History Flashcards
Introduction.
Smile. Make eye contact. Shake their hand. Offer the drape.
Introduction: “Hello, are you PATIENT NAME? I am Dr. Musso and I’ll be working with you today.”
-How do you prefer to be addressed?
-Can I get you anything to make you more comfortable?
-Tell me what brings you in today.
HPI Components?
CC If pain - Location Radiation Severity Quality Timing (onset, length) Frequency (how often) Setting Aggravating factors Alleviating factors Previous history of symptoms Associated symptoms (ROS)
ROS Components?
Constitutional Dermatologic Psych Neuro HEENT Breast CV Pulmonary GI GU MSK Endocrine Hematologic Lymph
Constitutional ROS
Changes in weight
Changes in appetite
Fever, chills, night sweats
Fatigue
Skin ROS
Rashes
Redness
Itching
Changes in size/shape of a lesion
Neuro ROS
Weakness/numbness in extremities Difficulty speaking Trouble with memory Headaches Dizziness Shaking
Neuro ROS
Weakness/numbness in extremities Difficulty speaking Trouble with memory Headaches (aura, night) Dizziness Shaking Stiff neck
HEENT ROS
Changes in vision Eye pain or discharge Changes in hearing Ear pain or discharge Nasal discharge, URI symptoms Sore throat Difficulty swallowing or speaking Oral ulcers
HEENT ROS
Changes in vision Eye pain or discharge Changes in hearing Tinnitus Ear pain or discharge Nasal discharge, URI symptoms Sore throat Difficulty swallowing or speaking Oral ulcers
CV ROS
Chest pain Palpitations Dizziness, near-syncope, syncope Edema SOB
Pulmonary ROS
SOB (on exertion, at rest, laying down) CP Wheezing Hemoptysis Coughing Mucus
Pulmonary ROS
SOB (on exertion, at rest, laying down) CP Wheezing Edema Hemoptysis Coughing (time of day) Mucus (color, amount)
GU ROS
Dysuria Frequency, urgency Hematuria Incontinence Retention
F: discharge, itching, redness, lesions, dyspareunia
M: scrotal lumps, swelling, lesions, discharge
GU ROS
Dysuria Frequency, urgency Hematuria Nocturia Incontinence Retention Decreased flow
F: discharge, itching, redness, lesions, dyspareunia
M: scrotal lumps, swelling, lesions, discharge
MSK ROS
Decreased ROM
Pain with movement
Joint pain (redness, swelling, rashes)
Hematologic ROS
Easy bruising, bleeding
Frequent infections
Lymph ROS
Enlarged or tender lymph nodes
Lymph ROS
Enlarged or tender lymph nodes
General template for the rest of the history?
PMHx PSHx Medications (including OTC, vitamins, herbs) Allergies Family Hx Social Hx
PMHx components?
Medical problems Hospitalizations [OB Hx] [Gyne Hx] [Psych Hx] [Injuries] [Childhood illnesses] [Immunization status] [Screening history] [Blood transfusions]
Social Hx components?
Substances: drugs, alcohol, tobacco Sexual hx (if not done in Gyne) Diet/exercise/sleep Home/work (exposures)/relationships Stress [Recent travel, sick contacts, pets]
CAGE questions?
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had guilty feelings about drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Sexual history questions?
“I would like to ask you some questions about your sexual health and practice.”
- Are you sexually active? With men, women, or both?
- Do you use condoms? Always? Other contraceptives?
- How many sexual partners have you had in the past year?
- Have you ever had an STD?
- Do you have any problems with sexual function?
- Have you ever been tested for HIV?
OB Hx questions?
- Have you ever been pregnant? How many times? Outcome of those pregnancies?
- Problems during pregnancy?
- U/S during pregnancy?
- Exposures during pregnancy?
- Vaginal or C-section?
Gyne Hx questions?
- Menarche?
- How often is period? How long?
- When was LMP?
- Any change in periods?
- Cramps? Heavy periods? Spotting between periods?
- Pain during intercourse?
- Vaginal discharge?
- Problems with bladder?
- Last Pap smear?
Peds History?
- OB Hx
- Medical problems after birth?
- First bowel movement?
- When did child first smile, sit up, crawl, talk, walk, dress self, use short sentences?
- Feeding?
- Immunizations?
- Routine check-ups?
- Hospitalizations?
- Medications? Allergies?
- Day care?
- Exposures
ROS: cold, urination, bowel, fever, ear pulling, vomiting, ear/eye discharge, rash, seizures
Daily activities for patients with dementia?
"Tell me about your day yesterday." Do you need help with: -Bathing/dressing/feeding yourself -Going to the bathroom -Transferring -Incontinence -Meds -Phone -Shopping -Preparing food -Cleaning, laundry -Travel -Managing money
Questions to screen for abuse?
Do you feel safe at home?
Is there any threat to your personal safety at home or anywhere else?
Does anyone treat you in a way that hurts you or threatens to hurt you?
I see some bruises on your arm; what happened there?
