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Clinical Examination > History > Flashcards

History Flashcards

1
Q

PMHx for patient bleeding

A

Surgical / dental history
Obstetric history
Trauma history
Ulcers
Jaundice
Kidney disease
Cancer / Chemotherapy
Spleen
NSAIDS / aspirin allergy

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2
Q

Hypertension history - symptoms

A

Headache, nausea, vomiting, blurred vision
Sweat / tremor (Phaeo)
Anorexia / weight loss / lethargy / itch (renal)

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3
Q

Mouth ulcer history - symptoms

A

Onset / location / duration
Associated: Bleeding, pain, discharge, halitosis, sensation, chewing, swallowing, taste, lumps in neck, ear pain, weight loss, fatigue, diet, trauma
Previous ulcers

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4
Q

Mouth ulcer history - PMHx

A

Cancer, infection, HIV, TB, STIs, cold sores, syphillis

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5
Q

Constipation history - symptoms

A

Onset, duration, frequency, character.

Associated symptoms - blood, mucus, diarrhoea, pain, prolapse, diet, lifestyle changes, psychiatric history / mood, neurological symptoms, weight loss, temperature, nausea, anorexia

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6
Q

Constipation - PMHx

A

Hirschsprung’s, abdominal surgery, diverticular disease, haemorrhoids, hypothyroidism, stroke, diabetes, pregnancy, Parkinson’s, MS.

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7
Q

Diarrhoea history - symptoms

A

Onset, timing, context, frequency, amount, character.
Ass sx - blood, mucus, urgency, incontinence, abdominal pain, bloating, vomiting, sick contacts, travelling, lethargy, dizziness.

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8
Q

Diarrhoea - PMHx

A

Past or FHx of IBD / bowel cancer / coeliac disease
Smoking / alcohol

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9
Q

HIV and elective surgery history

A

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

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10
Q

Reflux history - symptoms

A

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

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11
Q

Reflux PMHx

A

CKD
Hiatus hernia
Prev OGD
Gallstones
Scleroderma
Meds: steroids, iron, NSAIDs

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12
Q

Reflux investigations

A

FBC, iron studies
CXR
ECG
Urea breath test or stool antigen test for H pylori
Endoscopy + biopsy
Manometry (oesophageal motility study)

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13
Q

Jaundice history HxPC

A

Onset - when started, intermittent or constant
How noticed - eyes / skin / urine / stool
Pruritis
Previous episodes

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14
Q

Jaundice history - risk factor questions

A

Viral symptoms
Travel
Drugs
Blood transfusions
Pain (obstruction)
Weight loss
Pregnancy

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15
Q

Jaundice history - PMHx

A

Anaemia / sickle cell
Hepatitis
Liver disease
Gall stones
Biliary surgery
Breast or bowel cancer

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16
Q

Jaundice history - FHx

A

Hereditary spherocytosis
Gilberts syndrome
Jaundice

17
Q

Jaundice history - SHx and Medications

A

Alcohol
Drugs
Occupational exposure to hepatotoxic chemicals
Meds: OCP, paracetamol

18
Q

Claudication history - symptoms

A

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

19
Q

Claudication history - PMHx, SHx

A

IHD
CVA
DM
HTN
Hypercholesterolaemia
Renal disease

Medications and allergies

Smoking, drinking, occupation

20
Q

Leg ulcer history - symptoms

A

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

21
Q

Leg ulcer history - PMHx

A

Diabetes
Smoking
Alcohol
Steroids
Venous or arterial disease (claudication)

22
Q

Causes of leg ulcers

A

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

23
Q

Carpal tunnel history - symptoms

A

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

24
Q

Carpal tunnel - PMHx and SHx

A

Pregnant
Arthritis
Myxedema
Acromegaly

Occupation, smoking, alcohol, activities

25
Q

Causes of carpal tunnel syndrome

A

Pregnancy
Obesity
Hypothyroidism
Acromegaly
Diabetes
Amyloidosis
Occupation
RA

26
Q

Paediatric history - HxPC

A

Details of presentation
Related symptoms: oral intake, diet, breast or bottle fed, wet nappies (hydration), blood in motions
Ask parent concerns

27
Q

Paediatric history - birth

A

Maternal medical and obstetric history
History of pregnancy
Delivery - when and what method
Complications
Gestation and birth weight
Events since delivery

28
Q

Paediatric history - developmental

A

Movement and posture - gross and fine motor skills
Vision and manipulation
Hearing and speech
Social behaviour

29
Q

Paediatric history - SHx, FHx, Psych

A

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??

30
Q

Breast lump history - lump

A

Onset
Trauma
Hormones / menses association
Location
Duration
Character - size / shape / feel / compressible

31
Q

Breast lump history - associated symptoms

A

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

32
Q

Breast lump history - PMHx / meds / FHx

A

Usual PMHx
OCP / HRT
FHx breast cancer / BRCA

33
Q

DDx breast lump

A

Benign:
Fibroadenoma
Cyst
Fat necrosis
Lipoma
Acute mastitis
Abscess
Galactocele
Mammary duct

Malignant:
Breast cancer

34
Q

Neck lump history - lump

A

Onset
Location
Duration
Progress / change in shape / size / position
Exacerbation - swallowing, tongue protrusion

Past history of lumps

Clinical Examination (4 decks)

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