History taking Flashcards
1
Q
Questions to every symptom
A
- 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
2
Q
Interview - parts
A
- Identifying Data
- Present illness
- Past history
- Family history
- Social history
- Reliability
(7. Review of systems)
3
Q
Identifying Data
A
- Name
- Age
- Gender
- Race
4
Q
Present illness
A
- Chief complaint
- Other present complaint
- Complete chronological description of problems prompting patient’s visit
- Pain-> present
- (Present status) -> if already hospitalized
5
Q
Past History
A
- Allergies and drugs
1) Alergies
2) Medications
3) Tabacco
4) Alcohol
5) Other drugs (illegal) - Past illnesses
- Preventions
- Physiological activities
- Lifestyle
6
Q
Past illnesses
A
- 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
7
Q
Preventions
A
- Immunizations -> children
- Screening tests
1) mammography
2) cervix
3) colonoscopy
4) blood tests
1. Cholesterol
2. Glucose
8
Q
Physiological activities
A
- Urination
- Defecation
- Sleep
- Hunger -> changes
9
Q
Lifestyle
A
- Diet
- Exercise
- Stress
- Sexual activities
10
Q
Family History
A
- 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)
11
Q
Social history
A
- Household
- Occupation
- Education level
- Stress
- Exotic adventures
- Exposure
12
Q
Review of systems -> systems
A
- 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
13
Q
Review of systems -> general
A
- 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
14
Q
Review of systems -> skin
A
- Changes -> rashes, lumps, sores, itching, dryness
- Changes in color
- Changes in size or color of moles
- Changes in hairs or nails
15
Q
Review of systems -> Head
A
- Headache
- Head injury
- Dizziness
16
Q
Review of systems -> eyes
A
- Glasses or contact lenses
- Changes in vision
- Last examination
- Pain
- Redness
- Excessive tearing
- Double or blurred vision
- Spots, specks
- Illnesses -> glaucoma, cataract