History Flashcards
Components of history
CC HPI PMH PSH Gyn Hx Medications Allergies FH SH ROS
Components of HPI
- last time felt well/illness started
- 7 dimensions: Location, quality, severity (quantity), timing, setting/context, modifying factors, associated symptoms
- Anything you’re worried about?
- How has this affected your life?
- risk factors pertaining to CC
PMH
- Hospitalizations, Injuries, Childhood illnesses
- Exposures: environmental (chemicals, dust, fumes), animal (pets, livestock, lab animals), Travel, blood transfusion.
- Health maintenance: periodic exams, immunizations, exercise, nutrition, injury prevention, STD prevention/pregnancy prevention, health insurance coverage
PSH
-kinds and dates
Gyn Hx
- How many pregnancies?
- Term, premature, abortion, live
Medications
Prescription: name and dose
OTC
Supplements – herbs and vitamins
Allergies
Medications, Food, Environmental (what is allergen and what is reaction?)
FH
first degree relatives: who, state of health, any illnesses (DM, heart disease, HTN, stroke, obesity, cancer and type)
-other relatives
SH
- marital/partner status, family situations
- Work (type), disability etc
- alcohol, tobacco, drugs
- sexual history
- sources of stress/sources of support
ROS
General Skin Head Eyes Ears Nose Throat/dental Neck Breasts (women) Cardiovascular Lungs GI GU Heme Allergy/Immuno Endocrine Musculoskeletal Neuro Psych
ROS General
Weight change
Appetite
Fevers/chills/sweats
Excess fatigue/Exercise intolerance
ROS Skin
primary: Skin problems? What? Itching/dry skin Rashes secondary: Eczema changes in moles scaling
ROS Head
Headaches
Loss of consciousness/fainting
Seizures
Hx of head trauma
ROS Eyes
primary: Eye problems? What? Corrective lenses pain blurry vision double vision secondary: Scotomata/floaters VFDs Red Yellow (icterus) pain drainage
ROS ears
primary: pain hearing loss tinnitis vertigo secondary: discharge
ROS Nose
primary: discharge or congestion Post-nasal drip secondary: epistaxis obstruction abnormal odors
ROS Throat/dental
primary: sore hoarseness/change of voice ulcers secondary: cavities missing teeth toothache sore tongue
ROS Neck
lumps
goiter/big thyroid
stiff nect
ROS Breasts (women)
Monthly self exam?
Lumps or bumps?
Discharge
pain
ROS CV
Chest pain or pressure orthopnea paroxysmal nocturnal dyspnea peripheral edema cyanosis palpitations/sensations of rapid/skipped heart beats Hx heart murmur Intermittent claudication
ROS Lungs
dyspnea
cough (mucus? color?)
wheezing
hemoptysis
ROS GI
primary: pain? where? change in bowel habits nausea/vomiting blood in stool melena Hx liver disease secondary: dysphagia (solids, liquids) odynophagia clay-colored stools change in bowel habits Hx ascites Jaundice
ROS GU
primary: dysuria urinary freq urgency/hesitancy incontinence flank pain impotence secondary: discharge bleeding penile ulcers/fissures testicular swelling/pain/lumps
ROS Heme
Easy bruising
Easy bleeding
ROS Allergy/Immuno
Secondary: lymphadenopathy urticaria hay fever sensitivities to foods, pollens, mold, dander
ROS Endocrine
primary:
Diabetes (secondary: polyphagia, polydipsia, polyuria)
Abnormal weight loss/gain
Goiter (secondary: tremors)
abnormal periods? (secondary: age at menarche/menopause, cycle/duration/amount, date of LMP, menstrual pain/debility/swelling)
ROS Musculoskeletal
Pain/swelling/stiffness of joints
limitations of range of motion joints
secondary:
fractures/serious sprains
ROS Neuro
Dizziness Paralysis weakness on one side numbness or tingling/change in sensation bowel or bladder incontinence secondary: muscle atrophy gait abnormalities tremors involuntary movements
ROS Psych
mood? depression anxiety/fears sleep problems memory loss
SH alcohol
-how much do you drink?
-type of alcohol
-pattern (when was the last time you had 5(m)/4(f) drinks in a day?’
-CAGE:
tried to Cut down?
been Annoyed?
felt Guilty?
had an Eye opener?
SH tobacco
Do you smoke cigarettes? Have you ever?
previous attempts to quit
SH partner violence
- do you feel safe at home?
- have you ever been hit, punched, or hurt by someone in your home
SH sexual hx
- Do you have a partner?
- Sexually active? men women or both?
SH drugs
- Have you used any non-medical drugs?
- -> whether yes or no –> cocaine? heroin? etc
Depression screening
Start with: Do you feel sad or depressed? Or Over the past two weeks have you felt down, depressed, hopeless?” and “over the past two weeks have you felt little interest or pleasure in doing things?”
