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History taking by Mind Map: History taking
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History taking

Family history

Ask about any disease that runs in the family

Get information about 1st degree relatives

How old are the parents or how did they die

Siblings

Children

Drug history

All drugs the patient takes

Why

Dose

Frequency

Adherence

Prescribed or over the counter

Last taken

Allergy

Past medical history & surgery

History of present complaint

ask about each symptom to get details

FIFE

Feeling

Ideas

Functioning

Expectations

Pain assessment (SOCRATES)

Site

Onset

Character

Radiation

Associated symptoms

Timing, Duration, course, pattern

exacerbating and relieving factors

severity

effects on life style

Social and occupational history

Understanding the patient's context & social history

Occupation

Upbringing & education

Finance

Community support

Diet

Exercise

Relationship statues

Home life, Who lives with you, Who takes care of you, Home problems, Abuse

Leisure activities

Substance misuse, Tobacco, Alcohol, Street drugs

Sexual history

Beliefs

Systematic inquiry

General symptoms

Well being

appetite

wight change

energy

sleep

mood

Cardio

chest pain on exertion

shortness of breath, lying flat, at night, on minimal exertion, palpitation, pain in legs on walking, ankle swelling

Respiratory

Shortness of breath

cough

wheeze

sputum production (color, amount)

Blood in sputum

chest pain due to inspiration of cough

Gastrointestinal

Mouth (oral ulcers, dental issues)

Difficulty or pain swallowing

Nausea and vomiting

indigestion

heartburn

abdominal pain

change in bowl habit

change in color of stool

Genitourinary

Pain passing urine

Frequency passing urine (at night?)

Blood in the urine

Libido

Incontinence

Sexual partners

Men, Prostatic symptoms (like difficulty starting - hesitancy), Poor stream or flow, terminal dribbing, urethral discharge, erectile difficulty

Women, Last menstrual period (pregnancy), timing and regularity of periods, length of periods, abnormal bleeding, vaginal discharge, contraception, pain during intercourse

Neurological

headaches

dizziness (vertigo or light-headed?)

faints

fits

altered sensation

weakness

visual disturbance

hearing problems

memory and concentrating problems

Musculoskeletal

Joint pain, stiffness or swelling

Mobility

Falls

Skin

Bleeding or bruising

skin rash

Endocrine

Heat or cold intolerance

change in sweating

excessive thirst

Chief complaint

What seems to be the problem?

The problem in the patient's own words

Note the duration of each symptom

Starting

look at record and make sure it's the right patient

Greetings

Introduce yourself

Ask permission

Get age and birthdate

Before you start

Quite private space

Time: 15 minutes

Sit at eye level and gain eye content

First impression and look