Flashcards in Patient Interviewing: Deck (23):
Identifying Data and Source of the History
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.
History of Present Illness:
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) **
Chief Complaint (s):
One or more sx’s or concerns causing the pt to seek care
Past Medical History:
childhood illness, adult illnesses with dates for: medical, surgical, OB/GYN and psych; immunizations, screening tests, lifestyle issues and home safety
outlines age, health, death
Personal & Social History:
occupation, current household, personal interests and lifestyle, diet and exercise
Dose, Frequency, Adherence to the regimen, include OTC & herbals/alternative meds
Allergies: medication/food and description of reaction
Sources of support
Occupation: present and past, exposure to occupational hazards
Habits: ETOH (open ended q), tobacco (ppd x yrs), illegal drug use, coffee/caffeine intake, exercise, diet
immunizations and preventive screening
Review of systems: General:
Usual weight, recent weight change, clothing that ts more tightly or loosely than before; weakness, fatigue, or fever.
Review of systems: Skin:
Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.
Review of systems: Head, Eyes, Ears, Nose, Throat (HEENT):
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.
Review of systems: Neck
“Swollen glands,” goiter, lumps, pain, or stiffness in the neck.
Review of systems: Breasts
Lumps, pain, or discomfort, nipple discharge, self-examination practices.
Review of systems: Respiratory:
Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.
“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.
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.
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.
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.
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.
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.
Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.