HISTORY TAKING PPT Flashcards
principle reason’s for seeking consult or admission
it can be a symptom sign or physical findings, diagnostic procedure or treatment
not necessary the initial or first symptom
chief complaint
most important part of medical history
written in narrative form should be chronological as symptoms comes
History of present illness
PQRST OF PAIN
precipitating
quality
region
severity
time
PQRST OF PAIN
what brings out symptoms
what makes the symptoms worst?
Precipitating
PQRST OF PAIN
what is the symptom like?
example: pain; sharp throbbing
quality
PQRST OF PAIN
ask the patient to point out the specific location of pain and where pain radiates
region
PQRST OF PAIN
may report in pain scale
severity
PQRST OF PAIN
*onset of each symptom prior to date of admission/consultation
*duration of symptoms:
how long does symptom last?
recurrent: every 4 days
continous: no free periods
time relationships
following the summary of the previous admission, write the chief complaint
then the interval history follows the chief complaint
that will replace the HPI
interval history
response of interviewer
used when the person’s choice of words is ambigous or confusing
clarification
response of interviewer
in terms of duration, frequency and intervals
chronology
no diagnostic value but may have some effect on present illness
a. childhood illnesses?
b. immunizations?
c. allergies?
d. hospitalizations?
past medical history
General systems review (constitutional symptoms)
fever
chills
malaise
weight change
Integumentary systems review
pruritus
pigmentation
texture change
head and neck review
headache
diplopia
syncope
blurring
dizziness
photophobia
eye pain
hearing loss
ear pain
epsitaxis
sore throats
