History Flashcards
PMHx for patient bleeding
Surgical / dental history
Obstetric history
Trauma history
Ulcers
Jaundice
Kidney disease
Cancer / Chemotherapy
Spleen
NSAIDS / aspirin allergy
Hypertension history - symptoms
Headache, nausea, vomiting, blurred vision
Sweat / tremor (Phaeo)
Anorexia / weight loss / lethargy / itch (renal)
Mouth ulcer history - symptoms
Onset / location / duration
Associated: Bleeding, pain, discharge, halitosis, sensation, chewing, swallowing, taste, lumps in neck, ear pain, weight loss, fatigue, diet, trauma
Previous ulcers
Mouth ulcer history - PMHx
Cancer, infection, HIV, TB, STIs, cold sores, syphillis
Constipation history - symptoms
Onset, duration, frequency, character.
Associated symptoms - blood, mucus, diarrhoea, pain, prolapse, diet, lifestyle changes, psychiatric history / mood, neurological symptoms, weight loss, temperature, nausea, anorexia
Constipation - PMHx
Hirschsprung’s, abdominal surgery, diverticular disease, haemorrhoids, hypothyroidism, stroke, diabetes, pregnancy, Parkinson’s, MS.
Diarrhoea history - symptoms
Onset, timing, context, frequency, amount, character.
Ass sx - blood, mucus, urgency, incontinence, abdominal pain, bloating, vomiting, sick contacts, travelling, lethargy, dizziness.
Diarrhoea - PMHx
Past or FHx of IBD / bowel cancer / coeliac disease
Smoking / alcohol
HIV and elective surgery history
Introduce and clarify operation
Do they want to have it
Acknowledge HIV
History, current status, general medical / surgical history, social history
HIV history - when dx, sx, how infection, illnesses, labs, medications
Social
Allergies
Questions
Reflux history - symptoms
Pain - SOCRATES, relation to meal (duo better with food, gastric worse with food), triggers (coffee, cholesterol, EtOH, smoking, pregnancy, obesity, drugs e.g. NSAIDS)
Regional sx - dysphagia, odynophagia, vomiting, haematemesis, distension, acid, night cough, volume reflux, hoarse voice, night cough, resp sx, burp, regurgitation, malaena
General - weight loss, appetite, sweat, pallor, SOB, early satiety
Reflux PMHx
CKD
Hiatus hernia
Prev OGD
Gallstones
Scleroderma
Meds: steroids, iron, NSAIDs
Reflux investigations
FBC, iron studies
CXR
ECG
Urea breath test or stool antigen test for H pylori
Endoscopy + biopsy
Manometry (oesophageal motility study)
Jaundice history HxPC
Onset - when started, intermittent or constant
How noticed - eyes / skin / urine / stool
Pruritis
Previous episodes
Jaundice history - risk factor questions
Viral symptoms
Travel
Drugs
Blood transfusions
Pain (obstruction)
Weight loss
Pregnancy
Jaundice history - PMHx
Anaemia / sickle cell
Hepatitis
Liver disease
Gall stones
Biliary surgery
Breast or bowel cancer
Jaundice history - FHx
Hereditary spherocytosis
Gilberts syndrome
Jaundice
Jaundice history - SHx and Medications
Alcohol
Drugs
Occupational exposure to hepatotoxic chemicals
Meds: OCP, paracetamol
Claudication history - symptoms
Pain - site, onset, character, duration, aggravating / relieving factors (night, rest, stairs), radiation, severity
Walking distance
Associated symptoms - cold intolerance, sores on feet, buttock pain, impotence, chest pain, fainting episodes, visual disturbance, neurology suggestive of a stroke
Previous episodes and how they were managed
Claudication history - PMHx, SHx
IHD
CVA
DM
HTN
Hypercholesterolaemia
Renal disease
Medications and allergies
Smoking, drinking, occupation
Leg ulcer history - symptoms
Location
- Venous painless unless infected
- Arterial painful especially when legs elevated
Discharge
Bleeding
Cosmetic - arterial = punched out
Progression - how changed, shape, size, pain, ever disappear
Prior rx
Associated sx - other ulcers, local LNs, infection, claudication, white/blue shiny feet
Impact on work / social life
Leg ulcer history - PMHx
Diabetes
Smoking
Alcohol
Steroids
Venous or arterial disease (claudication)
Causes of leg ulcers
Venous insufficiency - leg swelling, varicose veins, pigmentation, high BP, sitting or standing for long periods, fracture or injury, previous surgery, obesity
Arterial insufficiency - diabetes, smoking, high cholesterol, high BP, renal failure, RA, obesity, PVD, clotting disorders
Trauma
Malignancy - skin cancers
Neuropathic - spine or neurological disorder, decreased sensation
Vasculitis - IV, SLE, RA
Psychiatric
Carpal tunnel history - symptoms
Onset
Unilateral or bilateral
Duration
Character
Aggravating - ? nocturnal
Relieving - ? shaking hand
Severity
Impact on activities
Radiation to arm
Ass sx:
Weakness
Clumsiness
Numbness
Cold intolerance (thyroid)
Injury
Wrist arthritis
Pain or lumps in axilla or neck
Weight change
Impact on ADLs
Carpal tunnel - PMHx and SHx
Pregnant
Arthritis
Myxedema
Acromegaly
Occupation, smoking, alcohol, activities
Causes of carpal tunnel syndrome
Pregnancy
Obesity
Hypothyroidism
Acromegaly
Diabetes
Amyloidosis
Occupation
RA
Paediatric history - HxPC
Details of presentation
Related symptoms: oral intake, diet, breast or bottle fed, wet nappies (hydration), blood in motions
Ask parent concerns
Paediatric history - birth
Maternal medical and obstetric history
History of pregnancy
Delivery - when and what method
Complications
Gestation and birth weight
Events since delivery
Paediatric history - developmental
Movement and posture - gross and fine motor skills
Vision and manipulation
Hearing and speech
Social behaviour
Paediatric history - SHx, FHx, Psych
Immunisation status
SHx
Who is at home, siblings also healthy
Smoking
Issues with school
FHx
Psych
Symptoms
Impact
RFs for mental health
Strength and protective factors
Abuse??
Breast lump history - lump
Onset
Trauma
Hormones / menses association
Location
Duration
Character - size / shape / feel / compressible
Breast lump history - associated symptoms
Pain
Redness
Itch
Discharge
Nipple changes / retraction
Skin changes - discolouration / peau d’orange
Lymph nodes
Weight loss
Anorexia
SOB
Dizzy
Bone pain
Other lumps
Menstrual history - menarche, childbirth, age, breastfeeding, LMP
Previous episodes
History of breast cancer
Mammograms
Investigations previously
Breast lump history - PMHx / meds / FHx
Usual PMHx
OCP / HRT
FHx breast cancer / BRCA
DDx breast lump
Benign:
Fibroadenoma
Cyst
Fat necrosis
Lipoma
Acute mastitis
Abscess
Galactocele
Mammary duct
Malignant:
Breast cancer
Neck lump history - lump
Onset
Location
Duration
Progress / change in shape / size / position
Exacerbation - swallowing, tongue protrusion
Past history of lumps
