Long case general history Flashcards
Social history
- Relationship, family children, pets
- Occupational history, past-time
- Driving, GP, access
- Independence, home modifications, ACAS
- Community/associations/faith
- Anxiety/depression
- Sleep/nutrition
- Perspective/insight/problem
Medical history - Cardiac
Symptoms - reduced exercise tolerance, palpitations. orthopnoea, paroxysmal noctural dyspnoea, cough
i. Coronary artery disease– MI, valve disease, pericarditis; HTN, dyslipidaemia, T2DM, family history, bypass grafts, angiograms
ii. Heart failure - echocardiograms; cardiac devices/pacing
iii. Arrhythmias- AF, SVT, VT, cardioversions, arrests
iv. Pericardial disease and valves
Medical history - Lung
Exercise tolerance, cough
i. Obstructive airways - asthma, COPD, bronchiectasis childhood infections – pertussis, smoking, cystic fibrosis CT chests, spirometry prior intubations
ii. Pulmonary hypertension - right heart catheterisation
iii. pleural disease - pneumothorax, effusions, empyema, resections
iv. interstitial lung disease, occupational exposure – silica, coal, dust, hay, birds, fumes/gases
v. sleep apnoea
Medical history - gastrointestinal
Heartburn, reflux, Abdominal pain, nausea/vomiting, diarrhoea, difficulty swallowing, dysphasia, constipation
i. Liver – etOH, hepatitis, ascites, pancreatitis
ii. Upper GI – peptic ulcer disease, GORD, gall bladder issues
iii. Lower GI - diarrhoea FI, colonscopies/gastroscopies, GI masses, coeliac disease
Medical history -renal
CKD -T2DM, HTN,
proteinuria – protein in urine, haematuria – dark urine
renal calculi, prostatitis, cysts
i. Dialysis – fluid management – fluid restriction,
Medical history - Infectious disease - systemic symptoms
loss of weight, loss of appetite, sweats, chills, rigors, myalgias, malaise
Medical history- Infectious disease - location of disease
cough/coryzal symptoms
meningism
joint pain
lower urinary tract symptoms
obstructive outflow symptoms
back pain
Abdomina RUQ pain
rashes
Medical history - Infectious disease - endogenous risk factors
lines
joint prostheses
cardiac prostheses/valve replacements
spinal fusions
vertebral fractures
recent surgery/dental extraction
renal calculi
Medical history - rheumatology
i. SLE/RA /scleroderma/vasculitis/PsA;
ii. OA gout reactive arthritis
iv. Function - Joint aspirates and injections, joint and tendon surgery and replacement, mobility and function, disease activity
v. associated lung/heart/GI/renal and neurological sequellae, serology
Medical history - oncology
i. Oncology previous cancer in family or patient, previous CTx/RTx surgeries, ii. Haematology -blood clots, bleeding disorders, previous bone marrow trephines, lymph node dissections; anaemia FI
Medical history - Endocrinology - bone and thyroid
i. Bone and thyroid- previous osteoporosis, fragility fractures, bisphosphonate
thyroid issues, previous parathyroid surgeries, pituitary syndromes, pituitary surgery, hypogonadism
Medical history - endocrine - metabolism
T2DM/T1DM insulin, hypoglycaemic issues,
microvascular disease (nephropathy, neuroapthy, retinopathy, gastroparesis, orthostatic hypotension, urinary overflow, erectile dysfunction)
macrovascular disease (stroke, PVD, IHD)
OSA, gastric bypass surgery, B12/thiamine deficiencies
Medical history - neurology -CNS
i. Neurology CNS – stroke, thrombolysis, rehab, residual deficit; migraines, epilepsy, neurosurgery – clips/coils
tumours
multiple sclerosis
cerebellopontine angle tumour
meningitis/encephalitis prior
syringomyelia
hydrocephalus
spinal cord impingement – cervical myelopathy
Medical history - neurology -PNS
ii. Neurology PNS – neuropathy, myopathy – disuse, drug related; mobility; parkinson’s disease, tremors, effect on daily life; carpal tunnel syndrome, nerve entrapments
Symptom history - chest pain
Cardiac MI - non MI - percarditis, valve prolapse, arrythmia Non cardiac - dissection, PE, chest wall Oesophageal
Symptom history - dyspnoea
Obstructive/restrictive lung disease - COPD/asthma/bronchiectsis, ILD, Pulmonary hypertension Angina, APO, arrhythmia - cardiac Anaemia Metabolic acidosis - lactic (sepsis, other cause shock), renal, DKA Vertebral - thoracic Muscle - MND, peripheral neuropathy, phrenic nerve palsy
Symptom history - weightloss, fatigue, sweats etc.
Malignancy Chronic infection Inflammatory disease Malabsorptive - pancreatic/small intestine (coeliac, surgery) hyperglycaemia/hypoglycaemia Hypothyroidism/hyperthyroidism/panhypopit renal failure cardiorespiratory failure Sleep apnoea Depression/anxiety
Symptom history - headache - secondary
Subarachnoid haemorrhage/ICH meningitis Central venous thrombosis Giant cell arteritis Acute glucoma Tumour Idiopathic intracranial hypertension
symptom headache - primary
Migraines Tension headache trigeminal neuralgia cervicogenic OA Cluster headaches post coital headache
Symptom - syncope/funny turn
Cardiac/vasovagal
PE
Micturition syncope
cough syncope
Orthostatic
hypotension
Seizure
TIA/stroke
cataplexy
acute hydrocephalus
Symptoms - back pain
Osteomyelitis/abscess
AAA rupture
Bony metastasis
Inflammatory back pain - seronegative ank spond
Vertebral fracture Muscle spasm
Facet joint
OA
Symptoms - diarrhoea
Infective -c.diff/HIV
transient bacteria/viral drug related
inflammatory cancer
malabsorptive thyroid/T2DM
carcinoid/VIPoma
Symptoms - joint/limb pain
PVD - acute ischaemic limb
DVT
synovitis – septic joint, viral, gout, RA, PsA, reactive arthritis, rheumatic fever,
Scl
Tendonitis
Tendon/ligamentous injury
Neuropathy - compressive/non compressive
Specialty history - atopy/allergy
childhood eczema
rhinitis
polyps
urticaria
anaphylaxis
drug allergies
RAST/skin tests
Specialty history - geriatric
glasses
macular degeneration
cataracts
hearing aids
optometry
appointments and access
mobility
hearing aids
urinary incontinence
faecal incontinence
end of life issues
falls and balance
vertigo/postural dizziness
Specialty history - HIV
HIV – diagnosed, CD4 count
medication history
compliance
sexual history
opportunistic infections
cancers
autoimmune disease
CVD
OP
etOH
Specialty history - transplantation
Live or cadaveric
HLA matching
CMV EBV status
bone marrow (allogenic/autogenic)
liver
kidney
lung
heart pre-transplant work up
indications and contraindications
post transplant rejection
Opportunistic infection
GVHD
Veno-occlusive disease of the liver
Chronic hypothyroidism, solid organ Ca, AML, infertility, recurrence, PTSD
Specialty history- immunosuppressives
prednisolone
cyclosporine
tacrolimus
mycophenylate
methotrexate
azathioprine
anti-TNF inhibitors
specialty - immunosuppressive SEs
Opportunistic infections - all
Coarse tremors, gingival hypertrophy, hirustism (cyclosporine, tacro)
T2DM, HTN, dyslipidaemia (pred, tacro, cyclospo)
Bone marrow suppression, mucositis, deranged LFTs, lymphoma (mycophenylate, methotrexate, azathioprine)
Demyelination, infusion site reactions, TB, hep B,C reactivation, CCF (anti-TNF)
Specialty -maternal
pregnancies
miscarriages
terminations
antepartum, peripartum, post partum complications
vaginal or caesarean births
cervical and breast cancer screening
age of menarche
Specialty - sexual history
number of sexual partners
barrier protection
OCP
erectile dysfunction
libido
Specialty - mental health
depression
anxiety
bipolar
schizophrenia
Suicidal ideation
Number of admits
psychiatrist
Medications currently taking
Vegetative Sx- lethargy, loss of interest and appetite, sleep disturbance, psychomotor retardation
Specialty -etOH - AUDIT-C
How often do you have alcohol drink-
0 never, 1 monthly or less,
- 2-4 times per month,
3- 2-3 times per week,
4, 4> times How many standard drinks containing alcohol do you consume?
• 0 1 or 2, 1. 3 or 4, 2. 5 or 6, 3. 7 to 9, 4. 10 or more
How often do you have 6 or more drinks on a single occasion
• 0. Never, 1. Less than monthly, 2. Monthly, 3. Weekly, 4. Daily or almost daily
4 or more men, 3 or more woman, but if questions 2 and 3 are 0 then likely below limits to drinking
Medical history - Rheumatology - differentiating symptoms
Raynauds
morning stiffness - difficulty getting out of bed
rashes- soles of feet, hands, prior psoriasis
Back pain with rest
joint pain with rest
eyes - pain, dryness, redness, visual loss
generalised loss of weight and appetite, malaise
