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History Taking and Physical Examination > Elements of a History > Flashcards

Elements of a History Flashcards

1
Q

Introduction

A

self (medical student), patient (name, how referred to), age

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2
Q

Chief Complaint

A

“verbatim, in quotes” – clarify if not a symptom

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3
Q

History of Present Illness (HPI)

[5 elements]

A

Usually state of health (timeline)

7 Cardinal Dimensions

Pertinent Postives/Negatives

Risk Factors

Impact on Baseline Function

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4
Q

7 Cardinal Dimensions of a Symptom

A
  1. Location
  2. Quality
  3. Quantity/Intensity
  4. Timing (onset, trajectory, pattern)
  5. Setting/Context (what was patient doing)
  6. Aggravating/Relieving Factors
  7. Associated Symptoms
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5
Q

Past Medical History (PMH)

A

Illnesses/Conditions: chronic health condition, hospitalizations, injuries, surgeries, pregnancies, childhood illnesses

Medications: Rx, OTC, vitamins, dose & frequency

Drug Reactions/Allergies

Special PMH: Exposures and Health Maintenance

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6
Q

Family History (FH)

A

Composition of Family (3 generations: parents, siblings, kids) – alive and well, living with illness, deceased

Heritable Illnesses in extended family

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7
Q

Chronic Medical Conditions to always ask about

A

diabetes, hypertension, coronary artery disease, hypercholesterolemia, pulmonary disease

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8
Q

Questions in the Past Surgical History

A

When, What, Complications, Long-term results

Help the patient w/ appendix, gallbladder, wisdom teeth, stitches?

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9
Q

Gynecologic History questions to ask

A

How many times have you been pregnant?

How many children do you have?

Go through each pregnancy

When was your last menstrual period?

Are periods regular/irregular? light/normal/heavy?

Post menopause and when?

Abnormal PAP tests

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10
Q

Social History elements

A

Patient Profile

Lifestyle/Habits

Sexual History

Stress/Support

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11
Q

Patient Profile questions to ask

A

Are you married or do you have a partner?

Who lives at home with you?

Do you feel safe at home? In your neighborhood?

What do you do for a living? Work, retired, disabled, homemaker?

Ethnicity

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12
Q

Alcohol questions to ask

A

How much do you drink??

How often? What type? Pattern?

What is the average number of drinks you have in a week?

What is the most number of drinks you have had on any one day of the week?

CAGE:

tried to Cut down?

been Annoyed by someone else?

felt Guilty about drinking?

had an Eye opener (drink in the morning)?

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13
Q

Tobacco questions to ask

A

Do you smoke cigarettes (cigars)?

Have you ever smoked?

For how many years?

How many packs a day?

Did you have quit or try to quit?

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14
Q

Recreational Drugs questions to ask

A

Any (recreational) drug use?

Marijuana, cocaine, heroin, ecstasy, crystal meth, hallucinogens, angel dust?

How often and for how long?

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15
Q

Sexual History questions to ask

A

Are you sexually active?

Are your partners men, women, or both?

How many sexual partners have you had in the last six months?

Are you using protection? If no, are you trying to become pregnant? Are you concerned about HIV and AIDS?

Have you had any STDs? any herpes, syphylis, gonorrhea, chlamydia

Are you satisfied with your sex life?

Do you have any concerns about your sex life?

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16
Q

Review of Systems

A

General

Skin

HEENT

Neck

Breasts (women)

Heart

Lungs

GI

GU/Gyn

Heme

Immuno/Allergies

Endocrine

Musculoskeletal

Neuro

Psych

17
Q

General ROS

A

How are you feeling?

Any weight change?

Change in appetite?

Fever?

Chills?

Sweats?

Fatigue/exercise intolerance?

18
Q

Skin ROS

A

Any skin problems?

Itching?

Dry skin?

Rashes?

–

Eczema

Change in moles

Scaling

19
Q

Head ROS

A

Headaches?

Fainting?

Seizures?

Ever hurt or injured your head?

Concussion?

20
Q

Eyes ROS

A

Any eye problems?

Do you wear glasses/corrective lenses?

Eye pain?

Blurry vision?

Double vision?

Defects in field of vision?

Floaters?

Red eyes, yellow eyes, eye drainage?

21
Q

Ears ROS

A

Any problems with hearing?

ear pain?

ringing in your ears?

feel like the room is spinning?

22
Q

Nose ROS

A

Any nasal congestion?

Nasal discharge?

Post nasal drip?

–

Nose bleeds?

Blockage?

Abnormal smells?

23
Q

Throat/Dental ROS

A

Any sort throat?

Hoarseness?

Change in voice?

Ulcers in your mouth?

–

cavities?

missing teeth?

toothache?

mouth or tongue pain?

24
Q

Neck ROS

A

Lumps in your neck?

Stiff neck?

Goiter?

25
Q

Breasts (women) ROS

A

Any lumps or bumps?

Any discharge from your nipples?

Any breast pain?

26
Q

Heart ROS

A

Any problems with your heart?

Any chest pain or pressure?

Any shortness of breath when laying down or sleeping?

Any swelling in your arms or legs?

Any blue skin?

Felt like your heart was racing or beating too fast?

History of a heart murmur?

Pain in your legs from walking?

27
Q

Lungs ROS

A

Any problems with your breathing?

Any shortness of breath?

Any difficulty breathing?

Cough? (dry cough or did you cough up mucus)

Wheezing?

Cough up blood?

28
Q

GI ROS

A

Any problems with your stomach or digestive system?

Abdominal pain? Where?

Change in bowel habits?

Any nausea or vomiting?

Any blood in your stool?

Any black stool? chalky stool?

Any history of liver disease? Yellow skin or eyes? Fluid in your belly?

Difficulty or painful swallowing?

29
Q

GU ROS

A

Any problems with urination?

Painful urination?

Urinating too often?

Suddenly feeling like you have to go?

Difficulty controlling urination?

Flank or kidney pain?

–

Any discharge from your penis/vagina?

Any bleeding? Ulcers/fissures? Swelling or lumps?

30
Q

Gyn ROS

A

Any abnormal periods?

–

Age when you had your first period?

Age at menopause?

LMP?

Menstrual pain?

31
Q

Heme ROS

A

Do you bruise easily?

Do you have trouble stopping a cut from bleeding?

32
Q

Immune ROS

A

Any allergies? sensitivies to food/pollen/dander

–

swollen lymph nodes?

hay fever?

33
Q

Endocrine ROS

A

Do you have diabetes? (excessive hunger, excessive thirst, excessive urination)

Abnormal weight gain/loss?

Goiter?

Tremors?

34
Q

Musculoskeletal ROS

A

Joint pain? swelling? stiffness?

Feel like you can’t raise your arms or move your wrists?

–

Any fractures or serious sprains?

35
Q

Neuro ROS

A

Dizziness?

Can’t move certain muscles?

Any muscle weakness?

Any numbness? tingling?

Any problems with bowel habits or urination?

–

muscle shrinkage?

tremors? walking issues?

involuntary movements?

36
Q

Psych ROS

A

How is your mood?

In the last two weeks, have you felt depressed or sad?

Do you feel anxious? fearful of anything?

Any issues with your sleep?

Any problems with your memory?

History Taking and Physical Examination (1 decks)

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