History and Physical Exam Flashcards
1
Q
Components of history taking?
A
- Chief concern
- history of presenting illness
- past medical history
- review of other systems
- family history
- social history
2
Q
Background?
A
- Critical part of medical diagnosis and management
- Make the patient comfortable
- Patient needs versus doctors needs
- Avoid use of scaring words – Cancer, Heart failure etc.
- Report the history in the patients description
- Avoid medical language in the history wherever possible
3
Q
Patient particulars and source of history?
A
- Name
- Age
- Sex
- Occupation – current and relevant previous
- Place of residence
- Marital status
- Next of kin and phone number or contacts
- Mention the source of the history
4
Q
Presenting complaint?
A
- Very brief but in patients own description eg Chest pain
- Duration : hours, days, months etc. – and not since Monday
Note: If more than 1, then indicate in order of importance – 1, 2, 3
5
Q
History of presenting complaint?
A
- Should be in patients own phraseology
- Indicate duration
- Should be chronological indicating the order in which symptoms presented
- More enquiry should be focused on the most likely system involved
6
Q
Review of Cardiovascular system?
A
- Breathlessness – at rest, on exertion, differences between night and day, precipitating factors, number of pillows, worse when lying flat (orthopnoea), worse when lying in bed at night (paroxysmal nocturnal dyspnoea)
- Chest pain – site, onset, character, radiation, severity, aggravating and relieving factors, accompanying symptoms e.g. N/V for GERD or breathlessness
- Dizziness
- Edema – or swelling of the feet/ abdomen/and other parts of the body
- Heart palpitations: note quality - (periodic) rapid beats or irregular beats, associated symptoms
- Peripheral vascular system – intermittent claudication (pain in calves, or buttocks – worse on exertion and relieved by rest), cold feet and hands (Raynaud’s phenomenon)
- passing urine at night (nocturia): how frequent
7
Q
Respiratory system?
A
- Cough – duration, dry, wet or productive
- Sputum – color, frothy, bloody
- Breathlessness
- Wheeze
- Hoarseness of voice
- Chest pain
- Hoarseness
- Nasal discharge or obstruction
- Loss of weight
- Sweating
- Occupation
- Smoking - number of cigarettes per day/years = pack years
8
Q
Gastrointestinal system?
A
- Pain – SOCRATES
- Appetite
- Difficulties in swallowing (dysphagia – solids vs liquids) vs pain on swallowing (odynophagia)
- Vomiting
- Diarrhea – duration, watery/ bloody. 6. Volume, precipitating or relieving factors
- Flatus
- Jaundice
- Flatulence – discomfort caused by gaseous accumulation
- Weight loss
- Constipation
9
Q
Central nervous system?
A
- Mental state – memory/ delusions/ hallucinations/ agitation/ intellectual capacity
- Loss of consciousness
- Headache
- Weakness or paralysis of part of the body
- Abnormalities of gait
- Numbness or pins or needles
- Dizziness/ giddiness
- Speech disturbances
- Visual disturbances
- Tremors
- Deafness
- Sphincters
10
Q
Endocrine?
A
- Hair
- Weight
- Pigmentation of skin
- Flushes
- Sweating
11
Q
Hematopoetic?
A
- Blood loss
- Sore tongue – signs of pernicious anemia
- Bruising
- Symptoms of anemia
12
Q
Musculoskeletal system?
A
- Joint pains
- Swelling
- Stiffness
- Mechanical dysfunction
- Associated systemic symptoms
13
Q
Past Medical/Surgical History?
A
- Previous Surgical procedures
- Previous admissions
- Important medical history – HIV/ DM/ HTN/ Epilepsy/ Asthma
- Vaccinations
- Obstetric and Gynae history
14
Q
Drug history?
A
- Adverse effects
- Over the Counter medicines
- Doses of medicines
- History of recreation drug uses
15
Q
Family and social history?
A
- Marital status plus number of children
- Genetic diseases
- Smoking
- Alcohol
- Occupation
