1.1 - Intro to PCM Flashcards
SOAP note
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
S = Subjective
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)
Allergies (Alls):
Traditionally, this section is for
medication allergies. Food or environmental
allergies may be listed in Past Medical History
Current Meds
Prescription,
over‐the‐counter, vitamins, herbals.
PSH
Past Surgical History
Social HIstory (SH)
tobacco (quantity and
duration), etOH (quantity and frequency),
illicit drugs (quantity, frequency, and route),
and if relevant, occupation, marital status,
sexual history)
Family History (FH):
Minimum of first degree
relatives (parents, siblings, kids). Or if
adopted, state that.
Vital Signs (VS)
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
First assessment includes
reason they came to the
appointment (restatement of the chief complaint)*
Reason they came to the doctor should have three
differentials
Second and third assessment possibilities:
Other active problems (hypertension, diabetes,
etc.)
– Family history (cancer, diabetes, hypertension,
heart disease)
– Lifestyle issues (Obesity, tobaccoism, alcohol use)
KCU plan considerations
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
address emotions with NURS
Name the patient’s expressed emotions
– Make an Understanding statement
– Respect the patient (praise them, acknowledge plight)
– Offer Support
OPPQQRST‐A
Onset Palliative Factors Provocative Factors Quality Quantity Radiation Severity Timing Associated symptoms
elements of a social history
- Demographics and occupational history
- Nutrition and diet
- Daily activities and exercise
- Alcohol, tobacco and recreational drug use
- Spirituality and beliefs
- Relationships
- SOMETIMES: Sexual history
demographics include
Age • Gender • Race or ethnic backgound • Religion/Spirituality • Residence
CDC recommended exercise
150 minutes per week of moderate
activity (brisk walking) and strength training 2 days of the week that
focuses on all major muscle groups.
pack years?
Number of packs smoked per day x number of years smoked = pack
years
[most tried to quit 7-8 times!!]
NIAAA Safe Drinking Limits
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.
CAGE Questions
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?)
domestic violence - SAFE
- SAFE
- Stress/Safety
- Afraid/Abused
- Friends/Family
- Emergency Plan
5 Ps for sexual history
- Partners • Prevention of Pregnancy • Protection from STDs • Practices • Past History of STDs
past STD history - Additional questions to identify HIV and viral hepatitis risk include
“Have you or any of your partners ever injected drugs?”
associated symptoms vs. ROS
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
key points for delivering bad news
- The Warning Shot
- No euphemisms
- No timelines
- Non‐anxious presence
- Use silence effectively
