Diagnostic reasoning, EBP, & types of histories

Question 1

3 Types of Histories

Answer 1

Comprehensive
Episodic
Problem-oriented

Question 2

7 Parts of Comprehensive Hx

Answer 2

1. Demographics
2. C/C
3. HPI
4. Past hx (med + sx)
5. Family hx
6. Social hx
7. Review of symptoms

Question 3

Episodic Hx

Answer 3

• Taken upon subsequent visits after the initial full data has been completed.
• Data from hx will depend on the purpose of the visit and the amount of time that has elapsed since the last visit.
• The health record is updated to include changes in health/illnesses/medications

Question 4

Problem-oriented (focused) Hx

Answer 4

• Taken when an individual presents with a specific problem.
• SOAP note format
• Data elicited will include what is relevant to the problem (23 y/o WF presents with burning upon urination).

Question 5

S? LIDTA

Answer 5

Severity

Question 6

S L? IDTA

Answer 6

Location

Question 7

SL I? DTA

Answer 7

Intensity

Question 8

SLI D? TA

Answer 8

Duration

Question 9

SLID T? A

Answer 9

Type

Question 10

SLIDT A?

Answer 10

Associate symptoms

Question 11

Review of Systems

Answer 11

the “pertinent positives” and “pertinent negatives” drawn from ROS that are relevant to the c/c

The presence or absence of these additional symptoms helps you generate the diff dx

Question 12

ROS- General

Answer 12

• weight changes
• clothing that fits differently (tight or loose?)
• weakness/fatigue
• fever

Question 13

ROS- Skin

Answer 13

• rashes
• lumps
• sore
• itching
• dryness
• changes in color
• changes in hair/nails
• changes in size/color of moles

Question 14

ROS- Head

Answer 14

• head injury
• h/a
• lightheadedness
• dizziness

Question 15

ROS- Eyes

Answer 15

• Vision
• glasses or contact lenses
• date of last eye exam
• pain
• redness
• excessive tearing
• double/blurred vision
• spots/specks
• flashing lights
• glaucoma
• cataracts.