exam history cvs

Health history

Dr.Mohammad Shaikhani.

Suggested scheme for basic history taking

• Name, age, occupation, country of birth, other clarification of identity

• Main presenting problem • Past medical history - 'Before we talk about why you have

come I need to ask you to tell me about any medical problems you have had in the past'.

• Specific past medical history - e.g. diabetes, jaundice, TB, heart disease, high blood pressure, rheumatic fever, epilepsy

• History of main presenting problem • Family history • Occupational history • Smoking, alcohol, allergies • Drug and other treatment history • Direct questions about bodily systems not covered by the

presenting complaint

Suggested scheme for basic history taking

• Bodily systems and questions relevant to taking a full history from most patients. If the specific questions have been covered by the history of the presenting problem they do not need to be included again. If the answers are positive then the characteristics of each must be clarified.

• Cardiorespiratory • Chest pain • Intermittent claudication • Palpitation • Ankle swelling • Orthopnoea • Nocturnal dyspnoea • Shortness of breath • Cough with or without sputum • Haemoptysis

Suggested scheme for basic history taking

• Gastrointestinal • Abdominal pain • Dyspepsia • Dysphagia • Nausea and/or vomiting • Change in appetite • Weight loss or gain • Bowel pattern and any change • Rectal bleeding • Jaundice

Suggested scheme for basic history taking

• Genitourinary • Haematuria • Nocturia • Frequency • Dysuria • Menstrual irregularity - women • Urethral discharge - men • Locomotor • Joint pain • Change in mobility

Suggested scheme for basic history taking

• Neurological • Seizures • Collapse or blackouts • Dizziness and loss of balance • Vision • Hearing • Transient loss of function (vision, speech, sight) • Paraesthesiae • Weakness • Wasting • Spasms and involuntary movements • Pain in limbs and back • Headache

List of clarifications for a complaint of pain

• Site • Radiation • Character • Severity • Time course • Aggravating factors • Relieving factors • Associated symptoms

Drug history

• Tell me all the drugs or medicines that you take. • Have any been prescribed from another clinic, doctor or dentist? • Do you buy any yourself from a pharmacy? • Are you sure you have told me about all tablets, capsules and

liquid medicines? • What about inhalers, skin creams or patches, suppositories, or

tablets to suck? • Were you taking any medicines a little while ago but stopped

recently? • Do you ever take any medicines prescribed for other people,

such as your spouse? • Do you use herbal or other complementary medicines?

Family history

• Are there any illnesses that run in your family?• ccasionally this will reveal major genetic trends such as

haemophilia. • More often there will be an answer such as 'They all have heart

trouble'.• Basic family tree of first-degree relatives• This should be plotted on a diagram for most patients, including

major illness, and cause and age of any deaths• Specific questions about the occurrence of problems similar to the

patient's• Ask the patient about items in the developing differential diagnosis,

e.g. 'Does anyone in your family have gallstones/epilepsy/high blood pressure?' if these seem likely diagnoses for the patient under consideration.

Alcohol history

• Doctor:Do you drink any alcoholic drinks?• Patient:Oh yes, but not much - just socially.• Doctor:Do you drink some every day?• Patient:Yes.• Doctor:Tell me what you drink.• Patient:I usually have two pints of beer at lunchtime and two or

three on my way home from work.• Doctor:And at the weekend?• Paitent:I usually go out Saturday nights and have four or five

pints.• Doctor:Do you drink anything other than beer?• Patient:On Saturdays I have a double whisky with each pint.