Case history taking and assessment

Identification: Age, sex, brought in by whom, chief complaint
Source of History (include reliability rating) : Patient, caregiver, family, friendsMedical records, Previsit questionnaire
History of Present Problems/Condition
Medications - old medication lists, herbal/alternative medications , Allergies/Adverse Drug Reactions: Name specific medications and characterize specific allergic/adverse drug reaction for each medication
Habits: tobacco, recreational drugs
Social History: Education, Marital Status/Children, Household members, Activities/Exercise, Travel, Occupational History/Toxin Exposures, Diet, Caffeine, Sexual Activity, Caregiver roles
Past Medical History: (ask about previous medical records, old lab/imaging/study reports)
Family History: Heart disease, cancer, diabetes, TB, HTN, mental health, Alzheimer's disease
Care Resources: past and present Home Health, Case Management, etc.
Personal History: Environment, Reverse developmental milestones


Review of Systems:
General: fevers, chills, malaise, fatiguability, night sweats, weight changes
Neurologic: syncope, seizures, weakness, paralysis, abnormal sensation/coordination, tremors, memory loss
Psychiatric: depression, mood changes, difficulty concentrating, nervousness, tension, suicidal ideation, irritability, sleep disturbances
Sensory Functions: visual changes, hearing changes, neuropathy, balance/coordination
Motor Functions: gait, falls, ataxia
Diet: preferences, restrictions (religious, allergic, disease), vitamins/supplements, caffeine, food/liquid intake diary, "look in fridge test", who prepares/obtains food
Skin: rash/eruption, itching, pigmentation, excessive sweating, nail/hair abnormalities
Head: Headaches, dizziness, syncope, severe head injuries, loss of consciousness
Eye: visual changes, blurring, diplopia, photophobia, pain, eye medication use, eye trauma, FH of eye disease
Ears: hearing loss, pain, discharge, tinnitus, vertigo
Nose: sense of smell, obstruction, epistaxis, postnasal drip, sinus pain, rhinorrhea
Oral: hoarseness, sore throat, gum bleeding/soreness, tooth abscess/extraction, ulcers, taste changes


Cardiac/Peripheral Vascular: Chest pain, palpitations, dyspnea, orthopnea, edema, claudication, HTN, previous MI, exercise tolerance, previous cardiac studies
Pulmonary: pleuritic pain, dypsnea, cyanosis, wheezing, cough/sputum, hemoptysis, TB exposure, previous CXR's
Gastrointestinal: appetite, digestion, dysphagia, heartburn, nausea, vomiting, hematemesis, diarrhea, constipation, stool changes, flatulence, hemorrhoids, hepatitis, jaundice, dark urine, history of ulcers/gallstones/polyps/tumors, previous X-rays
Renal/Urinary:dysuria, flank/suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, force of stream changes, STD's
Hematologic: anemia (dizziness/fatigue/dyspnea), easy bruising/bleeding, blood cell abnormalities, transfusions
Lymphatic: lymph node enlargement/tenderness
Endocrine/Metabolic: thyroid enlargement/pain, heat/cold intolerance, unexplained weight change, diabetes, polydipsia, polyuria, facial/body hair changes, increased hat/glove size, striae
Musculoskeletal: joint stiffness, pain, limited ROM, swelling, redness, heat, bone deformity
Sexual: libido, intercourse frequency, sexual difficulties, impotence
Gynecologic: itching, last Pap smear, menopause age
Breasts: pain, tenderness, discharge, lumps, mammograms, self-breast exams


MENTAL STATUS
Most of this exam is observed through the interview conversation with patient
General Appearance/Behavior: Grooming and hygiene, unusual movements, attitude, psychomotor activity, eye contact
Affect: (external range of expression) flat, blunted, labile, full/wide range
Mood: (internal emotional tone) dysphoric, euphoric, angry, euthymic, anxious
Thought Processes: Language (quality/quantity of speech), tone, associations, speech fluencyNote presence of: pressured speech, poverty of speech, blocking, flight of ideas, loosening of associations, tangentiality,Circumstantiality, echolalia, neologisms, clanging, perseveration, ideas of reference
Thought Content: note hallucinations, delusions, illusions, derealization, depersonalization, suicidal or homicidal ideation
Cognitive: (mostly covered by psychometric tests)level of consciousness, orientation
Insight: the patient's understanding of his or her problems and implications of these problems
Judgment: based on history of patient's decision making abilities