NOTE FOR TAKING HISTORY GET START: ‘‘Good morning, Mr. Smith; I’m Mary Jones, a medical student at the . . . School S chool of Medicine. I’ve been asked to interview and examine you in the next hour.’’ Alternatively, you may say,
‘‘Good morning, I’m Mary Jones; are you Mr. Smith? [Pause and wait for answer.] I am a medical student at t he . . . School of Medicine. I’ve been asked to interview and examine you in the next hour.’’
FORMAT OF THE HISTORY The major traditional sections of the history, with some patient-oriented changes, are as follows: Source and reliability Chief complaint History of the present illness and debilitating symptoms Past medical history Health maintenance Occupational and environmental history Biographic information Family history Psychosocial and spiritual history Sexual, reproductive, and gynecologic history Review of systems
CHIEF COMPLAINT
‘‘What is the medical problem that brought you to the hospital?’’ (+ duration)
HISTORY OF PRESENT ILLNESS AND DEBILITATING SYMPTOMS Chronology is the most practical framework for organizing the history. It e nables the interviewer to comprehend the sequential development of the underlying pathologic process.
BODILY LOCATION ‘‘Where in your back do you fe el pain?’’ ‘‘Can you tell me where you feel the pain?’’ ‘‘Do you feel it anywhere else?’’ ONSET (CHRONOLOGY) ‘‘When did you first notice it?’’ ‘‘How long did it last?’’ ‘‘Have you had the pain since that time?’’ ‘‘Then what happened?’’ ‘‘Have you noticed that it is worse during your menstrual period?’’
PRECIPITATING FACTORS ‘‘What makes it worse?’’ ‘‘What seems to bring on the pain?’’ ‘‘Have you noticed that it occurs at a certain time of day?’’ ‘‘Is there anything else besides exercise that makes it worse?’’ ‘‘Does exercise increase the shortness of breath?’’ ‘‘Does stress precipitate the pain?’’ PALLIATING FACTORS ‘‘What do you do to get more comfortable?’’ ‘‘Does lying quietly in bed help you?’’ ‘‘Does rest help?’’ ‘‘Does aspirin help the headache?’’ ‘‘Does eating make it better?’’ QUALITY ‘‘What does it feel like?’’ ‘‘Can you describe the pain?’’ ‘‘What do you mean by a ‘sticking pain’?’’ ‘‘Was it sharp (pause), dull (pause), or aching?’’ ‘‘When you get the pain, is it steady, or does it change?’’ RADIATION ‘‘When you get the pain in your chest, do you feel it in any other part of your body at the same time?’’ ‘‘When you experience your abdominal pain, do you have pain in any other area of your body?’’ SEVERITY ‘‘What do you mean by ‘a lot’?’’ ‘‘How many sanitary napkins do you use?’’ ‘‘How many times did you vomit?’’ ‘‘What kind of effect does the pain have on your work?’’ ‘‘How does the pain compare with the time you broke your leg?’’ ‘‘Can you fall asleep with the pain?’’ ‘‘How has the pain affected your lifestyle?’’ ‘‘On a scale from 1 to 10, with 10 the worst pain you can imagine, how would you rate t his pain?’’ TEMPORAL ‘‘Does it ever occur at rest?’’ ‘‘Do you ever get the pain when you are emotionally upset?’’ ‘‘Where were you when it occurred?’’ ‘‘Does the pain occur with your menstrual cycle?’’ ‘‘Does it awaken you from sleep?’’ ‘‘Have you noticed any relationship of the pain to e ating?’’ ASSOCIATED MANIFESTATIONS ‘‘Do you ever have nausea with t he pain?’’ ‘‘Have you noticed other changes that happen when you start to sweat?’’ ‘‘Before you get the headache, do you ever experience a strange taste or smell?’’
PAST MEDICAL HISTORY
The past medical history consists of the overall assessment of the patient’s health before the present illness. It includes all of the following: General state of health Past illnesses Injuries Hospitalizations Surgery Allergies Immunizations Substance abuse Diet Sleep patterns Current medications Complementary and alternative therapies
‘‘How has your health been in the past? QUESTIONS RELATED TO DRINK ALCOHOL: ‘‘Do you usually drink to get High?’’ ‘‘Do you drink Alone?’’ ‘‘Do you ever find yourself Looking forward to drinking?’’ ‘‘Have you noticed whether you seem to be becoming Tolerant of alcohol?’’ QUESTIONS RELATED TO SLEEP: ‘‘When do you go to bed?’’ ‘‘Do you have trouble falling asleep?’’ ‘‘Do you stay asleep the whole night, o r do you awaken in the middle of t he night, unable to go back to slee p?’’ Do you go to bed only when slee py?’’ ‘‘Do you adhere to a regular waking time?’’ ALL CURRENT MEDICATIONS SHOULD BE NOTED. THE FOLLOWING QUESTIONS SHOULD BE ASKED: ‘‘Do you use any prescription medications?’’ ‘‘Do you use any over -the-counter medications?’’ ‘‘Do you use any herbal medications or vitamins?’’
‘‘Do you use any recreational drugs?’’ OCCUPATIONAL AND ENVIRONMENTAL HISTORY The following questions regarding occupational and environmental exposure should be asked of all patients:
‘‘What type of work do you do?’’ ‘‘How long have you been doing this work?’’ ‘‘Describe your work.’’ ‘‘Are you exposed to any hazardous materials? Do you e ver use protective equipment?’’ ‘‘What kind of work did you do before you had your current job?’’
‘‘What was your wartime employment, if any?’’ ‘‘Where do you live? For how long?’’ ‘‘Have you ever lived near any factories, shipyards, or other potentially hazardous facilities?’’ ‘‘Has anyone in your household ever worked with hazardous materials that could have been brought home?’’ ‘‘What types of hobbies do you have? What types of exposures are involved?’’ ‘‘Do you now have, or have y ou previously had, environmental or occupational exposure to asbestos, lead, fumes, chemicals, dusts, loud noise, radiation, or other toxic factors?’’
Did the symptoms start after the patient began a new job? Did the symptoms abate during a vacation and then recur when the patient resumed work? Were the symptoms related to the implementation of any new chemical or process? Is there anyone else at work or are there any neighbors with a similar illness?
FAMILY HISTORY Alive or dead Age Any medical problems
It is important to inquire where t he patient’s parents were born. Where were the grandparents born? In what setting, urban or rural, did the patient grow up? In what country did the parents grow up? If the patient was born in another c ountry, at what age did he or she come to the United States? Does the patient maintain contact with other family members? Was the original family name changed? If the patient is married, is the spouse of the same ethnic background as t he patient? What is the patient’s native language? PSYCHOSOCIAL AND SPIRITUAL HISTORY The psychosocial history includes information on The education Life experiences Personal relationships of the patient
Patient’s lifestyle Other people living with the patient Schooling Military service Religious beliefs (in relation to the perceptions of health and treatment), Marital or significant-other relationships. You can start by asking one of the following questions:
‘Tell me a little about yourself: your background, education, work, family.’’ ‘‘Who are the important people in your life?’’ ‘‘What do you do for fun?’’ ‘‘How do you feel about the way your life is going?’’
A statement regarding the patient’s knowledge of symptoms and illness is important. Has the illness caused the patient to lose time from work? What kind of insight does the patient have with regard to the symptom? Does he or she think about the future? If so, how does it look? An excellent question that can elicit a vast amount of information is ‘‘What is your typical day like?’’
SEXUAL, REPRODUCTIVE, AND GYNECOLOGIC HISTORY
‘‘Now I am going to ask you some questions about your sexual health and practices.’ ‘‘Are you sexually active?’’ ‘‘Have you ever had intimate physical contact with anyone? ’’ If the answer is ‘‘Yes,’’ the next question should be ‘‘Did that contact include sexual intercourse?’’ The interviewer should also then ask, ‘‘Are your partners male, female, or both?’’ Some of the following questions about specific sexual behaviors and satisfaction may also be helpful in acquiring a sexual history:
‘‘Are you having any sexual problems?’’ ‘‘Are you satisfied with your sexual performance?’’ ‘‘Do you think your partner is?’’ If not, ‘‘What is unsatisfactory to you (or your partner)?’’ ‘‘Have you had any difficulty achieving orgasm?’’ ‘‘How frequently does it occur that your partner desires sexual intercourse and you do not?’’ ‘‘Are there any questions pertaining to your sexual performance that you would like to discuss?’’ ‘‘Most people experience some disappointment in their sexual function. Can you tell me what disappointments you might have?’’ ‘‘Many people experience what others m ay consider unusual sexual thoughts or wish to perform sexual acts that others consider abnormal. We are often bothered by these thoughts. What has been your experience?’’ ‘‘Do you have protected sex?’’ ‘‘Have you ever had a sexually t ransmitted disease?’’ ‘‘Have you been tested for HIV?’’ If yes, ‘‘What was the result?’’
ABDOMEN REVIEW OF SPECIFIC SYMPTOMS PAIN
‘‘Where is the pain?’’ ‘‘Has the pain changed its location since it started?’’ ‘‘Do you feel the pain in any other part of your body?’’ ‘‘How long have you had the pain?’’ ‘‘Have you had recurrent episodes of abdominal pain?’’ ‘‘Did the pain start suddenly?’’ ‘‘Can you describe the pain? Is it sharp? dull? burning? cramping?’’ ‘‘Is the pain continuous? Does it come in waves?’’ ‘‘Has there been any change in the severity or nature of the pain since it began?’’
‘‘What makes it worse?’’ ‘‘What makes it better?’’ ‘‘Is the pain associated with nausea? vomiting? sweating? constipation? diarrhea? bloody stools? abdominal distention? fever? chills? eating?’’ ‘‘Have you ever had gallstones? kidney stones?’’ If the patient is a woman, ask this question: ‘‘When was your last period?’’
NAUSEA AND VOMITING
‘‘How long have you had nausea or vomiting?’’ ‘‘What is the color of the vomit?’’ ‘‘Is there any unusually foul odor to the vomitus?’’ ‘‘How often do you vomit?’’ ‘‘Is vomiting related to eating?’’ If yes, ‘‘How soon after eating do you vomit? Do you vomit only after eating certain foods?’’ ‘‘Do you have nausea without vomiting?’’ ‘‘Is the nausea or vomiting associated with abdominal pain? constipation? diarrhea? a loss of appetite? a change in the color of your stools? a change in the color of your urine? fever? chest pain?’’ ‘‘Have you noticed a change in your hearing ability?’’ ‘‘Have you noticed ringing in your ears?’’ If the patient is a woman, ask this question:
‘‘When was your last period?’’ CHANGE IN BOWEL MOVEMENTS Take a careful history of bowel habits. A change in bowel movements necessitates further elaboration. Ask these questions of the patient with acute onset of diarrhea: ‘‘How long have you had the diarrhea?’’ ‘‘How many bowel movements do you have a day?’’
‘‘Did the diarrhea start suddenly?’’ ‘‘Did the diarrhea begin after a meal?’’ If yes, ‘‘What did you eat?’’ ‘‘Are the stools watery? bloody? malodorous?’’
‘‘Is the diarrhea associated with abdominal pain? loss of appetite? nausea? vomiting?’’ The patient with chronic diarrhea should be asked the following:
‘‘How long have you had diarrhea?’’ ‘‘Do you have periods of diarrhea alternating with c onstipation?’’ ‘‘Are the stools watery? loose? floating? malodorous?’’ ‘‘Have you noticed blood in the stools? mucus? undigested food?’’ ‘‘What is the color of the stools?’’ ‘‘How many bowel movements do you have a day?’’ ‘‘Does the diarrhea occur after eating?’’ ‘‘What happens when you fast? Do you still have diarrhea?’’ ‘‘Is the diarrhea associated with abdominal pain? abdominal distention? nausea? vomiting?’’ ‘‘Have you noticed that the diarrhea is wo rse at certain times of the day?’’ ‘‘How is your appetite?’’ ‘‘Has there been any change in your weight?’’ Patients complaining of constipation should be asked these questions:
‘‘How long have you been constipated?’’ ‘‘How often do you have a bowel movement?’’ ‘‘What is the size of your stools?’’ ‘‘What is the color of your stools?’’ ‘‘Is the stool ever mixed with blood? mucus?’’ ‘‘Have you noticed periods of constipation alternating with periods of diarrhea?’’ ‘‘Have you noticed a change in t he caliber of the stool?’’ ‘‘Do you have much gas?’’ ‘‘How’s your appetite?’’ ‘‘Has there been any change in your weight?’’ RECTAL BLEEDING Rectal bleeding may be manifested by bright red blood, blood mixed with stool, or black, tarry stools. Bright red blood per rectum, also known as hematochezia,
‘‘How long have you noticed bright red blood in your stools?’’ ‘‘Is the blood mixed with the stool?’’ ‘‘Are there streaks of blood on the surface of the stool?’’ ‘‘Have you noticed a change in your bowel habits?’’ ‘‘Have you noticed a persistent sensation in your rec tum that you have to move your bo wels, but you cannot?’’ Tenesmus is the painful, continued, and ineffective straining at stool. It is caused by inflammation or a space-occupying lesion such as a tumor at the distal rectum or anus. Hemorrhoidal bleeding is a common cause of hematochezia and streaking of stool with blood. Melena is a black, tarry stool that results from bleeding above the first section of the duodenum, with partial digestion of the hemoglobin. Inquire about the presence of melena Ask the patient who describes rectal bleeding the following questions:
‘‘How long have you noticed bright red blood in your stools?’’ ‘‘Is the blood mixed with the stool?’’
‘‘Are there streaks of blood on the surface of the stool?’’ ‘‘Have you noticed a change in your bowel habits?’’ ‘‘Have you noticed a persistent sensation in your rectum that you have to move your bowels, but you cannot?’’ Ask these questions of a patient who describes melena:
‘‘Have you passed more than one black, tarry stool?’’ If yes, ‘‘When?’’ ‘‘How long have you been having black, tarr y stools?’’ ‘‘Have you noticed feeling lightheaded?’’ ‘‘Have you had any nausea associated with these stools? any vomiting? diarrhea? abdominal pain? sweating?’’ JAUNDICE In any patient with icterus, the examiner should search for clues by asking the following questions:
‘‘How long have you been jaundiced?’’ ‘‘Did the jaundice develop rapidly?’’ ‘‘Is the jaundice associated with abdominal pain? loss of appetite? nausea? vomiting? distaste for cigarettes?’’ ‘‘Is the jaundice associated with chills? fever? itc hing? weight loss?’’ ‘‘In the past year have you had any transfusions? tattooing? inoculations?’’ ‘‘Do you use any recreational drugs?’’ If yes, ‘‘Do you use any drugs intravenously?’’ ‘‘Do you eat raw shellfish? oysters?’’ ‘‘Have you traveled abroad in the past year?’’ If yes, ‘‘Where? Were you aware that you may have consumed unclean water?’’ ‘‘Have you been jaundiced before?’’ ‘‘Has your urine changed color since you noticed that you were jaundiced?’’ ‘‘What is the color of your stools?’’ ‘‘Do you have any friends or relations who are also jaundiced?’’ ‘‘What type of work do you do? What other types of work have you done?’’ ‘‘What are your hobbies?’’ ABDOMINAL DISTENTION
‘‘How long have you noticed your abdomen to be distended?’’ ‘‘Is the distention intermittent?’’ ‘‘Is the distention related to eating?’’ ‘‘Is the distention lessened by belching or by passing gas from below?’’ ‘‘Is the distention associated with vomiting? loss of appetite? weight loss? change in your bowel habits? shortness of breath?’’
THE PEDIATRIC TAKING HISTORY
THE PHYSICAL EXAMINATIONS OF THE FOLLOWING AGE GROUPS: 1- Neonatal period (birth to 1 week of age) 2- Infancy (1 week to 1 year of age) 3- Toddler and early childhood (1 to 5 ye ars of age) 4- Late childhood (6 to 12 years of age) 5- Adolescence (12 to 22 years of age) THE PEDIATRIC HISTORY CONSISTS OF THE FOLLOWING: 1- Chief complaint 2- History of the present illness 3- Birth history 4- Past medical history 5- Nutrition 6- Growth and development 7- Immunizations 8- Social and environmental history 9- Family history 10-Review of systems The chief complaint and the history of the present illness are obtained in the same manner as with the adult patient. The history should identify the informant, and the interviewer should try to establish whether and where the child has a regular source of medical care. The history of the present illness should always include information about the effect of an acute illness on the child’s oral intake, act ivity level, hydration status, and ability to sleep. For a chronic problem, t he
examiner should look for effects on the child’s growth and dev elopment.
BIRTH HISTORY ‘‘How was your pregnancy?’’ maternal problems, medications taken illnesses, bleeding x-ray films birth on time
A gravida is a pregnant woman.
A nulligravida or gravida 0 is a woman who has never been pregnant.
A primigravida or gravida 1 is a woman who is pregnant for the first time or has been pregnant one time.
A multigravida or more specifically a gravida 2 (also secundigravida), gravida 3, and so on, is a woman who has
been pregnant more than one time. An elderly primigravida is a woman in her first pregnancy, who is at least 35 years old. This term is becoming less common as it may be considered offensive.
The term gravida is generally coupled with para (and occasionally additional terms) to indicate more details of the woman's obstetric history
A woman who has never given birth is a nullipara, a nullip, or para 0.
A woman who has never completed a pregnancy beyond 20 weeks is also referred to as being nulliparous, [6]
a nullipara or para 0.
A woman who has given birth one or more times is referred to as para 1, para 2, para 3 and so on.
A woman in her first pregnancy and w ho has therefore not yet given birth is a nullipara or nullip. After she gives birth she becomes a primip.
A woman who has given birth once before is primiparous , and would be referred to as a primipara or primip. A woman who has given birth two or more times is multiparous and is called a multip.
Grand multipara refers to a (grand multiparous) woman who has given birth five or more times.
‘‘How old were you at the time of your child’s delivery? How old was the baby’s father?’’ ‘‘How many times have you been pregnant? Have you had any miscarriages or children who died in infancy?’’ If ye s, ‘‘Do you know the cause? Were any o f your children born too early?’’ (contains an explanation of the shorthand notation for this information.) ‘‘When did you start prenatal care?’’ If prenatal care was started late, inquire tactfully about why by asking, ‘‘What is the reason you have not seen a doctor earlier?’’ ‘‘Did you have any illnesses during your pregnancy?’’ If yes, ask the mother to describe them, and find out when during the pregnancy they occurred. Be sure to ask about chronic illnesses, such as diabetes, hyperte nsion, asthma, or epilepsy, because these can have an effect on the health of the fetus. Also, inquire about any rashes that developed during pregnancy. ‘‘How much weight did you gain during your pre gnancy?’’ ‘‘During your pregnancy, did you take any drugs, recreational or o therwise? Any herbal products? Drink alcohol? Smoke cigarettes? Have any ‘x -rays’? Have any abnormal bleeding?’’ In asking these questions, the concern is whether the fetus has been exposed to any agents, known as teratogens, that can cause birth defects. Although concerns about teratogens are re al, many women who have taken innocuous medications during pregnancy feel guilt that their ingestion may have somehow harmed t heir child; in these cases, reassurance t hat the agent was safe may relieve a great deal of maternal anxiety. ‘‘Were you told during your pregnancy that you had high blood pressure? diabetes? protein in your urine?’’ ‘‘What were the results of your blood tests? Were you tested for Group B strep or any other infections?’’ Standard prenatal care includes testing for maternal blood group, hepatitis B surface antigen, syphilis, chlamydial infection, and, in the last trimester, group B streptococcal vaginal colonization. Testing for gestational diabetes is also becoming more prevalent. ‘‘What was your due date? When was the baby actually born?’’ Prematurity (birth before37 weeks’ gestation), and postmaturity (birth after 42 weeks’ gestation) are associated with increased risk of early mortality and with specific clinical syndromes. ‘‘When did you first feel the baby move? Was the baby active throughout pregnancy?’’ If t his is not the first pregnancy, ask the mother to compare this fetus’s activity with her other pregnancies. ‘‘How long was your labor? Were there any unusual problems with it?’’ ‘‘What type of delivery did you have, vaginal or cesarean?’’ If cesarean, ask for the reason. Was it because of a previous cesarean birth or a problem related to this pregnancy?* ‘‘Did the baby come out head first o r feet first?’’ ‘‘How long were your membranes ruptured be fore the child was born?’’ If the m embranes have been ruptured more than 18 hours, the risk of infection ascending from birth canal to the baby increases r apidly. ‘‘What was the child’s birth weight?’’ ‘‘Were you told of any abnormalities at birth?’’
‘‘Were you told the Apgar{ scores?’’ If the parents don’t know, ask, ‘‘Did he cry right away? Or did the doctors need to do something to help him start breathing?’’ ‘‘Did the child experience any problems in the newborn nursery, such as breathing difficulties? Jaundice? Feeding problems?’’ ‘‘Did the child receive oxygen in the nursery? antibiotics? phototherapy?’’ ‘‘After delivery, how long did the baby remain in the hospital?’’ ‘‘Did the child go home with you?’’ If not, ask why not. ‘‘Were you told that any problems wer e found on the newborn screening tests?’’{ If yes, ‘‘What were they? Was followup testing performed?’’ Note the order of these questions: they begin with the prenatal course, then focus on the actual birth, and then turn to the postnatal course
PAST MEDICAL HISTORY Does your child have any chronic health problems?’’ Common chronic health problems in children include asthma, seizure disorders, eczema, recurrent ear infections or urinary tract infections, sickle cell disease, cystic fibrosis, diabetes, gastroesophageal reflux disease, and cerebral palsy
It is important to identify allergies to medication (including penicillin), foods, or other substances.
‘‘How do you know the child is allergic to . . . ?’’ ‘‘What was the rash like?’’ A hivelike or urticarial rash is likely to be a true allergy. ‘‘Did the child have any problems other than the rash?’’ ‘‘How long after the child starte d the medication* did the rash appear?’’ ‘‘After the medication was stopped, how long did the rash last?’’ ‘‘Has the child ever taken the medication again with recurrence of the rash?’’
NUTRITION ‘‘Is the child being breast-fed?’’ If yes, ‘‘How often? For how long at each feeding? Is vitamin D o r supplemental fluoride being given?’’ ‘‘How many ounces of formula{ is the baby given a day? What kind of formula do you feed? How do you prepare it?’’ ‘‘When did you introduce solid foods, such as cereals?’’ ‘‘Has the child ever had a problem with vomiting? diarrhea? constipation? colic? Would you describe the child as ‘a fussy eater’?’’
For infants, differentiate diarrhea from normal liquid stools. If the child is breast -fed, the stools are usually a yellow or mustard-colored liquid and may follow each feeding. If the child is formula-fed, the stools are more likely to be yellowish-tan and firmer.
GROWTH AND DEVELOPMENT The child’s characteristics or temperament during infancy may be predictive of early developmental progress and of how he or she will respond to new experiences in years to come. ‘‘Would you describe your child as active, average , or quiet?’’ If this is not the mother’s first child, it is appropriate to ask how this infant compares with the family’s other children: Is this child slower, faster, or about the same in development?
‘‘When did the child first sleep t hrough the night?’’ ‘‘Do you have any concerns about the child’s development? If yes, ‘‘What are they ?’’ ‘‘Has the child ever failed to make progress or ever lost any ability he o r she once had?’’ ‘‘Does the child have difficulty keeping up with other children?’’ After asking general questions about the child’s development, you need to get information about specific developmental milestones that reflect the child’s ability in four areas: gross motor, language, fine motor, and personal/social development. The following questions should be asked: ‘‘At what age did the child roll over for the first t ime? sit without support? point at objects? Wave ‘bye-bye’? recognize objects by name? stand holding on? walk without support? say his or her first words? walk up and down stairs without support? learn to dress himself or herself? learn to tie shoes? put two words together? speak in full sentences?’’ ‘‘At what age was the child toilet-trained?’’ ‘‘How old do you think your child acts now?’’ ‘‘How often does your child have tantrums?’’ For the school-aged child, the child’s social, motor, and language development, as w ell as emotional maturation, are
reflected in current behavior. A nice way to broach this topic is to ask, ‘‘How would you describe your child as a person?’’ Follow up with some or all of these questions: ‘‘What do you enjoy the most about your child? the least?’’ ‘‘Does your child usually complete what he or she starts?’’ ‘‘How does your child get along with ot her children his or her age?’’ ‘‘How many hours of sleep does your child get each night?’’ ‘‘Does the child have any recurrent nightmares?’’ ‘‘Does the child have temper tantr ums?’’ Whereas tantrums in toddlers and preschoolers are not unusual at those ages, tantrums in a school-aged child are unusual and may indicate potentially serious problems. ‘‘What type of responsibility can he or she be given?’’ ‘‘How old was your child when he or she started school?’’ ‘‘In what grade is he or she now?’’ ‘‘How is he or she doing in school?’’ ‘‘Has he or she ever been left back?’’ ‘‘Has your child’s teacher ever t old you that he or she suspects a problem?’’ If yes, ‘‘What is the problem?’’ ‘‘What is your child’s grade level for reading? math?’’ ‘‘What does your child enjoy doing during his or her free time?’’ ‘‘What kinds of things scare him or her?’’ ‘‘How does the child get along w ith his or her brothers and sisters?’’ ‘‘How much time does your child spend watching TV? playing video games? on the computer?’’ ‘‘Does he or she have a TV in his or her room?’’
IMMUNIZATION HISTORY ‘‘How many sets of vaccines has your child had?’’ (The primary se ries is given at 2, 4, and 6 months of age.) ‘‘How many injections did the child get e ach time?’’ (Most schedules will have 2 or more injections per visit.) ‘‘Did the child get shots right after his or her first birthday? How many?’’ ‘‘How about at 15 to 18 months?’’
‘‘What shots did he or she get before kindergarten?’’ For the child 11 or older, ask, ‘‘Has she gotten any vaccines recently? How many?’’ Recent additions to the vaccine schedule provide adolescents with protection against pertussis, meningococcal disease, hepatitis A, and, for girls, human papillomavirus, the leading cause of cervical cancer. Also ask, ‘‘Did your child have a re action to any of the shots?’’
SOCIAL AND ENVIRONMENTAL HISTORY The social and environmental history should include the parents’ ages and occupations, as well as the current living conditions. Ask these questions: ‘‘How many rooms do you live in?’’ ‘‘Who lives in your home?’’ ‘‘Are there any pets?’’ ‘‘Does anyone in the household smoke? Are there carpets? Is dust a problem? Are there problems with cockroaches or other environmental contaminants?’’ ‘‘Does the child sleep in his or her own room? Does the child sleep in a crib or a bed? Does the child sleep in the parents’ bed?’’ ‘‘Is the child cared for in any other house?’’ ‘‘Who supervises the child during the day?’’ ‘‘How does the family have fun together?’’ ‘‘Do both the child’s parents share in family life?’’ ‘‘What is the condition of the paint and plaster in your home?’’ ‘‘Has the child had any known exposure to le ad?’’
FAMILY HISTORY FOR EACH INDIVIDUAL, THE FOLLOWING INFORMATION SHOULD BE OBTAINED: 1- If alive, name and current age 2- Presence of any illnesses, such as diabetes, asthma, coronary artery disease, hypertension, stroke, and c ancer 3- Presence of birth defects or genetic disorders such as sickle cell disease, hemophilia, cystic fibrosis and Tay-Sachs
disease; if known, each individual’s carrier status for a ny of these conditions should be noted as well 4-Any miscarriages or children who died in infancy or later 5-If deceased, age at and cause of death 6-Presence of consanguinity By analyzing the pedigree, the e xaminer can gain insight into the child’s risk for having specific diseases in the future.
REVIEW OF SYSTEMS THE ADOLESCENT INTERVIEW The HEADS mnemonic is a useful tool for remembering the main topics for the private adolescent interview.
For ‘‘Home,’’ you might ask the following questions: ‘‘How are things at home?’ ‘‘What are your responsibilities?’’ ‘‘What are the rules that you have to follow?’’ ‘‘Do you have brothers or sisters? How do you get along? What sort of things do you argue about?’’ For ‘‘Education,’’ you can ask the following questions: ‘‘How is school going?’’ ‘‘What grade are you in?’’ ‘‘What school do you go to?’’ ‘‘What subjects are you taking?’’ ‘‘What do you like best? least?’’ ‘‘What are your future plans?’’ ‘‘Do you feel safe at school?’’ If indicated, you might need to ask the following questions:
‘‘Have you been involved in any fights?’’ ‘‘Have you ever been suspended? What was that about?’’ ‘‘A’’ can stand for ‘‘activities’’ or ‘‘alcohol.’’ Some questions about activities are as follows: ‘‘Are you involved in any clubs or sports?’’ ‘‘What do you do after school?’’ ‘‘What do you like to do with your friends?’’ ‘‘Are your friends mostly girls? mostly boys? both?’’ Asking about alcohol use broaches a potentially sensitive subject, and there are many ways to introduce it; f or instance:
‘‘Do any of your friends use alcohol? Have you ever tried it?’’ ‘‘Lots of kids your age are curious about drinking. How about you?’’ ‘‘You mentioned that you like to go to clubs with your friends. Are any of you served alcohol there? How about you?’’ ‘‘D’’ stands for ‘‘drugs’’ or ‘‘depression.’’ Drug use can be asked about in the same way as alcohol. ‘‘How has your mood been?’’ ‘‘Do you ever find yourself feeling down and sad for more than a few hours?’’ If the teenager admits to a depressed mood, then you need to probe further: ‘‘How would you describe your mood?’’ The ‘‘S’’ stands for ‘‘safety’’ and ‘‘sex.’’ Safety refers not only to personal safety practices, such as using a seat belt or wearing a bike helmet, but also to the risk of violence in interper sonal relations: at home, with an intimate partner, at school, or in the community.
FEMALE GENITALIA HITORY
REVIEW OF SPECIFIC SYMPTOMS
ABNORMAL VAGINAL BLEEDING
‘‘How long have you noticed the vaginal bleeding?’’ ‘‘What types of contraceptives do you use?’’ ‘‘How often are your periods?’’ ‘‘What is the duration of your menstrual flow?’’ ‘‘How many tampons or napkins do you use on each day of your flow?’’ ‘‘Are there any clots of blood?’’ ‘‘When was your last period?’’ ‘‘Have you noticed bleeding between your periods?’’ ‘‘Do you have abdominal pain during your periods?’’ ‘‘Do you have hot flashes? cold sweats?’’ ‘‘Do you have children?’’ If yes, ‘‘When was your last one born?’’ ‘‘Do you think you might be pregnant?’’ ‘‘Are you under any unusual emotional stress?’’ ‘‘Have you noticed an intolerance to co ld? heat?’’ ‘‘Have you noticed a change in your v ision?’’ ‘‘Have you had any headaches? nausea? change in hair pattern? milk discharge from your nipples? ‘‘What is your diet like?’’
Abnormal uterine bleeding, also known as dysfunctional uterine bleeding, includes amenorrhea, menorrhagia, metrorrhagia, and postmenopausal bleeding
AMENORRHEA is the cessation or nonappearance of me nstruation. Before puberty, amenorrhea is physiologic, as it is during pregnancy and after menopause. In primary amenorrhea, menstruation has never occurred; in secondary amenorrhea, menstruation has occurred but has ceased, as in pregnancy. Long-distance joggers, patients with anorexia, or any woman with abnormally low body fat may have secondary amenorrhea. Diseases of the hypothalamus, pituitary gland, ovary, uterus, and thyroid gland are associated with amenorrhea. Galactorrhea, or milk discharge from the nipples, occurs in many individuals with pituitary tumors. Chronic disease is also frequently associated with secondary amenorrhea.
MENORRHAGIA is excessive bleeding at the time of the menstrual period. The flow may be increased, the duration may be increased, or both may occur. The number of pads or tampons a patient uses each day of the cycle helps quantify the flow. Menorrhagia in some cases may be associated with blood disorders such as leukemia, inherited clotting abnormalities, and decreased platelet states. Uterine fibroids are a leading cause of menorrhagia. Menorrhagia secondary to fibroids is related to the large surface area of the endometrium from which bleeding occurs.
METRORRHAGIA is uterine bleeding of normal amount at irregular, noncyclic intervals. Foreign bodies such as intrauterine devices, as well as ovarian and uterine tumors, can cause metrorrhagia. Often there is increased bleeding between cycles as well as heavier periods; this is termed menometrorrhagia. Bleeding that occurs more than 6 to 8 months after menopause is termed postmenopausal bleeding. Any postmenopausal bleeding must be investigated. Uterine fibroids or tumors of the cervix, uterus, or ovary may be responsible.
DYSMENORRHEA Dysmenorrhea, or painful menstruation, is a common symptom. It is often difficult to define as abnormal, because many healthy women have some degree o f menstrual discomfort. In most women, these cramps subside soon after the commencement of the menstrual flow. There ar e two types of dysmenorrhea: primary and secondary. PRIMARY DYSMENORRHEA is far more common. It begins shortly after menarche, is associated with colicky uterine contractions, and occurs with every period. Childbirth frequently alleviates this state permanently. SECONDARY DYSMENORRHEA is caused by acquired disorders within the uter ine cavity (e.g., intrauterine devices, polyps, or fibroids), obstruction to flow (e.g., cervical stenosis), or disorders of the pelvic peritoneum (e.g., endometriosis or pelvic inflammatory disease*). It usually occurs after several years of painless periods. Regardless of its cause, dysmenorrhea is described as intermittent, crampy pain accompanying the menstrual flow. The pain is felt in the lower abdomen and back, sometimes radiating down the legs. In severe case s, fainting, nausea, or vomiting may occur.
MASSES OR LESIONS
‘‘When did you first notice the mass (lesion)?’’ ‘‘Is it painful?’’ ‘‘Has it changed since you first noticed it?’’ ‘‘Have you ever had it before?’’ ‘‘Have you been exposed to anyone with venereal disease?’’
SYPHILIS may result in a chancre on the labia. Often unnoticed, it is a small, painless nodule or ulcer with a sharply demarcated border. Small, acutely painful ulcers may be chancroid or GENITAL HERPES.
A patient with an abscess of Bartholin’s glan d may present with an extremely tender mass in the vulva. Benign tumors, such as VENEREAL WARTS (condylomata acuminata), and malignant conditions manifest as a mass on the external genitalia. Some affected patients complain of a sensation of fullness or ma ss in the pelvis as a result of pelvic relaxation.
PELVIC RELAXATION refers to the descent or protrusion of the vaginal walls or uterus through the vaginal introitus. This is caused by a weakening of the pelvic supports. The anterior vaginal wall can descend, producing a cystocele that triggers urinary symptoms such as frequency and stress incontinence. The posterior vaginal wall can descend, producing a rectocele, which triggers bowel symptoms such as constipation, tenesmus, or incontinence.
The uterus can also descend, which results in uterine prolapse. In the most severe st ate, the uterus may lie outside the vulva with complete vaginal inversion, a condition known as procidentia.
VAGINAL DISCHARGE Vaginal discharges, also known as leucorrhea
VAGINAL ITCHING Vaginal itching is associated with monilial infections, glycosuria, vulvar leukoplakia, and any condition that predisposes a woman to vulvar irritation. Pruritus may also be a symptom of psychosomatic disease.
ABDOMINAL PAIN
‘‘When was your last period?’’ ‘‘Have you ever had any type of venereal disease?’’ ‘‘Is the pain related to your menstrual cycle?’’ If yes, ‘‘At what time in your cycle does it occur?’’ ‘‘Do you experience a burning sensation when you urinate?’’
Abdominal pain may be acute or chronic. Is the patient pregnant? Acute abdominal pain may be a complication of pregnancy. Spontaneous abortion, uterine perforation, and ecto pic tubal pregnancy all are life-threatening situations. Acute inflammation by gonococci of the fallopian tubes and ovary, salpingo-oophoritis, can produce intense lower abdominal pain. Acute lower abdominal pain localized to one side that occ urs at the time of ovulation is te rmed mittelschmerz. This pain is related to a small amount of intraperitoneal bleeding at the time of ovum release. Urinary t ract infection may also cause acute pain. Patients with urinary tract infections usually have associated urinary symptoms of burning sensation or frequency. Chronic abdominal pain may result from ectopic endometrial tissue, chronic pelvic inflammatory disease of the fallopian tubes and ovaries, and pelvic muscle relaxation with protrusion of the bladder, rectum, or uterus.
DYSPAREUNIA Dyspareunia is pain during or after sexual interco urse. Dyspareunia may be physiologic or psychogenic. Infections of the vulva, introitus, vagina, cervix, uterus, fallopian tubes, and ovaries have bee n associated with dyspareunia. Tumors of the rectovaginal septum, uterus, and ovaries have been described in patients who experienced painful sexual intercourse. Dyspareunia is often present in the absence of a physiologic disorder. A history of painful pelvic examinations and a fear of pregnancy are common in these patients. Women may have ‘‘penetration anxiety’’ until they are assured that the vagina can be penetrated by a penis. In these individuals, such anxiety may lead to vaginismus, a condition of severe pelvic pain and spasm when the labia are mere ly touched. In other women, dyspareunia may develop during times of stress or emotional conflict. The examiner can obtain valuable information by asking, ‘‘What else is going on in your life now?’’ Dryness of the vagina and labia may cause irritation that can result in dyspareunia. CHANGES IN URINARY PATTERN Stress incontinence is urinary incontinence that occurs wit h straining or coughing. Stress incontinence is more common among women than among m en. The female urinary bladder and urethra are maintained in position by several muscular and fascial supports. It has been postulated that estrogens may be responsible, at least in part, for a weakening of the pelvic support. With aging, the support of the bladder neck, the length of the urethra, and the competence of the pelvic floor are decreased. Repeated vaginal deliveries, strenuous exercise, and chronic coughing increase the chance for stress incontinence.
‘‘Do you lose your urine on straining? coughing? lifting? laughing?’’ ‘‘Do you lose your urine constantly?’’ ‘‘Do you lose small amounts of urine?’’ ‘‘Are you aware of a full bladder?’’ ‘‘Do you have to press on your abdomen to void?’’ ‘‘Are you aware of any weakness in your limbs?’’ ‘‘Have you ever had a loss of vision?’’ ‘‘Do you have diabetes?’’ Patients with pure stress incontinence describe urine loss without urgency that occurs during any activity that momentarily increases intra-abdominal pressure. Although stress incontinence is common among women, it is important to rule out other types of incontinence, such as neurologic, overflow, and psychogenic. Neurologic incontinence may result from cerebral dysfunction, spinal cord disease, and pe ripheral nerve lesions.
INFERTILITY
‘‘Do you have regular menstrual periods?’’ ‘‘Have you kept a chart of your basal body temperature?’’ ‘‘Have you ever had venereal disease?’’ ‘‘Have you been tested for thyroid disease?’’ ‘‘Have you taken any medications to promote fert ility?’’
GENERAL SUGGESTIONS
‘‘At what age did you start to menstruate?’’ ‘‘How often do your periods occur?’’
‘‘Are they regular?’’ ‘‘For how many days do you have menstrual flow?’’ ‘‘How many pads or tampons do you use each day of your flow?’’ ‘‘During your menstrual cycle, do you exper ience any breast tenderness or breast pain? bloating? swelling? headache? edema?’’ ‘‘When was your last menstrual period?’’
‘‘Have you ever been pregnant?’’ If the woman has been pregnant, ask the following questions: ‘‘What was the outcome of your pregnancy?’’ ‘‘How many full-term pregnancies have you had?’’ ‘‘Have you had any children born prematurely?’’ ‘‘How many living children do you have?’’ ‘‘How were your children delivered (vaginally, cesarean)?’’ ‘‘What were the birth weights of your children?’’ The interviewer might start by asking, ‘‘Are you satisfied with your sex life?’’ It is important for the examiner to determine the marital status of the patient. Is the patient married? How many times? For how long? Are there other sexual partners? If the patient is not married, is she currently having sexual relationships? What type of birth control is being used?
It is important to ask all sexually active women the following: ‘‘How easily can you reach an orgasm or climax?’’ ‘‘How strong is your sex drive?’’ ‘‘How easily are you sexually aroused?’’ ‘‘How easily does your vagina become moist during sex?’’ ‘‘Are your orgasms satisfying?’’
A gravida is a pregnant woman.
A nulligravida or gravida 0 is a woman who has never been pregnant. A primigravida or gravida 1 is a woman who is pregnant for the first time or has been pregnant one time.
A multigravida or more specifically a gravida 2 (also secundigravida), gravida 3, and so on, is a woman who has
been pregnant more than one time.
An elderly primigravida is a woman in her first pregnancy, who is at least 35 years old. This term is becoming less common as it may be considered offensive.
The term gravida is generally coupled with para (and occasionally additional terms) to indicate more details of the woman's obstetric history
A woman who has never given birth is a nullipara, a nullip, or para 0. A woman who has never completed a pregnancy beyond 20 weeks is also referred to as being nulliparous, [6]
a nullipara or para 0.
A woman who has given birth one or more times is referred to as para 1, para 2, para 3 and so on.
A woman in her first pregnancy and w ho has therefore not yet given birth is a nullipara or nullip. After she gives birth she becomes a primip.
A woman who has given birth once before is primiparous , and would be referred to as a primipara or primip. A woman who has given birth two or more times is multiparous and is called a multip.
Grand multipara refers to a (grand multiparous) woman who has given birth five or more times.
