1.1 - Intro to PCM

Question 1

SOAP note

Answer 1

S= Subjective= What you learn by taking the
patient’s history
• O = Objective = Exam including structural
findings, laboratory and radiology data; exam findings “full vs. focused”
• A = Assessment = What you think is going on
with the patient
• P = Plan = What you and the patient agree to
do about the problem, including OMT
performed

Question 2

S = Subjective

Answer 2

Chief complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
– Other active problems
• Past surgical history (PSH)
• Medications (Meds)
• Allergies
• Social History
• Family history (FH)
• Review of Systems (ROS)

Question 3

Allergies (Alls):

Answer 3

Traditionally, this section is for
medication allergies. Food or environmental
allergies may be listed in Past Medical History

Question 4

Current Meds

Answer 4

Prescription,

over‐the‐counter, vitamins, herbals.

Question 5

PSH

Answer 5

Past Surgical History

Question 6

Social HIstory (SH)

Answer 6

tobacco (quantity and
duration), etOH (quantity and frequency),
illicit drugs (quantity, frequency, and route),
and if relevant, occupation, marital status,
sexual history)

Question 7

Family History (FH):

Answer 7

Minimum of first degree
relatives (parents, siblings, kids). Or if
adopted, state that.

Question 8

Vital Signs (VS)

Answer 8

BP, Pulse, Respiration rate and Temp
(height and weight not required)
• Heart:
• Lungs:
• Osteopathic Structural Exam (OSE): Must have T‐
spine, can add other exam related to chief complaint

Question 9

First assessment includes

Answer 9

reason they came to the
appointment (restatement of the chief complaint)*
Reason they came to the doctor should have three
differentials

Question 10

Second and third assessment possibilities:

Answer 10

Other active problems (hypertension, diabetes,
etc.)
– Family history (cancer, diabetes, hypertension,
heart disease)
– Lifestyle issues (Obesity, tobaccoism, alcohol use)

Question 11

KCU plan considerations

Answer 11

1) Medications if indicated
2) Laboratory tests if indicated
3) Other diagnostic tests if indicated
(EKG, radiology, biopsy, etc.)
4) Self‐care (RICE, stop smoking, exercise, etc)
5) OMT (performed or plan to perform)
6) Followup

Question 12

address emotions with NURS

Answer 12

Name the patient’s expressed emotions
– Make an Understanding statement
– Respect the patient (praise them, acknowledge plight)
– Offer Support

Question 13

OPPQQRST‐A

Answer 13

Onset
Palliative Factors
Provocative Factors
Quality
Quantity
Radiation
Severity
Timing
Associated symptoms

Question 14

elements of a social history

Answer 14

• Demographics and occupational history
• Nutrition and diet
• Daily activities and exercise
• Alcohol, tobacco and recreational drug use
• Spirituality and beliefs
• Relationships
• SOMETIMES: Sexual history

Question 15

demographics include

Answer 15

Age
• Gender
• Race or ethnic backgound
• Religion/Spirituality
• Residence

Question 16

CDC recommended exercise

Answer 16

150 minutes per week of moderate
activity (brisk walking) and strength training 2 days of the week that
focuses on all major muscle groups.

Question 17

pack years?

Answer 17

Number of packs smoked per day x number of years smoked = pack
years
[most tried to quit 7-8 times!!]

Question 18

NIAAA Safe Drinking Limits

Answer 18

Men: 14 or fewer drinks per week, no more than 4 drinks in a day.
Women and those over age` 65: 7 per week, no more than 3 in a day.

Question 19

CAGE Questions

Answer 19

Has anyone ever suggested you CUT BACK?
• Are you ever ANNOYED when people talk about your drinking?
• Do you ever feel GUILTY about your drinking?
• Do you ever need a drink in the morning to steady your nerves (an
EYE OPENER?)

Question 20

domestic violence - SAFE

Answer 20

• SAFE
• Stress/Safety
• Afraid/Abused
• Friends/Family
• Emergency Plan

Question 21

5 Ps for sexual history

Answer 21

-  Partners
• Prevention of Pregnancy
• Protection from STDs
• Practices
• Past History of STDs

Question 22

past STD history - Additional questions to identify HIV and viral hepatitis risk include

Answer 22

“Have you or any of your partners ever injected drugs?”

Question 23

associated symptoms vs. ROS

Answer 23

Associated symptoms are symptoms that may
be related to the chief complaint.
• ROS is about making sure the clinician isn’t
missing something ELSE that might do a
patient harm

Question 24

key points for delivering bad news

Answer 24

• The Warning Shot
• No euphemisms
• No timelines
• Non‐anxious presence
• Use silence effectively