History Talking

exam jus around da corner, dis stupid hx taking make me sick . . anyway . . jus want to share da great knowledge of mine wit ur guys . . learn it well

1. Jaundice (yellowish of skin, usually on sclera of eyes)



> how long u have yellowish discoloration of eyes?

> when 1st noticed? who's the one noticed it?

> where else has the same problem (yellowish discoloration)?

> differentiate the severity of color when u 1st noticed and right now? getting worse or not?

> is it the 1st time u have this problem? if not, when u had the same problem?

> since u have this problem, did u has any . . .
+ abdominal pain (SOCRATES)
+ tea colored urine and pale/white stool?
+ itchiness, where? generalised?
+ fell tired, lethargy, loss of consciou, shortness of breath
+ loss of appetite
+ . . . . .

> associated with time (day/night)

> had any illness before? hep B? gallstone?

> married? protected sex? sexual activity?

> any blood transfusion before?

> take any IV drug? share needles?

> eat any seafood recently?

> job?

> travel history

> tatto/ piercing

> drink alcohol? how much?

> are u in any recent drug treatment?

> any family member had same problem?



2. Headache



> site?

> duration?

> onset? (continuous/ on off)

> character? (mild, moderate, severe)

> radiation? (eyes pain, neck stiffness)

> since u have this problem, did u has any . . .
+ nausea, vomiting, loss of appetite?
+ menses
+ neck stiffness, blurred vision
+ fatigue, lethargy
+ . . . . . . . . . .

> when u fell the headache? (day/night)

> does ur headache become worse when . . . .
+ changes in position
+ cough/sneezing/fever/running nose
+ bright light/loud noise
+ mood changes
+ . . . . . . . . . . . .

> does it disturb ur daily activity?

> married? take any oral contraceptive drug?

> do u . . .
+ smoking
+ always stress when working
+ consume alcohol, how much?
+ take any caffeine
+ take any coccaine
+ take any drug?
+ diet
+ any trauma to head before?

> any health problem? Diabetes? hypertension?

> any family members had same problem?


3. Breast Lump



> age?

> site of lump?

> how long had it?

> when 1st noticed it?

> 1st time had it? if not,when?

> size of the lump?

> how many lump did u noticed on ur breast?

> any place other than breast?

> pain? (SOCRATES)

> did u noticed any changes of . . .
+ both breasts shape
+ both nipples (retracted or not)
+ skin changes, redness?
+ ulceration
+ lump discharge
+ nipple discharge? color? how many?

> menstrual pattern
+ 1st period at what age?
+ regularity
+ duration
+ quantity of bleeding

> does ur lump associated with period?

> menopause? when?

> previous pregnancy
+ how many children?
+ breast feed all children? how long?

> drug (contraceptive/female sex hormone)

> trauma to the breast?

> diet/smoking/comorbid

> any family members had same problem?


4. Fever



> onset

> characteristic (continuous/ on off)

> exacerbating/relieving factor

> severity

> timing
+ episodic/continuous
+ duration
+ frequency
+ progression
+ variation (day/night)

> associated symptoms
+ chills,rigor,sweating,loss of appetite
+ sore throat,cough,runny nose
+ photophobia,phonophobia,rashes
+ periorbital pain,myalgia,bone pain
+ changes in urination,back pain
+ house area, travel history
+ bleeding joint