Patient Interviewing:

Question 0

History of Present Illness:

Answer 0

Expands on chief complaint; describes how symptoms developed
1.) location 2.) quality 3.) quantity or severity 4.) timing, including onset, duration, freq 5.) setting in which it occurs 6.) factors that have aggravated or relieved the sx’s 7.) associated manifestations
**Some use the mnemonic: OPQRST (Onset, Palliation/Pain, Quality, Radiation,
Severity, Timing) **

Question 1

Identifying Data and Source of the History

Answer 1

Age, gender, occupation, marital status
Source of the history—usually the patient, but can be a family member or friend, letter of referral, or the medical record
If appropriate, establish source of referral, because a written report may be needed.

Question 2

Chief Complaint (s):

Answer 2

One or more sx’s or concerns causing the pt to seek care

Question 3

Past Medical History:

Answer 3

childhood illness, adult illnesses with dates for: medical, surgical, OB/GYN and psych; immunizations, screening tests, lifestyle issues and home safety

Question 4

Family History:

Answer 4

outlines age, health, death

Question 5

Personal & Social History:

Answer 5

occupation, current household, personal interests and lifestyle, diet and exercise

Question 7

Medications:

Answer 7

Dose, Frequency, Adherence to the regimen, include OTC & herbals/alternative meds

Allergies: medication/food and description of reaction

Question 8

Psychosocial Hx:

Answer 8

Marital status:
Sources of support
Occupation: present and past, exposure to occupational hazards
Hobbies/typical day:
Habits: ETOH (open ended q), tobacco (ppd x yrs), illegal drug use, coffee/caffeine intake, exercise, diet
Spirituality
Cultural issues:
Sleep patterns

Question 9

Health maintenance:

Answer 9

immunizations and preventive screening

Question 10

Review of systems: General:

Answer 10

Usual weight, recent weight change, clothing that ts more tightly or loosely than before; weakness, fatigue, or fever.

Question 11

Review of systems: Skin:

Answer 11

Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.

Question 12

Review of systems: Head, Eyes, Ears, Nose, Throat (HEENT):

Answer 12

Head: Headache, head injury, dizziness, lightheadedness.
Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, ashing lights, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, ear aches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids.
Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they t, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.

Question 13

Review of systems: Neck

Answer 13

“Swollen glands,” goiter, lumps, pain, or stiffness in the neck.

Question 14

Review of systems: Breasts

Answer 14

Lumps, pain, or discomfort, nipple discharge, self-examination practices.

Question 15

Review of systems: Respiratory:

Answer 15

Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.

Question 16

Cardiovascular:

Answer 16

“Heart trouble,” high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, results of past electrocardiograms or other cardiovascular tests.

Question 17

Gastrointestinal:

Answer 17

Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

Question 18

Peripheral vascular:

Answer 18

Intermittent claudication; leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.

Question 19

Urinary:

Answer 19

Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.

Question 20

Genital:

Answer 20

Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth- control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection.

Question 21

Musculoskeletal:

Answer 21

Muscle or joint pain, stiffness, arthritis, gout, back-ache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness.

Question 22

Psychiatric:

Answer 22

Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.

Question 23

Neurologic:

Answer 23

Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements, seizures.