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History taking
Comprehensive History: Adult patient
| Question | Answer |
|---|---|
| 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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