Obtaining a Medical History

Obtaining a Medical History


Hello, in this video we will be covering how
to take a complete medical history. First we will start with the chief complaint,
and we will be using the OLDERFAQQR mnemonic to help us remember which questions to ask. Onset
Location Duration
Exacerbating or precipitating factors Remitting or palliative factors
Frequency of symptoms Associated symptoms
Quality of pain Quantity of pain or quantity of stool/vomit
Radiation General: fever/chills, weight change/appetite,
fatigue/sleep problems/night sweats H: headache, LOC
E: hearing loss, vertigo, tinnitus, otalgia E: loss of vision, blurry vision, diplopia,
lacrimation N: rhinorrhea, congestion, sneezing, epistaxis
T: sore throat, hoarseness Neck: dysphagia, neck swelling, neck stiffness
CV: chest pain, palpitations, DOE, syncope, orthopnea, PND
Respiratory: SOB, pleurisy, wheezing, cough, sputum, hemoptysis
Abdomen: N/V/D/C, heartburn, melena, jaundice, stool description
Skin: hair/nail changes, rashes/sores/lumps/bruises, itching
Extremities: edema, pallor, cyanosis Musculoskeletal: myalgia, arthralgia, claudication
Neuro: numbness/tingling, paralysis, tremors, fainting/blackouts/seizures, incontinence,
gait changes Psych: SIGECAPS, delusions/hallucinations,
mood Endocrine: polydipsia/polyphagia/polyuria,
cold intolerance, heat intolerance, lid lag, exophthalmos
GU: frequency, incomplete emptying, nocturia, force of stream, incontinence, dysuria, hematuria,
suprapubic pain PMH: chronic conditions, hospitalizations
PSH: surgeries Meds: prescription meds, OTC meds
Allergies: allergies and reaction FH: parents ages, medical conditions, and
cause of death, as well as health of siblings, children
SH: tobacco, alcohol, drugs, occupation, home situation
Exposures: trauma, travel, sick contacts, unprotected sex
Menstrual: LMP, menarche, cycle, duration, flow, #tampons, PMS, intermenstrual bleeding
Contraceptive: current contraceptive, past contraceptive, condom use, sexually active,
new partner, # partners, last pap, abnormal pap, STIs, HPV vaccination
OBhx: term/preterm/abortions, gestational ages, vaginal or C/S, birthweight, birth complications,
M/F

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