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History taking and physical examination > History taking > Flashcards

History taking Flashcards

1
Q

Questions to every symptom

A
  1. Location
  2. Quality
  3. Quantity to Severity
  4. Timing:
    1) Onset
    2) Duration
    3) Course including frequency
  5. The Setting (in which it occurs)
  6. Aggregating and Relieving factors
  7. Associated manifestations -> after Review of Systems come back and check
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2
Q

Interview - parts

A
  1. Identifying Data
  2. Present illness
  3. Past history
  4. Family history
  5. Social history
  6. Reliability
    (7. Review of systems)
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3
Q

Identifying Data

A
  1. Name
  2. Age
  3. Gender
  4. Race
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4
Q

Present illness

A
  1. Chief complaint
  2. Other present complaint
  3. Complete chronological description of problems prompting patient’s visit
  4. Pain-> present
  5. (Present status) -> if already hospitalized
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5
Q

Past History

A
  1. Allergies and drugs
    1) Alergies
    2) Medications
    3) Tabacco
    4) Alcohol
    5) Other drugs (illegal)
  2. Past illnesses
  3. Preventions
  4. Physiological activities
  5. Lifestyle
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6
Q

Past illnesses

A
  1. Internal medicine
    1) Diabetes
    2) Obesity
    3) Hypertension
    4) Asthma
    5) Cardio and Strokes
    6) Diverticular disease
    7) Hospitalizations
    8) Infectious diseases eg. HIV
  2. Surgical
  3. OB/Gyn
    1) OB
    1. How many pregnancies
    2. How many deliveries
    3. Complications
    4. Children health (deaths)
      • > G-P-M-L -> gravida-parity-miscarriages-living
    2) Menstrual history
    1. First
    2. Last
    3. Regularity and frequency
    4. Bleeding-> during menorrhea and cycle
    3) Sexual interview and STD
  4. Psychiatric

(5. Pediatric)
1. Which week of pregnancy
2. Birth weight
3. Apgar score
4. Complications during labor/pregnancy
5. Development

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7
Q

Preventions

A
  1. Immunizations -> children
  2. Screening tests
    1) mammography
    2) cervix
    3) colonoscopy
    4) blood tests
    1. Cholesterol
    2. Glucose
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8
Q

Physiological activities

A
  1. Urination
  2. Defecation
  3. Sleep
  4. Hunger -> changes
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9
Q

Lifestyle

A
  1. Diet
  2. Exercise
  3. Stress
  4. Sexual activities
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10
Q

Family History

A
  1. Diseases in family
    1) Diabetes
    2) Obesity
    3) Hypertension
    4) IHD
    5) Oncology
    6) Other-> which patient might have
  2. Health of:
    1) Parents
    2) Grandparents
    3) Siblings
    4) Children
    5) Grandchildren
  3. (Cause of death)
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11
Q

Social history

A
  1. Household
  2. Occupation
  3. Education level
  4. Stress
  5. Exotic adventures
  6. Exposure
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12
Q

Review of systems -> systems

A
  1. General
  2. Skin
  3. HEENT
  4. Neck
  5. Thorax
    1) Breasts
    2) Respiratory system
    3) Cardiovascular system
    4) Peripheral vascular system
  6. Abdomen
    1) Gastrointestinal system
    2) Urinary system
    3) Reproductive system
  7. Endocrine
  8. Hematologic
  9. Musculoskeletal
  10. Neurological
  11. Psychiatric
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13
Q

Review of systems -> general

A
  1. Weight
    1) Usual weight
    2) Recent weight change (eg. clothing that fits more tightly or loosely than before)
  2. Weakness and fatigue
  3. Fever, chills, night sweats
  4. Pain
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14
Q

Review of systems -> skin

A
  1. Changes -> rashes, lumps, sores, itching, dryness
  2. Changes in color
  3. Changes in size or color of moles
  4. Changes in hairs or nails
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15
Q

Review of systems -> Head

A
  1. Headache
  2. Head injury
  3. Dizziness
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16
Q

Review of systems -> eyes

A
  1. Glasses or contact lenses
  2. Changes in vision
  3. Last examination
  4. Pain
  5. Redness
  6. Excessive tearing
  7. Double or blurred vision
  8. Spots, specks
  9. Illnesses -> glaucoma, cataract
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17
Q

Review of systems -> ears

A
  1. Hearing
  2. Vertigo
  3. Tinnitus
  4. Earaches
  5. Infection
  6. Discharge
  7. Use of hearing aids if hearing is decreased
18
Q

Review of systems -> nose& sinuses

A
  1. Frequent colds
  2. Nasal stuffiness (niedroznosc)
  3. Discharge
  4. Itching
  5. Alergies
  6. Nosebleeds
  7. Sinus trouble
19
Q

Review of systems -> throat

A
  1. Condition of teeth and gums
  2. Bleeding gums
  3. Denture and if so how it fits
  4. Last dental examination
  5. Sore tongue
  6. Dry mouth
  7. Frequent sore throats
  8. Hoarseness (chrypka)
20
Q

Review of systems -> neck

A
  1. Swollen glands
  2. Goiter
  3. Lumps (guzki)
  4. Pain
  5. Stiffness
21
Q

Review of systems -> breasts

A
  1. Lumps
  2. Pain or discomfort
  3. Nipple discharge
  4. Self-examination practices
22
Q

Review of systems -> respiratory

A
  1. Cough
  2. Sputum
  3. Dyspnea -> shortness of breath
  4. Wheezing
  5. Pain with a deep breath (pleuritic)
  6. Last chest X-ray
23
Q

Review of systems -> cardiovascular

A
  1. Heart trouble
  2. Blood pressure
  3. Chest pain or discomfort
  4. Palpitations
  5. Valves and heart murmurs
  6. Orthopnea-> need to use pillows at night to ease breathing
  7. Need to sit up at night to ease breathing (Paroxysmal Nocturnal Dyspnea)
  8. Swellings in the hands, ankles or feet’s
  9. Results of past ECG or other tests
24
Q

Review of systems -> peripheral vascular

A
  1. Intermittent leg pain with exertion (claudication, chromanie)
  2. Leg cramps (skurcze)
  3. Varicose veins
  4. Past clots in the veins
  5. Swelling in calves (lydka), leg or feet
  6. Color change in fingertips or toes during cold weather
25
Q

Review of systems -> gastrointestinal

A
  1. Trouble swallowing
  2. Heartburn
  3. Appetite
  4. Nausea
  5. Bowel movements
    1) General -> constipations, diarrhea, frequency
    2) Stool color and size
    3) Change in bowel habits
    4) Pain with defecation
    5) Rectal bleeding & black and tarry stools
  6. Excessive belching or passing of gas
  7. Abdominal pain
  8. Food intolerance
  9. Liver
    1) Jaundice
    2) Liver or gallbladder trouble
    3) Hepatitis
26
Q

Review of systems -> urinary

A
  1. Frequency of urination
  2. Quantity-> polyuria, oliguria, anuria
  3. Nocturia
  4. Urgency
  5. Hematuria
  6. Pain or burning during urination
  7. Urinary infections
  8. Kidney or flank pain
  9. Kidney stones -> ureteral colic, suprapubic pain
  10. Incontinence
  11. Hesitancy
  12. Dribbling (kapanie, mala ilosc) and prostate function
27
Q

Review of systems -> reproductive woman

A
  1. Menstrual period
    1) age of first (menarche)
    2) last
    3) frequency& regularity
    4) amount of bleeding & bleeding between periods or after intercourse
    5) dysmenorrhea-> pain during
    6) premenstrual tension
  2. Menopause
    1) age of
    2) symptoms
    3) postmenopausal bleedings
    4) osteoporosis
  3. Infections
    1) vaginal discharge
    2) itching
    3) sores
    4) lumps
    5) STD and treatments (HIV)
  4. OB
    1) number of pregnancies
    2) number of deliveries
    3) type of deliveries
    4) number and cause of abortions
    5) complications of pregnancies
  5. Sexual
    1) sexual problems
    2) interest
    3) function
    4) satisfaction
    5) dyspareunia
    6) birth control methods
28
Q

Review of systems -> reproductive man

A
  1. STD
    1) history and treatment
    2) discharge from penis
    3) changes and sores on the penis
  2. Sexual
    1) sexual problems
    2) interest
    3) function
    4) satisfaction
    5) dyspareunia
    6) birth control methods eg. Condoms
    7) habits and preferences
  3. Testicular
    1) pain
    2) masses
    3) scrotal swelling
29
Q

Review of systems -> endocrine

A
  1. Thyroid trouble
  2. Heat or cold intolerance
  3. Excessive swelling
  4. Excessive thirst or hunger
  5. Change in glove or shoe size
30
Q

Review of systems -> hematologic

A
  1. Anemia
  2. Easy bruising or bleeding
  3. Past transfusions & reaction if so
31
Q

Review of systems -> musculoskeletal

A
  1. Muscle to joint pain
  2. Stiffness
  3. Arthritis
  4. Backache
  5. Swelling of joints or muscles
  6. Limitation of motion or activity
  7. Joint pain with other symptoms eg. fever, chills, rash, anorexia, weight loss or weakness
32
Q

Review of systems -> neurological

A
  1. Changes in mood, attention
  2. Speech changes
  3. Changes in orientation
  4. Memory
  5. Changes in insight or judgement
  6. Headache
  7. Dizziness, vertigo
  8. Fainting
  9. Weakness
  10. Paralysis
  11. Numbness or loss of sensation
  12. Tingling
  13. Tremors or other involuntary movements
  14. Seizures
33
Q

Review of systems -> psychiatric

A
  1. Mood
  2. Nervousness
  3. Depression
  4. Memory changes
  5. Suicidal ideation, plans or attempts
  6. Past counseling, psychotherapy or psychiatric admissions
34
Q

Diabetes mellitus interview

A
  1. History of disease
  2. Lifestyle
  3. Complications
35
Q

Diabetes mellitus history of disease

A

1) Time of diagnosis
1. When
2. Symptoms
3. Glucose level
4. Treatment
5. Weight
6. Which type

2) Now
1. Treatment
2. Glucose level-> now and usually
3. Last HbA1c
4. Episodes of hypoglycemia
5. Highest weight in life
6. Present a eight

36
Q

Diabetes mellitus lifestyle

A
  1. Diet

2. Sport

37
Q

Diabetes mellitus complications

A
  1. Kidneys
  2. Neuropathy
  3. Ophthalmological
  4. Hypertension
  5. IHD
  6. Stokes
38
Q

Diabetes mellitus complications -> kidneys

A
  1. Polidypsja
  2. Poliuria
  3. Nocturia
  4. History of creatinine, GFR
39
Q

Diabetes mellitus complications -> neuropathy

A

1) Autonomical system
1. Defecation -> constipation, diarrhea
2. Sweats

2) Somatic
1. Sensation in feet, palms
2. Episodes of diabetic foot, Chargot joints

40
Q

Diabetes mellitus complications -> ophthalmological

A
  1. Loss of vision
  2. Last ophthalmology examination
  3. Operations of cataract

History taking and physical examination (12 decks)

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