Complete adult medical history Flashcards
What information should you obtain for patient identification?
correct patient name, DOB, age, biological sex and/or gender identity, other descriptors as relevant to each patient
What info should you obtain for historian and reliability?
who is providing the medical history and the clinician’s assessment of their reliability
What is the chief complaint (cc)?
reason(s) for visit, directly quoted in the patient’s own words
What is the history of present illness? What info should be obtained?
HPI is the aspects of current illness (chronological narrative of the problem)
OLDCARTS- Onset, Location, Duration, Character, Aggravation/Alleviating factors, Radiation, Timing
OPQQRST- Oneset and chronology, Position and radiation, Quality, Quantification, Related symptoms, Setting, Transforming factors
what does OLDCARTS stand for?
Onset
Location
Duration
Character
Aggravating/Alleviating factors
Radiation
Timing
Severity
What does OPQQRST stand for?
Onset and chronology
Position and Radiation
Quality
Quantification
Related symptoms
Setting
Transforming factors
What constitutes past medical history (PMH)
allergies to medications
medications
adult illnesses and chronic medical conditions
surgeries
hospitalizations
psychiatric admissions
gynecologic and obsteric history
health maintenance examinations
what do you need to know about the patients allergies to medications?
description of reaction and discuss associated allergies (shellfish, latex, eggs, etc.)
what do you need to know about the patients medications?
prescription medication (current) - reason taken, dose, route, frequency
over-the-counter medication (current) - reason taken, dose, route, frequency
herbal remedies, vitamins, supplements (current) - reason take, dose, route, frequency
what do you need to know about the patients adult illnesses and chronic medical conditions?
ask open ended questions and prompt as needed. Ex. include high bp, hx of stroke or heart attack, coronary artery disease, asthma, tuberculosis, diabetes, kidney disease, thyroid disease, cancer, STIs, blood transfusions, mood or cognitive disorders, illnesses that began in childhood
what do you need to know about patients past surgeries?
reason for surgery
type of surgery
date of surgery
outcome
what do you need to know about patients past hospitalizations?
major disease/illness/accident
date of hospitalization
treatment
outcome
what do you need to know about patients psychiatric admissions?
diagnosis
date of hospitalization
treatment
outcome
what do you need to know about pts gynecologic and obstetric history?
age at menarche
last menstral period (LMP)
usual cycle length/flow
pregnancies
deliveries or c-section
living children
pregnancy losses (including abortions/miscarriages)
age of menopause
what do you need to know about pts health maintenance exams?
immunization hx as well as most recent mammogram, colonoscopy, etc
what sould be includded in pts family history (FH)?
should include at least three generations of blood relatives: grandparents, parents, siblings, and/or offspring. Ex include high bp, hx of stroke or heart attack, coronary artery disease, asthma, diabetes, kidney disease, thyroid disease, cancer, STIs, bleeding or clotting disorders, mood or cognitive disorders, birth defects or genetic disorders
patients family history consists of…
pedigree
social history (SH)
sexual history
what is included in the pts pedigree?
maternal and paternal grandparents - ages and diagnosis (or ages at death and causes of death)
mother - ages and diagnosis (or age at death, cause of death)
father - ages and diagnosis (or age at death, cause of death)
siblings - ages and diagnosis (or age at death, cause of death)
offspring - ages and diagnosis (or age at death, cause of death)
what factors are relevant in the pts social history?
HABITS - tobacco, alcohol, drugs of abuse, caffiene
HEATH PROMOTION - diet, physical activities/excersise, safety practices
PERSONAL LIFE - occupation (description, shifts, hours/weeks, hazards/exposures, use of PPE
*EDUCATION - current or highest level
*MILITARTY SERVICE
*PERSONAL RELATIONSHIPS AND SUPPORT SYSTEM - spouse/partner, children, caretakers
*ABUSE CONCERNS
*HOME/LIVING SITUATION
*SOURCES OF STRESS - home/work/financial
*LEISURE/HOBBIES
*SPIRITUAL/RELIGIOUS AFFILIATION/BELIEFS
EXPOSURE \S -recent travel, pets
what info is relevant for the pts sexual history?
sexually active?
partners
past STDs
pregnancy history/plans
protection from STDs
