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Common medical history questions

 

physical medicine it is common, after initial open questions about the patient’s generalhealth, toask questions in relation to each body system in turn:cardiovascular, respiratory, CNS,

gastrointestinal tract(including the liver), genitourinary tract (including the kidneys), etc !t isessential also to ask speci"cquestions about drug therapy, allergies and abnormal bleeding

#nother possible scheme is: AnaemiaBleeding disordersCardiorespiratory disordersDrug treatment and allergiesEndocrine diseaseF its and faintsGastrointestinal disordersHospital admissions and attendance

 $eatures of pain %orth noting in the history

CharacterSeveritySite&adiation (spread)'nseturationeriodicity#ggravating factors&elieving factors#ssociated phenomena

*+traoral e+amination he general appearance of the patient should be considered o they look ill or %ell- arethey an+ious./ook for obvious upper respiratory tract infection Note the skin comple+ion and mucosalcolour forsigns of anaemia or 0aundice #ssess the body in general and the head and neck for signs ofdeformityor asymmetry !n trauma cases look carefully for lacerations and abrasions/ook systematically at, or for:lymph nodes: these should be palpated forenlargement or change in te+turetrismus: de"ned as limitation of mouthopening of musculoskeletal origin, trismus

can be partial or complete Normal mouthopening is at least 12 mmrima oris (oral entrance): a small mouthopening can make surgery di3cult/imitation could be due to scarring or thepatient may naturally have a small mouths%ellings or deformity

!ntraoral e+amination

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 he si4e of the oral cavity and the distensibility of the soft tissues should be noted he softtissues should then be e+amined in sequence, and this sequence should al%ays be used bythat clinician, so no area is omittedbuccal sulci (upper and lo%er)5 oor of the mouthtongue (dorsal and ventral surfaces)

palate (hard and soft)oropharyn+gingivaeNe+t, the teeth may be e+amined and charted using a conventional system to identify thenumber presentand their distribution- noting dentures, cro%ns, bridges, implants, partial eruption of teethand coronal diseasehe periodontal condition should be noted he surgical or problem areashould no% be e+amined&edness or s%elling or in5 ammation should benoted, as should any discharge of pus /ook speci"cally for ulceration, erosion or keratosis of mucosalsurfaces and for any lumps or deformityConsider %hich teeth may be involved in thediseaseprocess and %hether any are in abnormal position

$eatures %orth noting during history and e+aminationof a lump or s%ellingurationChange in si4e#ny possible cause*+act anatomical site#ssociated lymph nodesSingle or multipleShapeSi4eColoure"nition of peripheryConsistency

6armth enderness#ttachment to skin#ttachment to deeper structures$luctuance!n5 ammationulsation7eneral %ell8being of the patient

$eatures %orth noting on e+amination of an ulcer#natomical locationSingle or multipleSi4eShape9ase*dge#d0acent tissuesischarge!s it painful.

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Bhaematological’ (eg anaemias) or Bcystic’ (particularlyin relation to the 0a%s), all of %hich tend to cut acrossthe other categories ;o%ever, as this is only an aidto memory, you may include %hatever categoriesyou "nd helpful

 he anatomical classi"cation might include:surface or glandular epitheliumconnective tissuemusclenervesvesselslymphatics 0ointsbonetooth (enamel, dentine, pulp, cementum,periodontal ligament, structures from tooth

development)