6011 Overview Flashcards
Patient History
Reliable tool for Dx. // 70 - 90% of Dx defined by history alone
Why is history important?
When paired with proper assessment technique and clinical reasoning - ensures quality, efficient, lower cost care
SOAP
S = Subjective = what patient Says (CC in patient’s words)
O = Objective = what you see (VS & Exam Findings & any results at time of visit, such as Accucheck or x-ray during visit)
A = Assessment (Impression / Diagnosis)
P = Plan
(E) Evaluation = How do you know if your plan worked?
Organize SOAP Note
Subjective information first. Name, Age, Ethnicity, CC
Chief Complaint (CC) History of Present Illness(HPI) - informs review of systems Past Medical History Family and Psychosocial History Review of Systems
“Throwing up for 3 weeks”
“Blurry vision” - patients words
Objective = vital signs, physical exam
“Pupils equal, reactive to light”
Importance of SOAP Note
Taking information from a patient and organizing it
Avoid: subjective or evaluating terms (“patient was rude” / “patient is combative”)
Make sure everything you write is OBJECTIVE. Don’t have anything in here that can hurt a patient’s feelings.
Documentation
Do not use diagnoses in findings –> Do not say “conjunctivitis” // conjunctive is red, errythemmis, etc
Your First Patient
Assessment starts when you wake up - starts when you look around at the environment. Think about your community and your resources
Step 1 - chart review
Start to narrow down risks (woman - pregnant?)
Trends - big picture (blood sugar 500 –> 300)
S - identifying info. Includes name / age / gender / occupation / interpreter? / who is providing information / referred by whom / reliability (“details of illness are confusing” - try to make comment as objective as possible)
Chief Complaint
In patient’s own words
This is NOT a diagnosis. Do not use “follow up” or “fracture of an ankle”
CC on intake may be different than what patient reveals to PCP
HPI (Also in “S” - part of what doctor Says)
MUST INCLUDE: location / quality / severity / duration & timing / context / modifying factors / associated signs and symptoms (7)
Context - “after I eat”
Associated S&S - visual changes with headache
HPI for chronic disease
DM / COPD
How is patient managing his/her problem. Think of systems that relate (eyes, nerve pain)
7 Dimensions of HPI
Location Quality Severity Duration & Timing Context Modifying factors Associated signs & symptoms
What is important about the interview?
Align your direction
Past Medical History
Depends on presentation (complete visits vs. episodic)
Include medications - and WHY patient is on this medication (Albuterol, asthma)
Note allergy and what allergy causes! (PCN causes rash)
Family History
1st degree blood relatives: siblings, parents
Anyone die of a heart attack before age 50?
Psychosocial History
“Take me through a day” / violence, work schedule, what they eat, exercise?
Social Hx and Habits
Body language Relationship - ask about sexual history Ask in a very 'matter of fact' way Get specific Exercise / Diet / Sleep
Review of Systems (“S”)
Symptoms patient is experiencing by body system over specified time period
Based on CC
Usually go general to specific
Document positives and negatives
Systems to include in ROS (14)
14 Systems Include:
Constitutional Eyes ENT CV Respiratory GI GU MSK Skin Neuro Psych Endocrine Hematological Allergic / Immunological
ROS or HPI?
If related to CC –> goes in HPI
+ ROS not related to CC
General to specific when asking questions
ROS - Constitutional
Objective Physical Exam - General Assessment
Psych (ROS)
Psych / Neuro / General
Endocrine (ROS)
Skin / General / Neuro
Hematological
Skin / HEENT / General
Allergic / Immunological
Skin / HEENT
ROS for GI
Any abdominal pain? N/V/D - General to Specific
HPI
7 Dimensions related to CC
Order of Physical Exam
General Assessment VS Skin HEENT Neck Cardiovascular Respiratory Abdomen / GI GU / GYN Musculoskeletal Neurological *Psych (what is objective? affect, speech)
Physical Exam - General
IPPA
Physical Exam - GI
IAPP
