Family Medicine: History Taking

Question 1

History taking

Answer 1

Patient age, gender, job

1. Chief complaint
   - ***Reason
   - Nature, Course, Effect
2. History of present illness (**Nature, **Course, ***Effect)
   - Onset / Similar problems in the past
   - Provocative / Alleviating / Treatment tried
   - Quality
   - Region + Radiation
   - Severity
   - Timing
   - Constitutional symptoms: LOW, LOA, Malaise
   - Associated symptoms
   - System review: Fever, Bowel habit changes, Urinary habit, LN, Exercise, Diet, Sleep, Skin, Psychiatric, Endocrine, Impact on life, family, Functional level, Social support, Emotional response
   - More focused questions
3. ***Reason, Idea, Concerns, Expectation
   - 有無唸過咩事?
   - 有無擔心d咩?
   - 最需要d咩?
   - Any questions / 有咩想講?
4. Other relevant history
   - **Medical
   - **Surgical
   - **Drug: Allergies
   - **Family
   - ***Social: Smoke, Drink, Occupation, Live alone
   (Travel)
   (Contact)
   (Cluster)
   (Red flag symptoms)
   (Discriminatory symptoms)
   (Risk factors)
5. Summary
6. DDx
   - Probability diagnosis
   - Red flags
   - Often missed
   - Masquerades
   - Patient wants to Tell you something (Hidden agenda / psychosocial problems)

Structured answer:

1. 前因
   - Risk factors
2. Disease
   - Primary disease: Symptoms (including Constitutional symptoms)
   - Symptoms of Metastasis (for Staging)
   - Associated disease
   - System review for Primary origin (if Secondary disease)
   - Treatment-related
3. 後果
   - Complications