Patient Interview 1.

Identifying Data and Source of the History

a. b. c. d. Identifying datasuch as name, age, DOB, gender, occupation, marital status, religion, residence, contact information, nationality, time & location of interview (Demographics) Source of the historyusually the patient, but can be family member, friend, letter of referral, or the medical record If appropriate, establish source of referral, since a written report may be needed. Varies according to the patients memory, trust, and mood

2. Chief Complaint(s)
a. b. The one or more symptoms or concerns causing the patient to seek care Can contain Problem List

3. Present Illness LPQRST

a. Amplifies the Chief Complaint, describes how each symptom developed i. Location Where is it? Does it radiate? ii. Precipitating Factors What brings it on? iii. Quality What is it like? iv. Quantity & Severity How bad is it? (Pain scale of 1-10) v. Timing, including Onset, Duration, and Frequency When did it start? How long does it last? How often did it come? vi. Setting in which they occur Environmental factors, personal activities, emotional reactions, or contributing factors. vii. Remitting/Exacerbating Factors Does anything make it better or worse? viii. Associated manifestations Have you noticed anything else that accompanies it? b. Includes patients thoughts and feelings about the illness c. Pulls in relevant portions of the Review of Systems (see below) d. May include medications, allergies, habits of smoking and alcohol, since these are frequently pertinent to the present illness

4. Past History
a. b. c. Lists childhood illnesses Lists adult illnesses with dates for at least four categories: medical; surgical; obstetric/gynecologic; and psychiatric Includes health maintenance practices such as: immunizations, screening tests, lifestyle issues, and home safety i. Example Categories General Health, Preventive Health Care, Immunization, Childhood Illnesses, Major Illnesses, Operations, Hospitalizations, Accidents, Allergies, Blood Transfusions, Medications, Drug and Alcohol Abuse, Diet, Screening Tests

5. Family History
a. b. Outlines or diagrams of age and health, or age and cause of death of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, etc. i. hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies, as well as symptoms reported by the patient

6. Personal and Social History

a. Describes educational level, family of origin, current household, personal interests, and lifestyle. i. Example Categories Social Situation, Education/Occupation, Habits (Including Drug, Alcohol, & Tobacco Use), Sexual History, Marital Status, Religion, Sexual History, Travel, Hobbies, Leisure and Entertainment, and Legal problems 1. Alcohol CAGE questions Have you ever had a drinking problem? and When was your last drink? An affirmative answer to the first question, along with a drink w/in 24 hours, has been shown to suggest problem drinking. a. Cutting down b. Annoyance if criticized c. Guilty feelings d. Eye-openers

7. Review of Systems Bates Text Book of Physical Methods Kellers Textbook of Internal Medicine A study guide to Epidemiology Morton Behavior Sciences and Health Care, OJ Saher and JE Carr

a.

Documents presence or absence of common symptoms related to each major body system i. General. Usual weight, recent weight change, clothes that fit more tightly or loosely than before. Weakness, fatigue, fever. ii. Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails. iii. Head, Eyes, Ears, Nose, Throat (HEENT) 1. Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts. 2. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. 3. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. 4. Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. iv. Neck. Lumps, swollen glands, goiter, pain, or stiffness in the neck. v. Breasts. Lumps, pain or discomfort, nipple discharge, self-examination practices. vi. Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. vii. Cardiovascular. Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other heart test results viii. Gastrointestinal. Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change in bowel habits, 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. ix. Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. x. Genital 1. Male: Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Exposure to HIV infection. 2. 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. Vaginal discharge, itching, sores, lumps, sexually transmitted diseases 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. Exposure to HIV infection. xi. Peripheral Vascular. Intermittent claudication, leg cramps, varicose veins, past clots in the veins. xii. Musculoskeletal. Muscle or joint pains, stiffness, arthritis, gout, and backache. If present, describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example, morning or evening), duration, and any history of trauma. xiii. Neurologic. Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements. xiv. Hematologic. Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions. xv. Endocrine. Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size. xvi. Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant

8. Mental Status Examination

a. b. c. d. e. f. g. h. i. PHYSICAL APPEARANCE: Ex.- healthy and well groomed, with good hygiene and clean garments. ATTITUDE: Ex.-compliant with all questions posed and able to produce details. MOOD: Ex.-vivid, calm, and relaxed, able to conduct with maturity. AFFECT: Ex.-within a normal range. SPEECH: Ex.-within normal range for tone, consistency and coherence. PERCEPTION: Ex.-no apparent hallucinations. THOUGHT CONTENT: Ex.-happy and relaxed at home. THOUGHT ASSOCIATION: Ex.-no apparent lack of coherence, flight of ideas, or rambling. COGNITIVE ABILITY: Ex.-normal working memory, ability to recollect dates and able to think abstractly i. Abstract Thoughts "You can lead a horse to water, but if you try to carry that horse across, you are both going to drown." j. RELIABILITY: Ex.-able to recall specific dates, family histories and surgical procedures all in detail

Bates Text Book of Physical Methods Kellers Textbook of Internal Medicine A study guide to Epidemiology Morton Behavior Sciences and Health Care, OJ Saher and JE Carr