HIV Flashcards
A 30-year-old female with multiple sexual partners presented with diarrhea, fever and weight loss, take a focused history.
Grip
Bio data
REPRODUCTIVE PROFILE
LMP: When was the first day of your last menstrual period?
Gravidity: Have you been pregnant before?
LCB: When was your last childbirth?
C-1 (Complain):
It says here that you’ve been experiencing fever, diarrhea and weight loss. Which one started first?
DOCTOR - Fever
Duration: When did it start?
Onset: Did it develop suddenly or gradually?
Character: Did you check your temperature? If yes, what was the value? If no, was it a high- or low-grade fever?
Timing: Is it present all through the day or only at specific times?
Other symptoms: Any chills, rigors or weakness (Same system as symptom)
Related phenomena: Any headache?
DOCTOR - Diarrhea
Duration: When did the diarrhea start?
Onset: Did it develop suddenly or gradually?
Character: Has it been improving or getting worse?
How many times do you stool in a day?
How much stool do you pass each time?
Timing: Is there any change with timing of the day?
Other: Any change in color or consistency? Any blood or mucus in the stool? Any abdominal pain or vomiting?
Related: Does the diarrhea alternate with constipation?
DOCTOR - Weight loss
Duration: When did it start? / When did you notice it?
Onset: Did it develop suddenly or gradually?
Character: What was your previous weight? What is your current weight? If no, how did you notice the weight loss?
Timing/Triggers: Do you know anything that may have triggered the weight loss?
Other symptoms: Any loss of appetite?
Related phenomena: Any dizziness, cough or fatigue.
C-3: CAUSES
- Have you had any unprotected intercourse?
- Do you have multiple sexual partners?
- Any history of blood transfusion?
- Do you have any tattoos?
- Do you use any injection drugs for recreation?
- Do you have a family history of cancers like colon cancer?
- Any history of neck swelling, heat intolerance and bulging eyes?
- Any history of cough, drenching night sweats with the fever?
- Do you consume food from unsanitary places?
C-4: COMPLICATIONS
- Any sore throat or painful swallowing with whitening of your tongue? (Oro-esophageal Candidiasis)
- Any history of memory loss or personality changes? (Dementia)
- Any history of foam in the urine or excessive urination?
(Nephropathy) - Do you have widespread rash all over your body? (Skin eruption)
- Any bone pain, back pain or coughing up blood? (Metastasis)
C-5: CARE SO FAR
For the above symptoms, have you taken any medication, done any investigation, visited any pharmacy, hospital or prayer house?
OBSTETRIC AND GYNECOLOGIC HISTORY
At what age did you start menstruating? - Menarche
Are your periods regular? How many days do you menstruate and how many days in-between each cycle?
Do you use any contraceptives?
Have you heard of or done a pap smear before?
Did you attend antenatal care?
Was there any complication during pregnancy or childbirth?
How long did you carry the pregnancy for?
PAST MEDICAL ISTORY
Are you a known hypertensive, diabetic, asthmatic, epileptic or sickle cell disease patient? Do you have peptic ulcer disease?
Any hospitalization or surgeries or blood transfusion in the past?
FAMILY AND SOCIAL HISTORY
Do you have a family history of hypertension, diabetes, epilepsy, asthma or sickle cell disease?
Do you smoke or consume alcohol?
If yes, how many bottles or packs per day?
DRUG HISTORY
Are DRUG HISTORY
Are you on any current or long term medications?
Do you have any known drug allergies?
SYSTEMS REVIEW
Do you have any headache or blurry vision?
Any cough or shortness of breath?
Any chest pain or bluish coloring of your lips and fingers?
Any pain or difficulty urinating?
Any bone or joint pain?
Any excessive bleeding or easy bruising?
