History

Question 1

Introduction.

Answer 1

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.

Question 2

HPI Components?

Answer 2

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)

Question 3

ROS Components?

Answer 3

Constitutional
Dermatologic
Psych
Neuro
HEENT
Breast
CV
Pulmonary
GI
GU
MSK
Endocrine
Hematologic
Lymph

Question 4

Constitutional ROS

Answer 4

Changes in weight
Changes in appetite
Fever, chills, night sweats
Fatigue

Question 5

Skin ROS

Answer 5

Rashes
Redness
Itching
Changes in size/shape of a lesion

Question 6

Neuro ROS

Answer 6

Weakness/numbness in extremities
Difficulty speaking
Trouble with memory
Headaches
Dizziness
Shaking

Question 7

Neuro ROS

Answer 7

Weakness/numbness in extremities
Difficulty speaking
Trouble with memory
Headaches (aura, night)
Dizziness
Shaking
Stiff neck

Question 8

HEENT ROS

Answer 8

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

Question 9

HEENT ROS

Answer 9

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

Question 10

CV ROS

Answer 10

Chest pain
Palpitations
Dizziness, near-syncope, syncope
Edema
SOB

Question 11

Pulmonary ROS

Answer 11

SOB (on exertion, at rest, laying down)
CP
Wheezing
Hemoptysis
Coughing
Mucus

Question 12

Pulmonary ROS

Answer 12

SOB (on exertion, at rest, laying down)
CP
Wheezing
Edema
Hemoptysis
Coughing (time of day)
Mucus (color, amount)

Question 13

GU ROS

Answer 13

Dysuria
Frequency, urgency
Hematuria
Incontinence
Retention

F: discharge, itching, redness, lesions, dyspareunia

M: scrotal lumps, swelling, lesions, discharge

Question 14

GU ROS

Answer 14

Dysuria
Frequency, urgency
Hematuria
Nocturia
Incontinence
Retention
Decreased flow

F: discharge, itching, redness, lesions, dyspareunia

M: scrotal lumps, swelling, lesions, discharge

Question 15

MSK ROS

Answer 15

Decreased ROM
Pain with movement
Joint pain (redness, swelling, rashes)

Question 16

Hematologic ROS

Answer 16

Easy bruising, bleeding

Frequent infections

Question 17

Lymph ROS

Answer 17

Enlarged or tender lymph nodes

Question 18

Lymph ROS

Answer 18

Enlarged or tender lymph nodes

Question 19

General template for the rest of the history?

Answer 19

PMHx
PSHx
Medications (including OTC, vitamins, herbs)
Allergies
Family Hx
Social Hx

Question 20

PMHx components?

Answer 20

Medical problems
Hospitalizations
[OB Hx]
[Gyne Hx]
[Psych Hx]
[Injuries]
[Childhood illnesses]
[Immunization status]
[Screening history]
[Blood transfusions]

Question 21

Social Hx components?

Answer 21

Substances: drugs, alcohol, tobacco
Sexual hx (if not done in Gyne)
Diet/exercise/sleep
Home/work (exposures)/relationships
Stress
[Recent travel, sick contacts, pets]

Question 22

CAGE questions?

Answer 22

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?

Question 23

Sexual history questions?

Answer 23

“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?

Question 24

OB Hx questions?

Answer 24

• 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?

Question 25

Gyne Hx questions?

Answer 25

• 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?

Question 26

Peds History?

Answer 26

• 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

Question 27

Daily activities for patients with dementia?

Answer 27

"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

Question 28

Questions to screen for abuse?

Answer 28

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?