History taking

Question 1

Questions to every symptom

Answer 1

1. Location
2. Quality
3. Quantity to Severity
4. Timing:
   1) Onset
   2) Duration
   3) Course including frequency
5. The Setting (in which it occurs)
6. Aggregating and Relieving factors
7. Associated manifestations -> after Review of Systems come back and check

Question 2

Interview - parts

Answer 2

1. Identifying Data
2. Present illness
3. Past history
4. Family history
5. Social history
6. Reliability
   (7. Review of systems)

Question 3

Identifying Data

Answer 3

1. Name
2. Age
3. Gender
4. Race

Question 4

Present illness

Answer 4

1. Chief complaint
2. Other present complaint
3. Complete chronological description of problems prompting patient’s visit
4. Pain-> present
5. (Present status) -> if already hospitalized

Question 5

Past History

Answer 5

1. Allergies and drugs
   1) Alergies
   2) Medications
   3) Tabacco
   4) Alcohol
   5) Other drugs (illegal)
2. Past illnesses
3. Preventions
4. Physiological activities
5. Lifestyle

Question 6

Past illnesses

Answer 6

1. Internal medicine
   1) Diabetes
   2) Obesity
   3) Hypertension
   4) Asthma
   5) Cardio and Strokes
   6) Diverticular disease
   7) Hospitalizations
   8) Infectious diseases eg. HIV
2. Surgical
3. OB/Gyn
   1) OB
   
   1. How many pregnancies
   2. How many deliveries
   3. Complications
   4. Children health (deaths)
      
      • > G-P-M-L -> gravida-parity-miscarriages-living
   2) Menstrual history
   1. First
   2. Last
   3. Regularity and frequency
   4. Bleeding-> during menorrhea and cycle
   3) Sexual interview and STD
4. Psychiatric

(5. Pediatric)
1. Which week of pregnancy
2. Birth weight
3. Apgar score
4. Complications during labor/pregnancy
5. Development

Question 7

Preventions

Answer 7

1. Immunizations -> children
2. Screening tests
   1) mammography
   2) cervix
   3) colonoscopy
   4) blood tests
   1. Cholesterol
   2. Glucose

Question 8

Physiological activities

Answer 8

1. Urination
2. Defecation
3. Sleep
4. Hunger -> changes

Question 9

Lifestyle

Answer 9

1. Diet
2. Exercise
3. Stress
4. Sexual activities

Question 10

Family History

Answer 10

1. Diseases in family
   1) Diabetes
   2) Obesity
   3) Hypertension
   4) IHD
   5) Oncology
   6) Other-> which patient might have
2. Health of:
   1) Parents
   2) Grandparents
   3) Siblings
   4) Children
   5) Grandchildren
3. (Cause of death)

Question 11

Social history

Answer 11

1. Household
2. Occupation
3. Education level
4. Stress
5. Exotic adventures
6. Exposure

Question 12

Review of systems -> systems

Answer 12

1. General
2. Skin
3. HEENT
4. Neck
5. Thorax
   1) Breasts
   2) Respiratory system
   3) Cardiovascular system
   4) Peripheral vascular system
6. Abdomen
   1) Gastrointestinal system
   2) Urinary system
   3) Reproductive system
7. Endocrine
8. Hematologic
9. Musculoskeletal
10. Neurological
11. Psychiatric

Question 13

Review of systems -> general

Answer 13

1. Weight
   1) Usual weight
   2) Recent weight change (eg. clothing that fits more tightly or loosely than before)
2. Weakness and fatigue
3. Fever, chills, night sweats
4. Pain

Question 14

Review of systems -> skin

Answer 14

1. Changes -> rashes, lumps, sores, itching, dryness
2. Changes in color
3. Changes in size or color of moles
4. Changes in hairs or nails

Question 15

Review of systems -> Head

Answer 15

1. Headache
2. Head injury
3. Dizziness

Question 16

Review of systems -> eyes

Answer 16

1. Glasses or contact lenses
2. Changes in vision
3. Last examination
4. Pain
5. Redness
6. Excessive tearing
7. Double or blurred vision
8. Spots, specks
9. Illnesses -> glaucoma, cataract

Question 17

Review of systems -> ears

Answer 17

1. Hearing
2. Vertigo
3. Tinnitus
4. Earaches
5. Infection
6. Discharge
7. Use of hearing aids if hearing is decreased

Question 18

Review of systems -> nose& sinuses

Answer 18

1. Frequent colds
2. Nasal stuffiness (niedroznosc)
3. Discharge
4. Itching
5. Alergies
6. Nosebleeds
7. Sinus trouble

Question 19

Review of systems -> throat

Answer 19

1. Condition of teeth and gums
2. Bleeding gums
3. Denture and if so how it fits
4. Last dental examination
5. Sore tongue
6. Dry mouth
7. Frequent sore throats
8. Hoarseness (chrypka)

Question 20

Review of systems -> neck

Answer 20

1. Swollen glands
2. Goiter
3. Lumps (guzki)
4. Pain
5. Stiffness

Question 21

Review of systems -> breasts

Answer 21

1. Lumps
2. Pain or discomfort
3. Nipple discharge
4. Self-examination practices

Question 22

Review of systems -> respiratory

Answer 22

1. Cough
2. Sputum
3. Dyspnea -> shortness of breath
4. Wheezing
5. Pain with a deep breath (pleuritic)
6. Last chest X-ray

Question 23

Review of systems -> cardiovascular

Answer 23

1. Heart trouble
2. Blood pressure
3. Chest pain or discomfort
4. Palpitations
5. Valves and heart murmurs
6. Orthopnea-> need to use pillows at night to ease breathing
7. Need to sit up at night to ease breathing (Paroxysmal Nocturnal Dyspnea)
8. Swellings in the hands, ankles or feet’s
9. Results of past ECG or other tests

Question 24

Review of systems -> peripheral vascular

Answer 24

1. Intermittent leg pain with exertion (claudication, chromanie)
2. Leg cramps (skurcze)
3. Varicose veins
4. Past clots in the veins
5. Swelling in calves (lydka), leg or feet
6. Color change in fingertips or toes during cold weather

Question 25

Review of systems -> gastrointestinal

Answer 25

1. Trouble swallowing 2. Heartburn 3. Appetite 4. Nausea 5. Bowel movements 1) General -> constipations, diarrhea, frequency 2) Stool color and size 3) Change in bowel habits 4) Pain with defecation 5) Rectal bleeding & black and tarry stools 6. Excessive belching or passing of gas 7. Abdominal pain 8. Food intolerance 9. Liver 1) Jaundice 2) Liver or gallbladder trouble 3) Hepatitis

Question 26

Review of systems -> urinary

Answer 26

1. Frequency of urination 2. Quantity-> polyuria, oliguria, anuria 3. Nocturia 4. Urgency 5. Hematuria 6. Pain or burning during urination 7. Urinary infections 8. Kidney or flank pain 9. Kidney stones -> ureteral colic, suprapubic pain 10. Incontinence 11. Hesitancy 12. Dribbling (kapanie, mala ilosc) and prostate function

Question 27

Review of systems -> reproductive woman

Answer 27

1. Menstrual period 1) age of first (menarche) 2) last 3) frequency& regularity 4) amount of bleeding & bleeding between periods or after intercourse 5) dysmenorrhea-> pain during 6) premenstrual tension 2. Menopause 1) age of 2) symptoms 3) postmenopausal bleedings 4) osteoporosis 3. Infections 1) vaginal discharge 2) itching 3) sores 4) lumps 5) STD and treatments (HIV) 4. OB 1) number of pregnancies 2) number of deliveries 3) type of deliveries 4) number and cause of abortions 5) complications of pregnancies 5. Sexual 1) sexual problems 2) interest 3) function 4) satisfaction 5) dyspareunia 6) birth control methods

Question 28

Review of systems -> reproductive man

Answer 28

1. STD 1) history and treatment 2) discharge from penis 3) changes and sores on the penis 2. Sexual 1) sexual problems 2) interest 3) function 4) satisfaction 5) dyspareunia 6) birth control methods eg. Condoms 7) habits and preferences 3. Testicular 1) pain 2) masses 3) scrotal swelling

Question 29

Review of systems -> endocrine

Answer 29

1. Thyroid trouble 2. Heat or cold intolerance 3. Excessive swelling 4. Excessive thirst or hunger 5. Change in glove or shoe size

Question 30

Review of systems -> hematologic

Answer 30

1. Anemia 2. Easy bruising or bleeding 3. Past transfusions & reaction if so

Question 31

Review of systems -> musculoskeletal

Answer 31

1. Muscle to joint pain 2. Stiffness 3. Arthritis 4. Backache 5. Swelling of joints or muscles 6. Limitation of motion or activity 7. Joint pain with other symptoms eg. fever, chills, rash, anorexia, weight loss or weakness

Question 32

Review of systems -> neurological

Answer 32

1. Changes in mood, attention 2. Speech changes 3. Changes in orientation 4. Memory 5. Changes in insight or judgement 6. Headache 7. Dizziness, vertigo 8. Fainting 9. Weakness 10. Paralysis 11. Numbness or loss of sensation 12. Tingling 13. Tremors or other involuntary movements 14. Seizures

Question 33

Review of systems -> psychiatric

Answer 33

1. Mood 2. Nervousness 3. Depression 4. Memory changes 5. Suicidal ideation, plans or attempts 6. Past counseling, psychotherapy or psychiatric admissions

Question 34

Diabetes mellitus interview

Answer 34

1. History of disease 2. Lifestyle 3. Complications

Question 35

Diabetes mellitus history of disease

Answer 35

1) Time of diagnosis 1. When 2. Symptoms 3. Glucose level 4. Treatment 5. Weight 6. Which type 2) Now 1. Treatment 2. Glucose level-> now and usually 3. Last HbA1c 4. Episodes of hypoglycemia 5. Highest weight in life 6. Present a eight

Question 36

Diabetes mellitus lifestyle

Answer 36

1. Diet | 2. Sport

Question 37

Diabetes mellitus complications

Answer 37

1. Kidneys 2. Neuropathy 3. Ophthalmological 4. Hypertension 5. IHD 6. Stokes

Question 38

Diabetes mellitus complications -> kidneys

Answer 38

1. Polidypsja 2. Poliuria 3. Nocturia 4. History of creatinine, GFR

Question 39

Diabetes mellitus complications -> neuropathy

Answer 39

1) Autonomical system 1. Defecation -> constipation, diarrhea 2. Sweats 2) Somatic 1. Sensation in feet, palms 2. Episodes of diabetic foot, Chargot joints

Question 40

Diabetes mellitus complications -> ophthalmological

Answer 40

1. Loss of vision 2. Last ophthalmology examination 3. Operations of cataract