general principles of history taking Flashcards
1
Q
consultation sequence
A
- history
- examination
- explanation to patient of findings, ddx ( possible diagnosis) and management plan (further tests and treatment
- ordering of, and explanation of, appropriate tests
- commencement of treatment, if indicated
2
Q
history taking sequence
A
- presenting (principle symptoms) (PS)
2.hx of presenting illness HPI
-details of current illness
-details of previous similar episodes
- extent of funtional disability
- effect of the illness - drug and treatment hx
- current treatment
- drug history ( dose, duration, indication, side effects); prescription over the counter and alternative therapies
past treatments
drug allergies or reactions - past history
- past illnesses
surgical operations ( dates, indication, procedures)
-menstrual and reproductive hx for women
-immunisations
-blood transfusions ( and dates) - social history
- upbringing and education level
- marital status, social support, living conditions and financial sitatuion
-diet and exercise
- occupation and hobbies
-overseas travel (where and when)
-smoking and alcohol use
-analgesic and illicit (street) drug use mood and sexual hx - family hx
- system review
3
Q
presenting symptom questioning
A
- where is the problem anatomically
- what is the nature of the symptom? (likely pathological dx)
- how does it affect the patient? (psychological and functional dx)
- why did the patient develop it? (etiology and dx)
4
Q
hx of the presenting illness
A
- first let the patient lead the discussion
- the dr then takes over the second part
- try noting these down in chronological order of systems
5
Q
noting down current symptoms (SOCRATES)
A
Site (localised or diffused)
Onset (gradual or rapid, continous or intermittent, gets worse or better or if a change has occurred)
Character (describe the symptom
Radiation (if symptom is pain or discomfort)
Alleviating factors
Timing (when syx first began “first thing that he/she noticed was unusual or wrong”)
Exacerbating factors (anything that may make the syx worse)
Severity (anything that may interrupt them from their daily life, can be graded from 1-10
6
Q
system review
A
general cardiovascular system respiratory system G.I system genitourinary system Haematological system Musculoskeletal system Endocrine system Reproductive and breast hx Neurological system and mental state the elderly patient concluding the interview
7
Q
system review - General
A
- have you had problems with tiredness
2. do you sleep well?
8
Q
system review - cardiovascular
A
- have you had any pain or pressure in your chest, neck or arm? (MI)
- Are you short of breath on exertion? how much exertion is necessary?
- have you woken u at night short of breath? (cardiac failure)
- can you lie flat w/o feeling breathless?
- have you had swelling of your ankle?
- have you noticed your heart racing or beating irregularly?
- have you had blackouts w/o warning (stokes-Adams attack) ALARM problem
- have you felt dizzy or blacked out when exercising? (severe aortic stenosis or hypertrophic cardiomyopathy) ALARM syx
- do you have pain in your legs on exercise
- do you have cold or blue hands or feet
- have you ever had rheumatic fever, a heart attack or high blood pressure
9
Q
system review - respiratory system
A
- are you ever short of breath? has this come on suddenly? (PE)
- have you had any cough?
- is your cough associated w/ shivers and shakes (rigors) and breathlessness and chest pain? (pneumonia)
- do you cough up anything?
- have you coughed up blood? (bronchial carcinoma) ALARM
- what type of work have you done? (occupational lung disease)
- do you snore loudly? do you fall asleep easily during the day? when? have you fallen asleep while driving? obtain a sleep hx
- do you ever have wheezing when you are short of breath?
- have you had fevers?
- do you have night sweats?
- have you ever had pneumonia or TB?
- have you had a recent chest x-ray
10
Q
system review - G.I
A
- Are you troubled by indigestion? What do you mean by indigestion?
- Do you have heartburn?
! 3. Have you had any difficulty swallowing? (Oesophageal cancer)
! 4. Have you had vomiting, or vomited blood? (Gastrointestinal bleeding) - Have you had pain or discomfort in your abdomen?
- Have you had any abdominal bloating or distension?
- Has your bowel habit changed recently? (Carcinoma of the colon)
- How many bowel motions a week do you usually pass?
- Have you lost control of your bowels or had accidents? (Faecal incontinence)
! 10. Have you seen blood in your motions? (Gastrointestinal bleeding)
! 11. Have your bowel motions been black? (Gastrointestinal bleeding)
! 12. Have you lost weight recently without dieting? (Malignancy) - Have your eyes or skin ever been yellow?
- Have you ever had hepatitis, peptic ulceration, colitis or bowel cancer?
- Tell me (briefly) about your diet recently.
11
Q
review of systems - Genitourinary
A
- Do you have difficulty or pain on passing urine?
- Is your urine stream as good as it used to be?
- Is there a delay before you start to pass urine? (Applies mostly to men)
- Is there dribbling at the end?
- Do you have to get up at night to pass urine?
- Are you passing larger or smaller amounts of urine?
- Has the urine colour changed?
! 8. Have you seen blood in your urine? (Urinary tract malignancy) - Have you any problems with your sex life? Difficulty obtaining or maintaining an erection?
- Have you noticed any rashes or lumps on your genitals?
- Have you ever had a sexually transmitted disease?
- Have you ever had a urinary tract infection or kidney stone?
12
Q
review of systems - Haematological system
A
- Do you bruise easily?
- Have you had fevers, or shivers and shakes (rigors)?
! 3. Do you have difficulty stopping a small cut from bleeding? (Bleeding disorder)
! 4. Have you noticed any lumps under your arms, or in your neck or groin? (Haematological
malignancy) - Have you ever had blood clots in your legs or in the lungs?
13
Q
review of systems - musculoskeletal
A
Musculoskeletal system
- Do you have painful or stiff joints?
- Are any of your joints red, swollen and painful?
- Have you had a skin rash recently?
- Do you have any back or neck pain?
- Have your eyes been dry or red?
- Have you ever had a dry mouth or mouth ulcers?
- Have you been diagnosed as having rheumatoid arthritis or gout?
- Do your fingers ever become painful and become white and blue in the cold? (Raynaud’s)
14
Q
review of systems - Endocrine
A
- Have you noticed any swelling in your neck?
- Do your hands tremble?
- Do you prefer hot or cold weather?
- Have you had a thyroid problem or diabetes?
- Have you noticed increased sweating?
- Have you been troubled by fatigue?
- Have you noticed any change in your appearance, hair, skin or voice?
- Have you been unusually thirsty lately? Or lost weight? (New onset of diabetes)
15
Q
review of systems - reproductive and breast history (women)
A
- Are your periods regular?
- Do you have excessive pain or bleeding with your periods?
- How many pregnancies have you had?
- Have you had any miscarriages?
- Have you had high blood pressure or diabetes in pregnancy?
- Were there any other complications during your pregnancies or deliveries?
- Have you had a Caesarean section?
! 8. Have you had any bleeding or discharge from your breasts or felt any lumps there?
(Carcinoma of the breast)
