(1) Medical History Flashcards
Why does the history matter?
- Provide evidence that appropriate care was given and to document patient’s response to that care; If it is not documented, it was not done
- Keep observations objective (personal and subjective opinions regarding patient or family do not belong)
Differences Between Subjective and Objective Data
Medical interview: subjective data
- what the patient tells you
- history, CC, ROS
Physical examination: objective data
- what you detect during examination
- all physical examination findings
Comprehensive vs Focused Assessment
Comprehensive:
1. For those you are seeing first time in office/hospital
2. Includes all elements of health history and complete physical
3. Provides fundamental knowledge about person and a baseline for future exams
4, Strengthens clinician-patient relationship
Focused/Problem-Oriented:
1. For returning/established patients OR specific urgent care visits
2. Addresses focused concerns or symptoms
3. Addresses symptoms restricted to specific body system
4. Applies exam relevant to concern
Chief Complaint (cc)
patient’s main reason for seeking care
History of Present Illness
The story of the patient’s problem
History of Present Illness:
“O, P, Q, R, S, T”
O = Onset
P = Palliative / Provocative factors
Q = Quality / characteristics of symptoms
R = Region / Radiation
S = Severity
T = Timing
History of Present Illness – Pertinent ROS
Include every organ system you feel might be connected to patient’s chief complaint; Include organ systems that you know to be related to patient’s suspected condition; Pertinent denials
Obtain a past medical history inclusive of…
- childhood illnesses
- adult illnesses
- surgeries, injuries, hospitalizations reverse chronologic order
- immunizations/vaccinations
- health screening / maintenance
What are (9) common childhood illnesses?
1) asthma
2) measles
3) mumps
4) rubella
5) chickenpox
6) pertussis
7) rheumatic fever
8) scarlet fever
9) polio
What are (23) common adult illnesses?
1) TIA/CVA
2) MI
3) CAD
4) valvular heart disease
5) HTN
6) DM
7) HLD
8) asthma
9) chronic bronchitis
10) emphysema, COPD
11) hepatitis
12) liver disease
13) TB
14) arthritis
15) PUD
16) renal disease
17) nephrolithiasis
18) cancer
19) glaucoma
20) thyroid disorder
21) migraine, seizures
22) substance abuse
23) mental health disorders (depression/anxiety)
What are common immunizations?
1) COVID
2) Influenza
3) Tetanus
4) Childhood vaccinations: pertussis, diphtheria, polio, measles, mumps, rubella, varicella
5) Hep B, HiB, HPV
6) pneumococci, meningococci
What are common health screening tests and maintenance?
Health screening:
1) TB test
2) HIV
3) CXR
4) colonoscopy
5) PSA
6) Pap smear
7) mammogram
8) occult blood test, lipids, metabolic panels, blood sugar, CBCs
Health maintenance:
Dental / podiatric / ophthalmologic appointments
Discuss the significance of obtaining the family history:
A properly collected family history can identify whether a patient has a higher risk for a disease.
Identify the (5) main elements of a social history:
1) Important & relevant information about the patient as a person
- Place of birth, ethnicity, current residence
2) Education and occupation history
- Environmental hazards
- Travel
- Military
3) Home situation and significant others/ children
- Is home, neighborhood safe
- Support systems
- Relationship status
- Religious beliefs
- Safety measures: seat belts, guns, medications, etc.
4) Personal habits
- Tobacco, alcohol, drug use
- Exercise and sleep
- Diet
- Hobbies & recreational activities
5) The patient’s outlook
- Baseline level of function
- Activities of daily living
Demonstrate ways to make the patient feel comfortable and relaxed to facilitate exchange of information.
- Refrain from judgement
- Explain why you need the information
- Confidentiality
