HISTORY TAKING

HISTORY TAKING

A. MEDICINE

1. HAEMOPTYSIS

CS: Male,50 years old. Complain of coughing out blood.

HOPI

· Frequency – is it recurrent?

· Quantity and appearance

o Amount: ½ teaspoon?

o Fresh blood?

o Any blood streak+clear sputum

o Blood clot in sputum?

· Associated symptoms

o SOB?

o Chest pain? (ask for pleuritic pain, central?)

o Fever?

§ Chills and rigor?

§ Low grade or high?

§ Night sweats?

· TB history

o Any TB in the past? On treatment(complete)?

o Contact with people having TB?

o Closed contact with TB pt?

Systemic Review

· Any loss of weight or appetite?

· Ask for signs of anemia (tiredness, diziness, gidiness)

· Calf pain?

Past Medical History

· Any childhood infection?

· History of any chronic illness?(DM, HT)

· History of valvular damage?

· Admitted/investigated?(Any xray, sputum examination,bronchoscope,any blood transfusion?)

Drug History

· On drugs? (anticoagulant)

Social History

· Chronic smoker?

· History of travel overseas/crowded places?

2. INTERMITTENT CLAUDICATION

CS: Male, 50 years. Complain of old pain at the right leg while walking for the pass 1 month.

HOPI

· Site of pain? (Right calf?)

· What brought on the pain? (Onset)

· Nature of pain?

· Radiate to buttock? (Gluteal claudication)

· Duration: last for?

· Relief at rest?

· Do you have swelling on calf?

· Claudication distance (how long were the pt able to walk before he experience the pain?(100m?2km?)

· Severity: Impact on job?

Risk Factors

· DM(on treatment?)

· HPT (on treatment?)

· Chronic smoker?

· History of coronary heart disease?

· Previous stroke?Chest pain? TIA?

· Any investigation done?(doppler's ultrasound?) Medication given?

· Family history?

3. MIGRAINE

CS: Female, 16 years old. Complain of frequent headache.

HOPI

· Site of pain

o Unilateral? Bilateral? Temporal side? Frontal?

· Experience since?

· Nature of the pain (throbbing)

· Duration? (minutes? Hours?)

· Intensity (scale out of 10, 1 is least pain 10 is the worse)

· Associated symptoms

o Nausea, vomiting (relief after vommiting?)

o Aura(mood changes, flashes of light, fortification spectrum-zig zag lines)

o Neck stiffness

· Aggravating factors

o Noise, lights(photophobia) stress, menstrual cycle

o Food(cheese,chocolate, red wine, OCP)

· Relieving

o Dark room and quiet, medication-what?

· Any trauma

· Infection

Family history

· Family members who also had migrain?

Drug History

· Contraceptive?

Social History

· Occupation? Is it stress?

· Smoking? Alcohol?

· Is the headache investigated?? (CT? MRI?)

4. WHEEZING

CS: Male, 18 years old. Complain of wheezing

HOPI

· First time having the problem? Since when?

· Progression

· Duration: How long? Any particular time?

· Severity: how long it lasts

· Aggravating factors/worsen?

o Smoke, at night, drugs, food, weather, dust(ask any carpets or plush toys at home)pets, excess exercise,eczema/skin rash, any allergy to drugs, stress, eating seafood:worse?

· Relieving factors?

o Inhaler(blue:short acting, brown-long acting: how frequent? How many puffs? Nebulizer? Any admission to the hospital?)

o Getting better when taking it?

Systemic Review

· Chest pain? (describe it.. Tightness of the chest?)

· Any dry cough?

Past Medical History

· Any life threatening episodes(emergency admitted)? Any nebulizer/ventilator given?

Family History

· Any family history of astma?

Social History

· Chronic smoker?

· Occupation? (factory worker)

· Exposure to insecticides

5. SHORTNESS OF BREATH

CS: Male,45 years old. Complain shortness of breath

HOPI

· Duration?

· First time?

· Worsening?

· Associated symptoms

o Cough?

o Chest pain?

o Wheezing?

o Palpation?

· Any sputum production?

o Mucoid/pus purulent/foul smelling

o Hemoptysis

o Amount

· Early morning cough?

· Paroxysmal Nocturnal dyspnea?

· Aggravating factor

o Changes of weather, environmental pollution:smoke/haze

· Relieving factor

o Inhaler, nebulizer(any admission)

Systemic Review

· Recent loss of weight, loss of appetite

· Leg swelling?

Past Medical History

· Past history of TB?

· History of DM?

· Admission for life, threatening episodes

Social History

· Smoking?

· Occupational history?

6. ACUTE CHEST PAIN

CS: Male, 40 years old. Complain of chest pain for 1 hour duration

HOPI

· Site: central

· Onset: sudden

· Nature of pain: crushing pain

· Radiation: left arm, neck and jaw

· Associated symptoms:

o Profuse sweating, nausea, vomiting, coughing

· Duration: more than 20 minutes

· Intensity: grade 1-10

· Relieving factors

o No relieving factor, not relieved by nitrates

· Frequency

o Is this first episode? Ask whether first time admitted? Intensity compared to previous episode.

o If 2nd episode, ask about nitrates/GTN.

Risk Factors

· Atherosclerosis

· Hypertension

· Diabetes Mellitus

· Hyperlipidaemia

· Chronic smoking

· Significant family history(first degree family):-M<55,f<65

· Sedentary lifestyle

B. SURGERY

1. JAUNDICE

CS: male, 20 years old. Complain of yellow discoloration of the skin for 1 week

HOPI

· Duration?

· Getting worse?

· Tea colour urine? Pale colour stool? Change in bowel habit?

· Anemic?(lethargic, tired..etc)

· Any bruises/itchiness?

· Git symptoms

o Any mass?

o Pain at rhc?

· Associated symptoms

o Nausea? Vommiting?

o Fever (low grade? High? Chills and rigor?)

o Weight loss? Loss of appetite?

Past medical history

· Hepaitis, Cholecystitis

Surgical history

· Cholengitis or gall stone removal?

Family history

· Any family members experience the same thing or gotten sick

Drug history

· Oral contraceptives

· Drugs? Antibiotic? PCM? Anti Tb?

Social history

· Occupation: health care professional(needle prick), gardener/farmer:leptospira

· Eat seafood? Iv drugs usage? promiscuity? tatooing? alcoholic?

· Distaste for cigarettes? (if previously he is a chronic smoker..)

· Leptospirosis(any trips to those area affected)

· Mushroom poisoning

2. THYROID

HOPI

· Mass

o Site

o Size (larger/shrunken)

o Tenderness

o Mobility

o Since when?

· Any hoarseness of voice, dysphagia?

· GI - Loss of weight despite increase in appetite

· CNS - Restless, easily feel irritated/emotionally disturbed

· Insomnia?

· Profuse sweating/heat intolerance

· CVS - Palpation

· Any muscle weakness(usually prox), difficult in doing activities(comb hair, etc)

Menstrual history

· oligomenorrhea

Past surgical history

· Surgery at the neck?

Drugs History

· Drug for heart(amiodarone-drug induced thyrotoxicosis)

Family history

· Any with same problem?

3. BREAST LUMP

HOPI

· Site: upper inner/upper outer/lower inner/lower outer

· Duration: when discover first lump

· Size: how big:10 cent, enlarge/shrink? Shape?

· Consistency: soft, firm, hard, regular/irregular, nodular?

· Pain: painful/painless

· Mobility

· Any nipple discharge? What color?, Any skin changes? any lymph node in axilla?

Menstrual History

· Menarche and menapause-when?

· When get first child/breastfeeding-how long?, why stop?(if abrupt)

· Take any oral contraceptives/ hormone replacement theraphy?

Family History

· Any Ca history?

Social History

· Smoking? Fatty diet? Exposure to radiation, sunbathing?

· Any investigation done before, mammogram?

4. ULCER/LUMP

HOPI

· Onset - how notice?, is is first time?, getting worse?

· Site & size(change in size?)

· Change in character (color, discharge)

· Painful/tender?

· Severity? - movement affected?

· Any history trauma?

· Muscle weakness/Numbness?

Past medical history

· Any chronic illness – DM, HT

Drugs History

· In any drugs(DM)

· Compliance?

Family history

· History of Ca

· Family history of DM

5. BENIGN PROSTATIC HYPERPLASIA

HOPI

· Dysuria

o Onset

o Site of pain

o Duration

o Getting worse

o Nature of pain

o Relieving factor

· Sign of BPH

o Weak urinary stream

o Prolonged emptying of the bladder

o Abdominal straining

o Hesitancy

o Irregular need to urinate

o Incomplete bladder emptying

o Post-urination dribble

o Frequent urination

o Nocturia (need to urinate during the night)

o Urgency

o Incontinence (involuntary leakage of urine)

o Problems in ejaculation

· Any fever(rule out UTI)

· Hematuria

· Passing stone in urine

Past Medical & Surgical History

· History of kidney disease(renal stones?)