a clear cornea
    • Conjunctivitis: diffuse dilation of conjunctival vessels with redness that is maximal peripherally, mild discomfort, mild blurring of vision, watery discharge (viral), purulent discharge (bacterial)
  • Excessive dryness/tearing eyes
    • Increased production (conjunctival inflammation, corneal inflammation)
    • Impaired drainage (ectropion, nasolacrimal duct obstruction)
  • Itching
    • Seasonal/environmental allergies, asthma, eczema, hay fever, foreign body


Ask about:

  • Hearing loss
    • Acute vs. gradual
    • Bilateral vs. unilateral
    • Family history of hearing loss
  • Use of hearing aids
  • Last hearing examination (audiometry)
  • Tinnitus
    • Unilateral vs. bilateral
    • Intermittent vs. constant
    • Recent head trauma
    • Sound exposure (occupational, shooting ranges, MP3 players, etc.)
    • High vs. low pitch
    • Pulsating or continuous
    • Presence/absence of hearing loss
    • Presence/absence of vertigo
    • Recent medication exposure: aminoglycosides, ASA, loop diuretics, cisplatin (chemotherapy), anti-malarial agents
    • Concomitant neurological illness: MS, acoustic neuroma
    • Otologic source: Otitis media, otosclerosis, Meniere's disease
  • Vertigo
    • Differentiate true vertigo from light-headedness
      • "Is environment spinning (true vertigo) or are you spinning"
    • Is vertigo reproducible with changes in movement? (As in benign paroxysmal positional vertigo)
    • Duration (Seconds with BPV, minutes with TIA's, days with Meniere's and viral labyrinthitis)
    • Associated with hearing loss/tinnitus? (As in Meniere's disease)
  • Blurred vision
  • Otalgia
    • History of ear infections
    • Foreign body in ear canal
    • Ramsay Hunt syndrome
    • Bell's palsy
    • Referred pain from the eustachian tube, TMJ, trismus, teeth, tonsils, throat, etc.
  • Otorrhea
    • Amount
    • Colour
    • Smell
    • Types of hearing loss
      Conductive Sensorineural
      -External ear (obstructed, otitis externa, tumor, trauma, congenital)
      -Middle ear (congenital, otitis media, tumors, eustachian tube dysfunction, tympanic membrane perforation)
      -Congenital/hereditary (teratogens, infections, meningitis)
      -Adults (noise exposure, ototoxic drugs, meniere's, Multiple sclerosis, CVA, syphilis, diabetes, trauma)

Nose and Sinuses

Ask about:

  • Nasal congestion/obstruction
    • Unilateral vs. bilateral
    • Acute: < 4 weeks
    • Subacute: 1-3 months
    • Chronic: > 3 months
  • Cough (acute vs. chronic)
  • Rhinorrhea: watery vs. purulent, presence of blood
  • Post-nasal drip
  • Facial pressure/sinus pain
  • Halitosis (bad breath)
  • Known allergies: itching, sneezing
  • Change in smell
  • Recent or past traumas/surgeries
  • Epistaxis
    • Air moisture content
    • Foreign body
    • Intranasal drug use
    • Facial trauma
    • Anticoagulation therapy
  • Snoring
    • Obstructive sleep apnea: snoring, obesity and increased levels of fatigue
  • Frequent sinus infections
    • Number of antibiotics last year
    • Use of nasal steroid sprays and saline solutions
    • Over-the-counter remedies
  • Environmental exposures/allergies


Ask about:

  • Dental history
    • Condition of teeth and gums
    • Last dental examination
    • Bleeding gums
  • Cold sores (HSV1)
  • Use of tobacco
    • Chewing and smoking tobacco are both associated with increased risk for oral cancer
  • Use of dentures
    • Appropriate fit
    • Difficulty breathing
  • Dry mouth (xerostomia)
    • Concomitant dry eyes may indicate Sjögren’s syndrome


Ask about:

  • Neck Mass
    • Location (lateral vs. midline)
    • Unilateral vs. bilateral
    • Onset, duration, rate of growth
    • Tenderness
      • Non-tender, slow growing mass is suggestive of malignancy
      • Tender, rapid onset of swelling is more suggestive of acute infectious etiology
      • Referred otalgia
    • Dysphagia, globus sensation
    • Hoarseness
    • Age of patient: pediatric vs. adult
    • Risk factors for cancer (tobacco use, alcohol, radiation)
    • Consititutional symptoms (fever, chills, night sweats, weight loss)
    • Previous infections, oral or skin lesions, biopsies
  • Swollen neck or glands
    • Symptoms of thyroid disease
    • Iodine deficiency
    • Presence of foreign body
    • HIV infection
    • Malignancy
    • Dentures (sialadenitis)
  • Pain or stiffness in the neck
    • Recent trauma/whiplash
    • Herpes zoster infection
    • Recent symptoms of infection
    • Rule out meningitis


Ask about:

  • Sore throat
  • Odynophagia/dysphagia
    • Worse with solids or liquids
    • Location of pain/discomfort
  • Globus
  • Gastroesophageal reflux disease (GERD)
    • Heartburn
    • Differentiate from cardiac, pulmonary, or vascular chest pain
    • Acidic taste in the mouth
    • Chronic cough/clearing throat
    • Hoarseness
    • Alcohol and caffeine intake
    • Associations with postural changes (lying or bending over)
  • Hoarseness
    • Smoking history
    • Recent inhalation of toxic fumes
    • Dysphagia
    • Hemoptysis
    • Hoarseness >2 wk: ENT referral
    • Trauma
    • Surgeries
    • Lymphoma
    • Shortness of breath
    • Ability to cough
  • Chronic or acute cough
    • Production of sputum: purulent vs. mucoid
    • Medications
    • Foreign body
    • Signs of infection
    • Ability to cough
  • Chronic halitosis
  • Thyroid
    Hypothyroidism Hyperthyroidism
    -Impaired hearing, hoarseness
    -Weight gain, decreased appetite, constipation
    -Arthralgia, myalgia, weakness, paresthesia, dry/itchy skin
    -Poor concentration or memory, depression
    -Cold intolerance
    -Diplopia, eye irritation
    -Weight loss, increased appetite, diarrhea
    -Oligomenorrhea, loss of libido, polyuria
    -Tremor, dysphoria
    -Irritability, heat intolerance, hyperactivity

Past Medical History (PMHx)

Specifically ask about:

  • Thyroid disease
  • Cancers (head and neck, hematological)
  • Radiation exposure (including sun exposure)
  • Past surgical history, including:
    • Vision correction surgery
    • Tonsillectomy
    • Adenoidectomy
    • Myringotomy
    • Tympanostomy tubes
    • Mastoidectomy
    • Thyroidectomy

Family History (FmHx)

Specifically ask about:

  • Atopy
    • Eczema
    • Allergies
    • Asthma
  • Sinus problems
  • Ménière’s disease
  • Vertigo
  • Cancer (head and heck, hematological)
  • Deafness

Social History (SocHx)

Specifically ask about:

  • Ethnicity (those of Asians descent have increased risk of nasopharyngeal cancers)
  • Diet
    • Frequency and use of caffeinated beverage
    • Alcohol
    • Fatty foods
    • Eating within three hours of bedtime (GERD)
  • Occupational exposures
    • Drilling
    • Mining
    • Mould
    • Smoke
    • Sound
  • Hobbies
  • Travel history

Substance Use History (SubHx)

Specifically ask about:


Gather complete list, including ototoxic drugs like:

  • Aminoglycosides
  • Diuretics
  • Chemotherapy drugs
  • Anti-malarial agents


Note allergies and ensure they concord with those listed in the EMR


Note immunization history as described in the immunization history section.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.


  1. Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
  2. Färkkilä M. Headache – EBM Guidelines. Essential Evidence Plus. Published June 17, 2009. Accessed February 24, 2011.
  3. Nadeau M, Parma DP. Headache (diagnosis). Essential Evidence Plus. Updated October 16, 2009. Accessed February 24, 2011.
  4. Garza I, Schwedt T. Medication overuse headache: Etiology, clinical features and diagnosis. UptoDate. Updated October 2009. Accessed February 24, 2011.
  5. Federici T. Retinal Detachment. Essential Evidence Plus. Updated October 30, 2009. Accessed February 24, 2011.
  6. Froehling D, Silverstein M, Mohr D, Beatty C. The rational clinical examination: Does this dizzy patient have a serious form of vertigo? JAMA. 1993;271(5):385-388.
  7. Harrison A. Approach to Adult with Epistaxis. UpToDate. Updated February 2010. Accessed February 2011.
  8. Chow AW, Doron S. Evaluation of acute pharyngitis in adults. UpToDate. Updated September 4, 2013. Accessed November 9, 2013.
  9. Emerick K, Lin D. Differential Diagnosis of a Neck Mass. UpToDate. Updated August 2010. Accessed February 2011.
  10. Bruch J, Kamani D. Hoarseness in Adults. UpToDate. Updated July 2010. Accessed February 2011.
  11. Pawa J, Lesniak D, Lott A. Approach to the Osce: The Edmonton Manual of Common Clinical Scenarios, 2nd edition, Edmonton AB: University of Alberta Medical Studens’ Association; 2011: 130-132, 172-173, 176, 180-181, 186-187