Class notes
History taking notes for medical students
- Course
- Institution
Hi. These are some notes I made from class pertaining on how to take history from patients presenting with common conditions like cough, epigastric pain etc.
[Show more]
Seller
Follow
sleepymed
Content preview
HISTORY TAKING- Introduction + consent + confirm patient details (name, age, gender,
nationality, address, occupation)
- What brought you to the PHC today? How long has it been happening?
ANEMIA
- Fatigue, lethargy
- Headache
- Palpitations
- Pale skin or conjunctiva
- Dyspnoea
- Hair loss
- Less common symptoms :
- Restless leg syndrome
- Pica (a craving non-food substances, such as ice or dirt – commonly seen in
children and pregnant women)
- Tinnitus
- Pruritus
- Mouth ulcers
- Vertigo/dizziness
- Underlying diseases associated with iron deficiency anaemia-
- Dysphagia: oesophageal malignancy, plummer vilson
- Dyspepsia / indigestion: gastric cancer, peptic ulcer disease
- Abdominal pain: coeliac disease, malignancy, inflammatory bowel disease
- Change in bowel habit: bowel cancer, coeliac disease, inflammatory bowel
disease
- Rectal bleeding: anal fissure, rectal cancer, haemorrhoids, inflammatory
bowel disease
- Change in urine color - haemolytic anemia
- Weight loss: inflammatory bowel disease, bowel cancer
- Past medical history
- Past surgical history
- Past drug and allergy history - OTCs, vitamins, nsaids, ocp (females)
- Past family history - anemia, jaundice, cholelithiasis, splenectomy, bleeding
disorders, and abnormal hemoglobins
- Diet history - pica, chewing ice
- Social history - smoking + exercise + pets + travel + household exposures to
potentially noxious agents
- Menstrual history - are they regular? Cycle length? Menorrhagia?
Pregnancies, abortions? OCP use
- ICE - IDEAS, CONCERNS, EXPECTATIONS
, DIARRHEA
- Duration - acute (<14 days), chronic (>14 days) or intermittent?
- Onset - when did it start?
- Frequency
- Is there tenesmus, urgency or incontinence?
- Consistency, volume:
- watery, unformed or semisolid?
- large-volume and not excessively frequent (small-bowel disease)?
- small-volume and excessively frequent (large-bowel disease)?
- associated with blood, mucus or pus?
- Shape of stool and smell
- Color
- Blood / mucus in stool
- Timing - day or night = Is sleep disturbed by diarrhoea, suggesting organic
disease?
- Any other gastrointestinal symptom, e.g. abdominal pain and vomiting?
- Any exacerbating/ relieving factors?
- Any one else in family has symptoms?
- Past medical history - IBD, gastrointestinal
- Past surgical history - GI surgery, bowel obstruction
- Family history of gastrointestinal disorder, e.g. gluten enteropathy, Crohn’s?
- Drug and allergy history - laxatives? Antibiotics? Antidepressants
- Diet history - anything from outside?
- Travel history - any endemic areas? contact with contaminated water?
- Social history - smoking, alcohol, exercise, accomodation (close living
spaces)
- Females - menstrual history
- ICE
PEPTIC ULCER
- Burning epigastric pain -
- After meals - gastric
- Relieved by meals - duodenal
- Awaken at night? - duodenal
- Gradual pain
- Radiating to back
- Pain typically follows a daily pattern specific to the patient. + remission for
weeks/ months
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller sleepymed. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.94. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
84866 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now