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History taking

Comprehensive History: Adult patient

What are the 7 primary components of Past Medical History? Childhood illnesses, adult illnesses, psychiatric illnesses, hospitalizations, medications, allergies, and health maintenance
What are the 7 primary components of the HPI? Location, quality, quantity (severity), timing, setting, alleviating/aggravating factors, associated symptoms
What are the major childhood illnesses that should be inquired of in the PMH? Measles, mumps, rubella, scarlet fever, rheumatic fever, and polio
What are the major allergies which should be inquired about in the PMH? Food allergies, animals or insects, and latex
What 3 questions should be involved in the skin review of systems? Any rash, itching, or color changes
What 20 components should be evaluated in the review of systems? Skin, head, eyes, ears, nose, mouth, throat, neck, breast, respiratory, cardiac, gastrointestinal, urinary, reproductive, peripheral vascular, musculoskeletal, neurologic, hematologic, endocrine, and psychiatric
What should be inquired about during the eye portion of the ROS? Double or blurry vision, color changes
What should be inquired about during the breast portion of the ROS? Lumps, pain or discomfort, discharge, regularity of self examination
What should be inquired about during the genital review of systems (male)? Discharge, sores, testicular pain or masses, STD's and sexual preference (Note: pain on urination can be asked here but is commonly asked during urinary portion of ROS)
What should be inquired about during the genital review of systems (female)? Age at menarche, regularity/frequency/duration of periods, last menstrual period, age at menopause (if applies), menopausal symptoms, discharge, itching, sores, STD's and sexual preference, number of pregnancies, deliveries, abortions, and birth control.
What should be inquired about during the hematologic review of symptoms? Easy bruising or bleeding, past transfusions and any reactions to them
What should be inquired about during the endocrine ROS? heat or cold intolerance, excessive sweating, diabetes, excessive thirst or hunger
What should be inquired about during the psychiatric ROS? Nervousness, stress, depression, memory problems
What questions should be asked in succession to detect a drinking problem? Start with, "How much alcohol do you drink?", follow with "Have you ever had a drinking problem?" and "When was your last drink?"; if affirmative to first and within 24 hrs to second follow with CAGE (Cut Down, Annoyed by criticism, Guilt, Eye-opener)
What should be inquired about during the neurologic ROS? Weakness, paralysis, numbness or loss of sensation, tingling, tremors or other involuntary movements
Created by: rahjohnson
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