HISTORY TAKING Flashcards
GYNAE HISTORY
what are the key symptoms to ask about?
- abdominal pain
- pelvic pain
- post-coital bleeding
- intermenstrual bleeding
- abnormally heavy bleeding
- abnormally painful bleeding
- post-menopausal bleeding
- abnormal vaginal discharge
- dyspareunia (duration, location, nature)
- vulval skin changes + itching
- systemic sx (fatigue, fever, weight loss)
GYNAE HISTORY
what should you cover?
- presenting complaint
- ICE
- menstrual history
- contraception
- reproductive plans
- past gynae history
- past medical history
- obstetric history
- drug history
- family history
- social history
GYNAE HISTORY
what should you include in menstrual history?
- duration of periods
- frequency (how often, are they regular)
- volume (how heavy)
- any pain
- date of last menstrual period
- age at menarche
- age at menopause (if relevant)
GYNAE HISTORY
what should you include in past gynae history?
- gynae conditions
- gynae surgery or procedures
- cervical screening history
GYNAE HISTORY
what should you include in obstetric history?
- gravidity and parity
- current pregnancy (gestation, symptoms, complications, recent scans)
- previous pregnancies
GYNAE HISTORY
what should you specifically ask about for family history?
- history of ovarian, endometrial or breast cancer
- bleeding disorders
- blood clots
NEUROLOGICAL HISTORY
what are the key symptoms to ask about?
- headache
- seizures
- loss of consciousness
- muscle symptoms (weakness, twitching, spasms, stiffness)
- sensory symptoms (numbness, tingling, sensory loss)
- speech disturbance (dysarthria and aphasia)
- vision changes
- hearing loss
- loss of sense of smell
- dizziness/vertigo
- altered mental state
NEUROLOGICAL HISTORY
what are the components of a neuro history?
- presenting complaint
- ICE
- past medical history
- neurodevelopmental history
- allergies
- drug history
- family history
- social history
NEUROLOGICAL HISTORY
what should you include in neurodevelopmental history?
- pregnancy + birth history ( any complications)
- did they reach developmental milestones on time?
- any significant illnesses in childhood
- any challenges in school or social interactions
- any concerns about behaviour and emotion
MEMORY IMPAIRMENT HISTORY
what should you ask for presenting complaint?
- onset (sudden or gradual, any triggers)
- progression (sudden or gradual, any tasks now difficult, steady or fluctuates)
- triggers (recent infections, changes to medications or increased stress, problems going to toilet or pain, thirsty or dehydrated)
ASSOCIATED SYMPTOMS
- depression/low mood
- hallucinations
- behavioural changes
- changes to sleeping patterns
- difficulties speaking, recognising objects, planning activities + recognising people/places
- changes to bowel habits (constipation or incontinence)
- issues passing urine (burning, stinging or increased frequency)
CARDIOVASCULAR HISTORY
what are the key symptoms?
- chest pain
- SOB
- palpitations
- syncope
- oedema
- intermittent claudication
- systemic sx (fatigue, fever, weight loss or weight gain)
HEADACHE HISTORY
what are the key symptoms to ask about?
- vomiting
- visual disturbance
- neck stiffness
- fever
- dizziness
- rash
- weight loss
- motor or sensory deficits
- triggers
- onset
RESPIRATORY HISTORY
what are the key respiratory symptoms?
- SOB
- cough
- coughing up blood
- wheeze
- chest pain
- systemic symptoms (fatigue, fever, weight loss)
DEPRESSION HISTORY
what are the components of a depression history?
- introduction
- screening for depression
- biological symptoms
- cognitive symptoms
- assess suicide risk
- screening for other psych diagnoses
- past psychiatric history
- past medical history
- drug history
- family history
- social history
- insight
DEPRESSION HISTORY
how would you initially screen for depression?
during the past month have you:
- been bothered by feeling low, depressed or hopeless?
- had little interest or pleasure doing things?
DEPRESSION HISTORY
what are the biological and cognitive symptoms to ask about?
BIOLOGICAL SYMPTOMS
- sleep cycle disruption
- low mood
- appetite changes
- reduced libido
- fatigue
COGNITIVE SYMPTOMS
- reduced concentration
- negative perception of current/future situation
- negative perception of self
DEPRESSION HISTORY
how would you assess suicide risk?
“When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like this”
- any thoughts about taking own life
- how often do you think about taking own life
- any thoughts about how
- any plans
- any attempts
- any self-harming thoughts
- any self-harm
- anything stopping from ending life
- drinking alcohol or recreational drug use
- felt able to see friends + socialise
DEPRESSION HISTORY
how would you screen for other psychiatric diagnoses?
MANIA (BIPOLAR)
- periods of euphoria, particularly high, energetic or euphoric
SCHIZOPHRENIA
- auditory hallucinations
- feel people discussing you negatively
- fear people may be out to get you
- thought insertion
- thought withdrawal
- thought broadcasting
- tactile hallucinations
HEAD INJURY HISTORY
what are the components of a head injury history?
- introduction
- presenting complaint
- before head injury
- during head injury
- after head injury
- now
- ICE
- past medical history
- drug history
- family history
- social history
HEAD INJURY HISTORY
what do you want to know about before the head injury?
- when the injury happened
- activities before injury
- any precipitating causes
- previous head injuries
HEAD INJURY HISTORY
what do you want to know about during the head injury?
- mechanism of injury
- loss of consciousness
- any witnesses
HEAD INJURY HISTORY
what do you want to know about after the head injury?
- any vomiting
- any memory loss
- did they need help
- any other injuries
- any neck pain
PAEDIATRIC HISTORY
what are the components?
- presenting complaint
- feeding (breastfed/formula, eating + drinking)
- toileting (urine output, wet nappies, bowels + poo appearance)
- past medical history
- surgical history
- prenatal history (obstetric problems, medications during pregnancy)
- birth history (any concerns/problems)
- neonatal history (any NICU admissions?)
- development (meeting milestones, any concerns?)
- growth history (growing along centile)
- immunisation history
- drug history
- allergies
- family history (siblings, parents)
- social services involvement
- social history (school, friends, diet)
ALCOHOL HISTORY
what are the components?
- screen using CAGE or AUDIT
- alcohol intake (pattern, how much)
- impact of alcohol (signs of dependence, what happens when trying to stop)
- effect on day to day life
- current mood
- suicide risk
- past medical history
- drug history + allergies
- social history (smoking, drug use, gambling)
UROLOGICAL HISTORY
what are the key symptoms?
- dysuria (pain when urinating)
- blood in urine
- passing too much urine
- difficulty passing urine
- unable to pass urine
- incontinence
- systemic sx (fever, N+V, weight loss)
GI HISTORY
what are the key symptoms?
- vomiting
- abdominal pain
UPPER GI
- jaundice
- blood in vomit
- reflux
- difficulty swallowing
- pain during swallowing
LOWER GI
- abdominal distention
- constipation
- diarrhoea
- greasy stools
- malaena
- blood in stool
SYSTEMIC SYMPTOMS
- aphthous ulceration
- anorexia
- weight loss
- N+V
- fever
- itchy
- confusion
SEXUAL HISTORY
what are the components of a sexual history?
- presenting complaint (vaginal or penile)
- gynae history (if appropriate)
- obstetric history (if appropriate)
- menstrual history (if appropriate)
- rectal symptoms
- oral symptoms
- ICE
- last sexual contact
- sexual violence
- blood borne virus risk assessment
- past medical history
- drug history
- social history
SEXUAL HISTORY
what vaginal symptoms should you ask about?
- abnormal vaginal discharge
- post-coital vaginal bleeding
- intermenstrual vaginal bleeding
- post-menopausal bleeding
- pain during sex
- abdominal and pelvic pain
- vulval skin changes, itching or lesions
SEXUAL HISTORY
what penile symptoms should you ask about?
- urethral discharge
- pain when weeing
- testicular pain or swelling
- penile skin change, itching or lesions
- penile swelling
- abdominal or pelvic pain
SEXUAL HISTORY
what rectal symptoms should you ask about?
- rectal discharge
- rectal pain
- rectal lump
- anal skin changes, itching or lesions
SEXUAL HISTORY
what do you need to know about last sexual contact?
- when was the last time you had sex
- nature of sexual contact (vaginal, anal, oral, sex toys, condoms)
- relationship (regular partner or one-off)
- contraception
- any other sexual partners
- STI screen (when was it last done?)
SEXUAL HISTORY
what should you ask to explore sexual violence?
- do you feel safe with your current partner?
- any violence towards you in this relationship?
- have you ever had sex that you have not consented to?
- have you ever had any procedures to your genitals for non-medical purposes such as cutting, piercing or burning?
SEXUAL HISTORY
how would you explore blood borne virus risk?
- when was last HIV blood test
- any partners from abroad/born abroad?
- any partners tested positive for HIV?
- ever injected recreational drugs
- ever used recreational drugs during sex?
- have you ever paid someone for sex or been paid?
- vaccination history (HPV, hep A and B)
ANXIETY HISTORY
what symptoms should you ask about?
PSYCHOLOGICAL
- nervous, restless, tired or fatigued
- sense of impending doom
- difficulty thinking about anything other than fear or worry
- feeling urgent need to leave situation
- low sense of self worth
PHYSICAL
- hot + sweating or very cold + shivering
- hyperventilation
- rapid heart rate or palpitations
- headache
- nausea
- SOB
- pins and needles
PSYCHIATRIC HISTORY
what are the components?
- presenting complaint
- past psychiatric history
- forensic history
- past medical history
- allergies
- drug history
- family history
- personal history (childhood, school/education, occupation, relationships, personality)
- social history (living circumstances, smoking, alcohol, drug use)
- insight
PSYCHIATRIC HISTORY
what would you include in personal history?
- childhood
- school and education
- occupation
- relationships
- personality (how they would describe themself)
UNINTENTIONAL WEIGHT LOSS
what should you ask about?
WEIGHT LOSS
- noticed any weight loss
- how much
- time frame
- usual eating habits and diet
- trying to lose weight + exercise
SYMPTOMS
- rapid weight loss
- fever
- night sweats
- fatigue
- dysphagia
- change in bowel habit
- blood in poo
- unresolving cough
FALLS HISTORY
what do you want to know about before the fall?
- when did it occur
- did you think you were going to fall
- did you have any symptoms e.g. dizziness
FALLS
what do you want to know about during the fall?
- how did you fall
- did you trip or just fall
- can you remember the fall
- did anything break your fall
- did you hit your head
- what did you fall onto
- did you black out at any point
- do you remember the fall
FALLS HISTORY
what do you want to know about after the fall?
- how long were you on the floor
- did you manage to get yourself up
- did anyone see the fall
- did they come and help
- how did you feel after the fall
FALLS HISTORY
what do you want to know about now?
- how do they feel at the moment
- any pain
- any bruising or swelling
- any weakness
- are you worried about falling again
- have you had any further falls
TIREDNESS HISTORY
what symptoms can you screen for?
- Cardio = chest pain, SOB, leg oedema, cough
- GI = change in bowel habit, N+V, pain, blood loss
- GU = nocturia, polyuria, haematuria
- Gynae = menorrhagia, menstrual irregularities
- rheum = joint pain, stiffness, swelling, rashes
- neuro = headaches, vomiting, vision change, sensory changes, weakness, tremors
- haem = pallor
- endo = polyuria, weight changes, skin changes, postural hypotension
- infective = fever, night sweats, weight loss, LN
- psych = low mood
SEIZURE HISTORY
what do you want to know about before the event?
- any symptoms (feel sweaty, lightheaded, palpitations)
- what were they doing
- any abnormal sensations
- any arm or leg weakness
- any headaches
- any falls prior to the episode
SEIZURE HISTORY
what do you want to know about during the event?
- were you aware?
- any recording?
- stiffening + jerking
- any tongue biting
- any incontinence
- go pale or blue
SEIZURE HISTORY
what do you want to know about following the event?
- how long does it last
- what were they like when they woke up
- can they recall the event
- did you feel sleepy
- did you have muscle pain
- did you bite your tongue
EATING DISORDER HISTORY
what are the different components?
- weight history
- eating behaviours
- any purging behaviours
- physical symptoms
- psychological symptoms
- ICE
- past medical history
- family history
- social history
EATING DISORDER HISTORY
how can you explore weight history?
SLIM
- weight at different STAGES of life
- any periods of weight LOSS
- what is their IDEAL weight
- what are their MINIMUM and MAXIMUM weights
EATING DISORDER HISTORY
how would you explore eating behaviours?
- what is intake like on a typical day
- are eating habits similar to friends and family
- has anyone expressed concern about amount you are eating?
FERTILITY HISTORY
what are the stages?
- conception history
- pregnancy history (outcomes, mode of delivery, baby health)
- menstrual history (regular, LMP, pain)
- sexual history (pain or bleeding, any STIs)
- PMH (smears, vaccinations, allergies)
- drug history
- family history (genetic problems, early menopause)
- social history (smoking, alcohol, drug use, diet, exercise)
- partner history
OPHTHALMIC HISTORY
what symptoms should you ask about?
- vision disturbance
- red eye
- discharge
- grittiness
- dry eyes
- itching
- photophobia
- swelling or tenderness of eyes
RHEUMATOLOGICAL HISTORY
what symptoms should you screen for in presenting complaint?
PRISMS
pain
rashes, skin lesions or nail changes
Immune
Stiffness
Malignancy
Swellings and sweats
BACK PAIN HISTORY
what are the key symptoms to ask about?
- motor or sensory disturbance
- urinary retention or incontinence
-haematuria - fever
- malaise
- weight loss
- early morning stiffness
- muscular spasms
DERMATOLOGICAL HISTORY
what are the steps of a derm history?
- presenting complaint (SOCRATES)
- treatments
- any previous episodes
- contact history
- ICE
- travel history
- past medical history (sun exposure, allergies)
- drug history
- family history
- social history (smoking, alcohol, drug use, diet, occupation)
BREAST LUMP HISTORY
what are the key symptoms to ask about?
- breast pain
- nipple discharge
- nipple eczema
- nipple inversion
- erythema
- ulceration
- dimpling
- fever
- weight loss
- malaise
- lymph nodes
- bone pain
