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Internal Medicine > OHCEPS - The History > Flashcards

OHCEPS - The History Flashcards

1
Q

What is the presenting complaint (PC)?

A

This is the patient’s chief symptom(s) IN THEIR OWN WORDS and should be no more than a single sentence.

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2
Q

What happens if the patient has several symptoms?

A

Present them as a list which you can expand on later in the history.

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3
Q

What should be asked in order to obtain the PC?

A

An open question –> “What is the problem?”, “What made you come to the doctor?”.
NOT “What brought you here?” –> Answer is a taxi, or an ambulance (joke).

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4
Q

What must be asked in the history of the presenting complaint (HPC)?

A

Ask about and document the details of the presenting complaint (PC).

  1. By the end of this –> Clear idea about the nature of the problem.
  2. HOW + WHEN it started.
  3. HOW the problem PROGRESSED over time.
  4. What impact it has on the patient in terms of their general health, psychology, social and working lives.
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5
Q

In how many phases should the HPC be taken?

A

In two phases.

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6
Q

What happens in the 1st phase of the history of the presenting complaint (HPC)?

A
  1. Ask an open question.
  2. Allow the patient to talk for about 2 minutes. Don’t interrupt!.
  3. This will also allow you to make an initial assessment of the patient in terms of education level, personality, and anxiety.
  4. Using this info –> Adjust your responses and interaction.
  5. It should also become clear to you exactly what symptom the patient is MOST CONCERNED about.
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7
Q

What happens in the 2nd phase of HPC?

A
  1. Revisit the whole story –> ask more detailed questions.
  2. Useful to say “I’d just like to go through the story again, clarifying some details”.
  3. This is your chance to verify time-lines + the relationship of one symptom to another.
  4. Clarify pseudo-medical terms (what does the patient mean by “vertigo”, “flu”, or “rheumatism”).
  5. THIS SHOULD FEEL LIKE A CONVERSATION, NOT AN INTERROGATION.
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8
Q

What should have been established by the end of the HPC?

A

A PROBLEM LIST –> Run through these with the patient summarizing what you have been told and ask them if you have the information CORRECT + If there is ANYTHING FURTHER that they would like to share with you.

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9
Q

What should be determined about each symptom?

A
  1. Exact nature of symptom.
  2. Onset
  3. Periodicity and frequency
  4. Change over time
  5. Exacerbating factors
  6. Relieving factors
  7. Associated symptoms
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10
Q

What should be asked to determine the onset of each symptom?

A
  1. The DATE it began.
  2. HOW it began (suddenly, gradually - over how long?)
  3. If longstanding –> WHY is the patient seeking help NOW?.
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11
Q

What should be asked to determine the periodicity and frequency of each symptom?

A
  1. Is the symptom CONSTANT or INTERMITTENT?
  2. How long does it lasts each time?
  3. What is the exact manner in which it comes and goes?
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12
Q

What should be determined for pain?

A
  1. Site
  2. Radiation
  3. Character
  4. Severity
  5. Mode and rate of onset
  6. Duration
  7. Frequency
  8. Exacerbating factors
  9. Relieving factors
  10. Associated symptoms
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13
Q

How must the site of pain be determined?

A

Where the pain is worst - ask the patient to point to the site with ONE finger!

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14
Q

What should be asked to determine radiation of the pain?

A

Does the pain move anywhere else?

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15
Q

What should be asked to determine the character of pain?

A

Dull, aching, stabbing, burning etc.

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16
Q

What are 3 possible associated symptoms with pain?

A
  1. Nausea
  2. Dyspepsia
  3. Shortness of breath
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17
Q

What should be asked with long-standing problems?

A

If the symptom is long standing, ask why the patient is seeking help now. HAS ANYTHING CHANGED?
It is often useful to ask WHEN THE PATIENT WAS LAST WELL!
This helps focus their minds on the start of the problem which may seem distant and less important to them.

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18
Q

What must be done after talking about the PC?

A

A brief screen of other bodily systems - Systematic enquiry (SE).

19
Q

During systematic enquiry (SE) what must be asked, regarding general symptoms?

A
  1. Weight change (loss or gain)
  2. Change in appetite (loss or gain)
  3. Fever
  4. Lethargy
  5. Malaise
20
Q

During systematic enquiry (SE) what must be asked, regarding respiratory symptoms?

A
  1. Cough
  2. Sputum
  3. Hemoptysis
  4. Shortness of breath
  5. Wheeze
  6. Chest pain
21
Q

During systematic enquiry (SE) what must be asked, regarding cardiovascular symptoms?

A
  1. Shortness of breath on exertion
  2. Paroxysmal nocturnal dyspnea
  3. Chest pain
  4. Palpitations
  5. Ankle swelling
  6. Orthopnea
  7. Claudication
22
Q

During systematic enquiry (SE) what must be asked, regarding GI symptoms?

A
  1. Indigestion
  2. Abdominal pain
  3. Nausea
  4. Vomiting
  5. Change in bowel habit
  6. Constipation
  7. Diarrhea
  8. PR blood-loss
  9. Dysphagia
23
Q

During systematic enquiry (SE) what must be asked, regarding genito-urinary symptoms?

A
  1. Urinary frequency
  2. Polyuria
  3. Dysuria
  4. Hematuria
  5. Nocturia
  6. Menstrual problems
  7. Impotence
24
Q

During systematic enquiry (SE) what must be asked, regarding neurological problems?

A
  1. Headaches
  2. Dizziness
  3. Tingling
  4. Weakness
  5. Tremor
  6. Fits
  7. Faints
  8. “Funny turns”
  9. Black-outs
  10. Sphincter disturbance
25
Q

During systematic enquiry (SE) what must be asked, regarding locomotor symptoms?

A
  1. Aches
  2. Pains
  3. Stiffness
  4. Swelling
26
Q

During systematic enquiry (SE) what must be asked, regarding skin symptoms?

A
  1. Lumps
  2. Bumps
  3. Ulcers
  4. Rashes
  5. Itches
27
Q

What should be done during past medical history (PMH)?

A
  1. Some aspects of the patient’s past illnesses or diagnoses may have already been covered.
  2. HERE, you should obtain detailed info about past illnesses + surgical procedures.
  3. Ask if they’re under doctor for anything else, or have ever been to hospital before.
  4. Ensure you get DATES + LOCATION for each event.
28
Q

What conditions must be specifically asked about during PMH?

A
  1. Diabetes
  2. Rheumatic fever
  3. Jaundice
  4. Hypercholesterolemia
  5. Hypertension
  6. Angina
  7. MI
  8. Stroke or TIA
  9. Asthma
  10. TB
  11. Epilepsy
  12. Anesthetic problems
  13. Blood transfusions
29
Q

For each specific condition, what should be asked during PMH?

A
  1. WHEN was it diagnosed?
  2. HOW was it diagnosed?
  3. HOW has it been treated?
30
Q

What should be asked about operations during PMH?

A

Any previous ANESTHETIC PROBLEMS.

31
Q

What else should be asked during PMH?

A
  1. Immunizations

2. Company/insurance medicals

32
Q

What should be kept in mind during the PMH?

A

Don’t take anything for granted!
For each condition that the patient reports having, ask exactly HOW it was diagnosed (where?by whom?) and HOW it has been treated since.
If the patients reports “asthma”, ask WHO made the diagnosis, WHEN the diagnosis was made, if they have ever had a lung function tests, if they have ever seen a chest physician at a hospital, if they are taking any inhalers?

33
Q

Mention an occasion in which the patient gives a medical term to a long-standing symptom.

A

Asthma –> Could be how they refer to their wheeze which is, in fact, due to CHF.

34
Q

What should be kept in mind during asking about ALLERGIES?

A

Very important:

  • -> Patient will often tell you about their hay-fever and forget about the rash they had when they took penicillin.
  • -> Ask specifically if they have had any “reactions” to drugs or medication.
35
Q

If a patient reports an allergy, what should be done next?

A

Obtain the EXACT NATURE of the event and decide if the patient is describing a true allergy, an intolerance, or simply an unpleasant side-effect.

36
Q

What must be done during the drug history (DHx)?

A

List ALL the medication the patient is taking, including the DOSE and FREQUENCY of each prescription.
If patient is unsure –> confirm with pharmacy or GP.
–> Make a special note of any drugs that have been started or stopped recently.

37
Q

Is it important to ask about patient compliance?

A

Yes:

  1. Does he know what dose they take?
  2. Do they ever miss doses?
  3. If they are not taking the medication - what’s the reason?
  4. Do they have any compliance aids such as pre-packaged weekly supply?
38
Q

The patient may not consider some medications to be “drugs”. Mention some that must not be forgotten to be asked?

A
  1. Eye drops
  2. Inhalers
  3. Sleeping pills
  4. Oral contraception
  5. OTC drugs
  6. Vitamin supplements
  7. Herbal remedies
  8. “Illicit” or “recreational” drug-use
39
Q

What should be asked about alcohol?

A
  1. The quantity as accurate as possible.

2. Is the consumption spread evenly over the week or concentrated into a smaller period.

40
Q

What should be asked during “smoking section”?

A
  1. Attempt to quantify the habit in pack-years.
  2. Ask about previous smoking as many will call themselves non-smokers if they gave up yesterday or even on their way to the hospital or clinic!
  3. Remember to ask about PASSIVE smoking.
41
Q

What are the family history (FHx) details?

A
  1. Make up of the current family, including AGE and GENDER of parents, siblings, children and extended family as relevant.
  2. The health of the family.
  3. Ask about diagnosed conditions in other living family members.
  4. Document age of death + cause of death for all deceased 1st degree relatives.
42
Q

What should be done during the social history (SHx)?

A
  1. This is the chance to document the details of the patient’s personal life which are relevant to the working diagnosis.
  2. The patient’s general well-being and recovery/convalescence.
  3. It will help you understand the IMPACT of the illness on the patient’s functional status.
43
Q

What should be asked during SHx?

A
  1. Marital status
  2. Sexual orientation
  3. Occupation (or previous occupations if retired)
  4. Other people who live at the same address
  5. The type of accomodation
  6. Does the patient own or rent their accomodation?
  7. Are there any stairs? How many?
  8. Does the patient have any aids or adaptations in their house? (rails near the bath, stairlift)
  9. Does the patient use any walking aids (stick, frame scooter)
  10. Does the patient receive any help day-to-day? Who from? Who does the laundry, cleaning, cooking, and shopping?
  11. Does the patient have relatives living nearby?
  12. What hobbies does the patient have?
  13. Does the patient own any pets?
  14. Has the patient been abroad recently or spent any time abroad in the past?
  15. Does the patient drive?
44
Q

What does the standard history framework involve?

A
  1. Presenting complaint (PC)
  2. History of presenting complaint (HPC)
  3. Systematic enquiry (SE)
  4. Past medical history (PMH)
  5. Allergies
  6. Drug history (DHx)
  7. Alcohol
  8. Smoking
  9. Family history (FHx)
  10. Social history (SHx)

Internal Medicine (107 decks)

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