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

1. trouble swallowing 2. heartburn 3. appetite, nausea, 4. abdominal pain, 5. bowel movements, constipation, diarrhea, colour, size, consistency 6. food intolerance, gas, belching

History and Inspection Flashcards by Clare Scanlon

Components of Adult History (there are 7)

Identifying Data
Chief Complaint
Present illness
Past History
Family History
Personal & Social History
Review of systems

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The seven attributes of a symptom

Location
Quality
Quantity or severity (for pain rate using scale 1-10)
Timing (onset, duration & frequncy)
Setting in which it occurs
Aggrevating or relieving factors
Associated manifestations

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Identifying data includes (kind of obvious I know)

Age, gender, occupation, marital status

Source of history (patient, parent, relative etc)

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Present illness

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)

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Past History

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

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Family History

All immediate relatives (parents, siblings, children, grandchildren) &amp; grandparents
--> Age &amp; 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

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Personal & Social

Occupation
Schooling (last year of schooling)
Home situation &amp; significant others
Sources of stress
Military service (important life experiences) 
Leisure activities
religious/ spiritual beliefs
ADLs (activities of daily living)
Lifestyle habits: exercise, diet

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Review of systems

Start general and go from head-toe

General
Skin
HEENT
Neck
Breasts
Respiratory: more detailed later
CV
GIT
Urinary
Genital
Peripheral vascular
Musculoskeletal
Psychiatric
Neurologic
Hematologic
Endocrine

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General Review of systems

weight changes, weakness, fatigue, fever

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Skin

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

changes in hair, nails & moles

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

for later

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Neck

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

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Breast

Lumps, pain, nipple discharge, self-examination

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Respiratory system

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

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CVS 9 major questions

High blood pressure
Chest Pain
Palpitations
Shortness of breath with exertion
Shortness of breath when lying flat
History of heart attack
Rheumatic fever
Heart murmur
Last ECG

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

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GIT

trouble swallowing
heartburn
appetite, nausea,
abdominal pain,
bowel movements, constipation, diarrhea, colour, size, consistency
food intolerance, gas, belching

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Urine

Frequncy, urgency, burning or pain 
Nocturia, hematuria
Urinary infections
Kidney stones
Incontinence
Males: reduced caliber or force of urinary stream, hesitancy, dribbling

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Genital-Male

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

Genital- female

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

Peripheral vascular

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

Musculoskeletal

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)

Psychiatric

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

Neurologic

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

Hematologic

Anemia, brusing or bleeding, past transfusions or transfusion reactions

Endocrine

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

OPQRST used in relation to what??

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 ```

SOAP

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

History taking according to lecture

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

Occupational and environmental history

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

Family history

``` Information about the health of the entire family diseases in the family + Genetic implication hypertension diabetes MI ```

Psychosocial history

Education, life style, sexual history

Follow up questions for chest pain (4 Qs)

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

Common causes of cardiac chest pain

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

Other common causes of chest pain

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

Common causes of GIT pain

Ulcer Bowel disease Hiatal hernia (GERD) Pancreatitis Cholecystitis

Inspection of the patient | Height & Weight

Height: normal, gigantism, dwarf Weight: normal, anorhexia, cachxia, obesity

``` BMI Ranges Normal Overweight Obese Severe Extreme ```

``` 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 ```

Metabolic syndrome- criteria for waist circumference

> 88 cm in females | > 102 cm in males

Eye Abnormalities Pupils Conjunctiva Sclera Others

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)

Throat & Pharynx Neck

Tonsilitis, mononucleosis, uvula oedema Tongue-cracked, dry etc Teeth & gums Neck: Thyroid gland goiter

Chest abnormalities

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

Abdomen abnormalities

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

Cullen's sign

superficial edema and brusingin the subcutaneous fatty tissue around umbilicus Can indicate acute pancreatitis