1. Relationship, family children, pets 2. Occupational history, past-time 3. Driving, GP, access 4. Independence, home modifications, ACAS 5. Community/associations/faith 6. Anxiety/depression 7. Sleep/nutrition 8. Perspective/insight/problem

Long case general history Flashcards by Luke Bonavia

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

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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

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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

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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

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Medical history -renal

CKD -T2DM, HTN,

proteinuria – protein in urine, haematuria – dark urine

renal calculi, prostatitis, cysts

i. Dialysis – fluid management – fluid restriction,

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Medical history - Infectious disease - systemic symptoms

loss of weight, loss of appetite, sweats, chills, rigors, myalgias, malaise

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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

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Medical history - Infectious disease - endogenous risk factors

lines

joint prostheses

cardiac prostheses/valve replacements

spinal fusions

vertebral fractures

recent surgery/dental extraction

renal calculi

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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

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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

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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

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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

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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

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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

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Symptom history - chest pain

Cardiac MI - non MI - percarditis, valve prolapse, arrythmia Non cardiac - dissection, PE, chest wall Oesophageal

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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

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

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. 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