History taking Flashcards
Questions to every symptom
- Location
- Quality
- Quantity to Severity
- Timing:
1) Onset
2) Duration
3) Course including frequency - The Setting (in which it occurs)
- Aggregating and Relieving factors
- Associated manifestations -> after Review of Systems come back and check
Interview - parts
- Identifying Data
- Present illness
- Past history
- Family history
- Social history
- Reliability
(7. Review of systems)
Identifying Data
- Name
- Age
- Gender
- Race
Present illness
- Chief complaint
- Other present complaint
- Complete chronological description of problems prompting patient’s visit
- Pain-> present
- (Present status) -> if already hospitalized
Past History
- Allergies and drugs
1) Alergies
2) Medications
3) Tabacco
4) Alcohol
5) Other drugs (illegal) - Past illnesses
- Preventions
- Physiological activities
- Lifestyle
Past illnesses
- Internal medicine
1) Diabetes
2) Obesity
3) Hypertension
4) Asthma
5) Cardio and Strokes
6) Diverticular disease
7) Hospitalizations
8) Infectious diseases eg. HIV - Surgical
- OB/Gyn
1) OB- How many pregnancies
- How many deliveries
- Complications
- Children health (deaths)
- > G-P-M-L -> gravida-parity-miscarriages-living
1. First
2. Last
3. Regularity and frequency
4. Bleeding-> during menorrhea and cycle
3) Sexual interview and STD - Psychiatric
(5. Pediatric)
1. Which week of pregnancy
2. Birth weight
3. Apgar score
4. Complications during labor/pregnancy
5. Development
Preventions
- Immunizations -> children
- Screening tests
1) mammography
2) cervix
3) colonoscopy
4) blood tests
1. Cholesterol
2. Glucose
Physiological activities
- Urination
- Defecation
- Sleep
- Hunger -> changes
Lifestyle
- Diet
- Exercise
- Stress
- Sexual activities
Family History
- Diseases in family
1) Diabetes
2) Obesity
3) Hypertension
4) IHD
5) Oncology
6) Other-> which patient might have - Health of:
1) Parents
2) Grandparents
3) Siblings
4) Children
5) Grandchildren - (Cause of death)
Social history
- Household
- Occupation
- Education level
- Stress
- Exotic adventures
- Exposure
Review of systems -> systems
- General
- Skin
- HEENT
- Neck
- Thorax
1) Breasts
2) Respiratory system
3) Cardiovascular system
4) Peripheral vascular system - Abdomen
1) Gastrointestinal system
2) Urinary system
3) Reproductive system - Endocrine
- Hematologic
- Musculoskeletal
- Neurological
- Psychiatric
Review of systems -> general
- Weight
1) Usual weight
2) Recent weight change (eg. clothing that fits more tightly or loosely than before) - Weakness and fatigue
- Fever, chills, night sweats
- Pain
Review of systems -> skin
- Changes -> rashes, lumps, sores, itching, dryness
- Changes in color
- Changes in size or color of moles
- Changes in hairs or nails
Review of systems -> Head
- Headache
- Head injury
- Dizziness
Review of systems -> eyes
- Glasses or contact lenses
- Changes in vision
- Last examination
- Pain
- Redness
- Excessive tearing
- Double or blurred vision
- Spots, specks
- Illnesses -> glaucoma, cataract
Review of systems -> ears
- Hearing
- Vertigo
- Tinnitus
- Earaches
- Infection
- Discharge
- Use of hearing aids if hearing is decreased
Review of systems -> nose& sinuses
- Frequent colds
- Nasal stuffiness (niedroznosc)
- Discharge
- Itching
- Alergies
- Nosebleeds
- Sinus trouble
Review of systems -> throat
- Condition of teeth and gums
- Bleeding gums
- Denture and if so how it fits
- Last dental examination
- Sore tongue
- Dry mouth
- Frequent sore throats
- Hoarseness (chrypka)
Review of systems -> neck
- Swollen glands
- Goiter
- Lumps (guzki)
- Pain
- Stiffness
Review of systems -> breasts
- Lumps
- Pain or discomfort
- Nipple discharge
- Self-examination practices
Review of systems -> respiratory
- Cough
- Sputum
- Dyspnea -> shortness of breath
- Wheezing
- Pain with a deep breath (pleuritic)
- Last chest X-ray
Review of systems -> cardiovascular
- Heart trouble
- Blood pressure
- Chest pain or discomfort
- Palpitations
- Valves and heart murmurs
- Orthopnea-> need to use pillows at night to ease breathing
- Need to sit up at night to ease breathing (Paroxysmal Nocturnal Dyspnea)
- Swellings in the hands, ankles or feet’s
- Results of past ECG or other tests
Review of systems -> peripheral vascular
- Intermittent leg pain with exertion (claudication, chromanie)
- Leg cramps (skurcze)
- Varicose veins
- Past clots in the veins
- Swelling in calves (lydka), leg or feet
- Color change in fingertips or toes during cold weather
Review of systems -> gastrointestinal
- Trouble swallowing
- Heartburn
- Appetite
- Nausea
- 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 - Excessive belching or passing of gas
- Abdominal pain
- Food intolerance
- Liver
1) Jaundice
2) Liver or gallbladder trouble
3) Hepatitis
Review of systems -> urinary
- Frequency of urination
- Quantity-> polyuria, oliguria, anuria
- Nocturia
- Urgency
- Hematuria
- Pain or burning during urination
- Urinary infections
- Kidney or flank pain
- Kidney stones -> ureteral colic, suprapubic pain
- Incontinence
- Hesitancy
- Dribbling (kapanie, mala ilosc) and prostate function
Review of systems -> reproductive woman
- 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 - Menopause
1) age of
2) symptoms
3) postmenopausal bleedings
4) osteoporosis - Infections
1) vaginal discharge
2) itching
3) sores
4) lumps
5) STD and treatments (HIV) - OB
1) number of pregnancies
2) number of deliveries
3) type of deliveries
4) number and cause of abortions
5) complications of pregnancies - Sexual
1) sexual problems
2) interest
3) function
4) satisfaction
5) dyspareunia
6) birth control methods
Review of systems -> reproductive man
- STD
1) history and treatment
2) discharge from penis
3) changes and sores on the penis - Sexual
1) sexual problems
2) interest
3) function
4) satisfaction
5) dyspareunia
6) birth control methods eg. Condoms
7) habits and preferences - Testicular
1) pain
2) masses
3) scrotal swelling
Review of systems -> endocrine
- Thyroid trouble
- Heat or cold intolerance
- Excessive swelling
- Excessive thirst or hunger
- Change in glove or shoe size
Review of systems -> hematologic
- Anemia
- Easy bruising or bleeding
- Past transfusions & reaction if so
Review of systems -> musculoskeletal
- Muscle to joint pain
- Stiffness
- Arthritis
- Backache
- Swelling of joints or muscles
- Limitation of motion or activity
- Joint pain with other symptoms eg. fever, chills, rash, anorexia, weight loss or weakness
Review of systems -> neurological
- Changes in mood, attention
- Speech changes
- Changes in orientation
- Memory
- Changes in insight or judgement
- Headache
- Dizziness, vertigo
- Fainting
- Weakness
- Paralysis
- Numbness or loss of sensation
- Tingling
- Tremors or other involuntary movements
- Seizures
Review of systems -> psychiatric
- Mood
- Nervousness
- Depression
- Memory changes
- Suicidal ideation, plans or attempts
- Past counseling, psychotherapy or psychiatric admissions
Diabetes mellitus interview
- History of disease
- Lifestyle
- Complications
Diabetes mellitus history of disease
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
Diabetes mellitus lifestyle
- Diet
2. Sport
Diabetes mellitus complications
- Kidneys
- Neuropathy
- Ophthalmological
- Hypertension
- IHD
- Stokes
Diabetes mellitus complications -> kidneys
- Polidypsja
- Poliuria
- Nocturia
- History of creatinine, GFR
Diabetes mellitus complications -> neuropathy
1) Autonomical system
1. Defecation -> constipation, diarrhea
2. Sweats
2) Somatic
1. Sensation in feet, palms
2. Episodes of diabetic foot, Chargot joints
Diabetes mellitus complications -> ophthalmological
- Loss of vision
- Last ophthalmology examination
- Operations of cataract