Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Internal > History and Inspection > Flashcards

History and Inspection Flashcards

1
Q

Components of Adult History (there are 7)

A
  1. Identifying Data
  2. Chief Complaint
  3. Present illness
  4. Past History
  5. Family History
  6. Personal & Social History
  7. Review of systems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

The seven attributes of a symptom

A
  1. Location
  2. Quality
  3. Quantity or severity (for pain rate using scale 1-10)
  4. Timing (onset, duration & frequncy)
  5. Setting in which it occurs
  6. Aggrevating or relieving factors
  7. Associated manifestations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Identifying data includes (kind of obvious I know)

A

Age, gender, occupation, marital status

Source of history (patient, parent, relative etc)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Present illness

A

The complete & chronological account of the problem(s) prompting the patient to seek care. Include onset, setting, manifestations and treatments.
Each main symptom should be described using the 7 features (LQQTSAA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Past History

A 
A. Childhood illnesses
B. Adult illnesses: 
i. Medical (DM, HTN, COPD,asthma, HIV etc) 
ii. Surgical 
iii. Obstetric/gynecologic 
iv. Psychiatric

for all should include dates, types and any hospitalisations associated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Family History

A 
All immediate relatives (parents, siblings, children, grandchildren) & grandparents
--> Age & health or age at death.
Record family +/- 
HTN, CAD, high cholesterol, stroke, 
DM or thyroid disease
renal disease
cancer (type)
arthritis, allergies
TB, asthma or lung disease
headaches, seizure disorders, mental illness, suicide, alcohol or drug addiction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Personal & Social

A 
Occupation
Schooling (last year of schooling)
Home situation & significant others
Sources of stress
Military service (important life experiences) 
Leisure activities
religious/ spiritual beliefs
ADLs (activities of daily living)
Lifestyle habits: exercise, diet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Review of systems

A

Start general and go from head-toe

  1. General
  2. Skin
  3. HEENT
  4. Neck
  5. Breasts
  6. Respiratory: more detailed later
  7. CV
  8. GIT
  9. Urinary
  10. Genital
  11. Peripheral vascular
  12. Musculoskeletal
  13. Psychiatric
  14. Neurologic
  15. Hematologic
  16. Endocrine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

General Review of systems

A

weight changes, weakness, fatigue, fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Skin

A

Rashes, lumps, bumps, sores, itching, colour changes,

changes in hair, nails & moles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

HEENT (Head, ears, eyes, Nose, Throat)

A

for later

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Neck

A

lumps, goiter, pain, stiffness, “swollen glands”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Breast

A

Lumps, pain, nipple discharge, self-examination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Respiratory system

A

Cough, sputum (colour, quantity), hemoptysis, dyspnea, wheezing, pleurisy,
+/- asthma, bronchitis, emphysema, pneumonia, Tb

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

CVS 9 major questions

A
  1. High blood pressure
  2. Chest Pain
  3. Palpitations
  4. Shortness of breath with exertion
  5. Shortness of breath when lying flat
  6. History of heart attack
  7. Rheumatic fever
  8. Heart murmur
  9. Last ECG

(dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, fatigue, cyanosis)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

GIT

A
  1. trouble swallowing
  2. heartburn
  3. appetite, nausea,
  4. abdominal pain,
  5. bowel movements, constipation, diarrhea, colour, size, consistency
  6. food intolerance, gas, belching
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Urine

A 
Frequncy, urgency, burning or pain 
Nocturia, hematuria
Urinary infections
Kidney stones
Incontinence
Males: reduced caliber or force of urinary stream, hesitancy, dribbling
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Genital-Male

A 
hernias
Discharge from or sores on penis
testicular pain or lumps
Hx of STI's, treatment
Sexual habits etc
19
Q

Genital- female

A

Age at menarche, regularity, frequency and duration of period
bleeding between periods or after intercourse
last menstrual period
age at menopause, symptoms or postmenopausal bleeding
Vaginal discharge, itching, sores, lumps
STI’s and treatment
Number of pregnancies, type of deliveries
number of abortions (spontaneous/induced) , complications
birth control

20
Q

Peripheral vascular

A 
Intermittent claudication
leg cramps
varicose veins
past clots
swelling in calves, legs, feet
colour change in fingertips or toes in cold weather
swelling, redness, tenderness
21
Q

Musculoskeletal

A

muscle or joint pain + associated swelling, redness, tenderness, stiffness, weakness, loss of movement (include timing of symptoms ie morning/evening)
History of trauma
Neck or back pain
Joint pain w/ systemic symptoms (fever rash, chills, anorexia, weight loss, weakness)

22
Q

Psychiatric

A

Nervousness, tension, mood, depression, memory change, suicide attempts

23
Q

Neurologic

A

Headache, dizziness, vertigo, fainting, blackout, seizures, weakness, paralysis, numbness, tingling, tremors, involuntary movements, seizures

24
Q

Hematologic

A

Anemia, brusing or bleeding, past transfusions or transfusion reactions

25
Q

Endocrine

A

Heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, changes in glove size or shoe size

26
Q

OPQRST used in relation to what??

A

OPQRST is an mnemonic used to accurately discern reasons for a patient’s symptoms and history in the event of an acute illness.

Onset
Pain
Quality
Region
Severity
Timing
27
Q

SOAP

A

SOAP
Subjective: how patient feels/thinks about himself. How does he look. Includes general appearance/condition of patient
Objective – relevant points of patient complaints/vital sings, physical examination/daily weight,fluid balance,diet/laboratory investigation and interpretation
Assessment – address each active problem after making a problem list. Make differential diagnosis.
Plan – about management, treatment, further investigation, follow up and rehabilitation

28
Q

History taking according to lecture

A

Source and reliability -Patient or some one else? ‘hetero-anamnesis’

Chief complaint-The patient’s brief statement why he/she sought medical attention.

History of present illness- What, when, how, where, which, who and why

General state of health:
Past illnesses 
Hospitalisations
Injuries 
Surgery 
Allergies 
Immunisations

Substance abuse
Diet
Sleep patterns
Current medication

29
Q

Occupational and environmental history

A

Exposure to disease-producing substances
Duration +/- protective devices?
medical screening?

30
Q

Family history

A 
Information about the health
of the entire family diseases in the family
\+ Genetic implication
hypertension diabetes
MI
31
Q

Psychosocial history

A

Education, life style, sexual history

32
Q

Follow up questions for chest pain (4 Qs)

A 
“Where is the pain?”
“Does it radiate?” “Where?”
“For how long have you had the pain?” 
“Do you have recurrent episodes of
pain?
33
Q

Common causes of cardiac chest pain

A

Coronary artery disease
Aortic valvular disease Pulmonary artery hypertension Mitral valve prolapse Pericarditis
HOCM (hypertrophic obstructive cardiomyopathy)

34
Q

Other common causes of chest pain

A

Vascular: Dissection of the aorta
Pulmonary: Embolism, Pneumonia
Pleuritis, PTX



35
Q

Common causes of GIT pain

A

Ulcer
Bowel disease
Hiatal hernia (GERD) Pancreatitis Cholecystitis

36
Q

Inspection of the patient

Height & Weight

A

Height: normal, gigantism, dwarf

Weight: normal, anorhexia, cachxia, obesity

37
Q 
BMI Ranges
Normal
Overweight
Obese
Severe
Extreme
A 
Normal: 20.1-25 kg/m2
Overweight: 25.1-30 kg/m2
Obese: 30.1-35 kg/m2
Severe: 35.1 kg/m2
Extreme: >40 kg/m2
38
Q

Metabolic syndrome- criteria for waist circumference

A

> 88 cm in females

> 102 cm in males

39
Q

Eye Abnormalities
Pupils
Conjunctiva
Sclera

Others

A

Pupils: anisocoria (unequal pupils)
cataract
Conjunctiva: anemic, conjunctivitis
Sclera: icterus, blue sclera

Exophtalmus (Grave’s hyperthyroidism) enophtalmus (post dispacement of eyeball in orbit),
strabism (cross-eyed)

40
Q

Throat & Pharynx

Neck

A

Tonsilitis, mononucleosis, uvula oedema

Tongue-cracked, dry etc
Teeth & gums

Neck: Thyroid gland goiter

41
Q

Chest abnormalities

A 
Pectus carinatus, Pectus excavatus, Empysematic chest
Pink puffer (obstructive emphysema or heart disease with hypoxia)
Blue bloater (pulmonary disease with hypercapnia)
42
Q

Abdomen abnormalities

A

Hernia, ascites, caput medusae, strias,
Cullen sign
Surgical scars - Must be documentated (appendectomy, mediansaggittal laparotomy etc.)

43
Q

Cullen’s sign

A

superficial edema and brusingin the subcutaneous fatty tissue around umbilicus

Can indicate acute pancreatitis

Internal (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions