History

Question 1

Mnemonic to remember the beginning of history

Answer 1

OLDCARTSFAA

1. Onset
2. Location
3. Duration
4. Character
5. Alleviating/Agravating
6. RAdiation
7. Treatments
8. Timing
9. Severity
10. Frequency/Progression
11. Associated Symptoms
12. Alarm symptoms

Question 2

Introduction

Answer 2

• CC (in patients own words)
• introduction First and last name
• title ( I am a PA student working with Dr. ______)
• confirm patient name and DOB
• how would you like me to address you
• time for the encounter
• anything else you would like to address
• Tell me what’s going on?

Question 3

Alarm Symptoms to be asked about in Hx

Answer 3

Numbness, weakness, fever, night sweats

over age of 45? SOB, chest pain

Question 4

ROS: general questions

Answer 4

1. fever
2. chills
3. night sweats
4. weight change (up or down)
   
   1. how much?
5. overall health

Question 5

ROS: Skin

Answer 5

1. lesions
2. rashes
3. itching (pruritus)
4. sores
5. changes in hair or nails
6. changes in moisture of skin
7. changes in temperature of skin
8. changes in color of skin
9. changes in texture of skin

Question 6

Pruritus

Answer 6

itching

Question 7

odynophagia

Answer 7

painful swallowing

Question 8

oliguria

Answer 8

little or no urine

Question 9

dysuria

Answer 9

painful urination

Question 10

Past Medical Hx

Answer 10

• Do you have any current or previous medical issues that were seen by a provider for
• hospitalizations
• surgeries?
• Immunizations, travel, exposures (sometimes relevant)

Question 11

Medications

Answer 11

Are you currently taking any medications?

• if so, dose, frequency, compliance, what for?
• OTC meds or supplements

Question 12

Allergies

Answer 12

• do you have any allergies to medications
• to foods or environmental triggers
• and reaction

Question 13

Family History

Answer 13

• person and age, medical problems
• example: siblings: 2 sisters, healthy
• any conditions that run in the family?

Question 14

Social History

Answer 14

• tobacco
• ethanol
• drugs
• employment
• living situation
• diet or exercise or hobbies
• sexual history

Question 15

Binge Drinking is what BAC

Answer 15

> or equal to 0.08%

Question 16

Binge Drinking and Heavy Drinking in Women

Answer 16

• Binge Drinking =
  
  • having a BAC = or > 0.08%
    
    • 4 or more drinks on a single occasion, usually within 2 hours
• Heavy Drinking =
  
  • 8 drinks or more per week

Question 17

Binge Drinking and Heavy Drinking in Men

Answer 17

• Binge Drinking =
  
  • having a BAC equal to or > 0.08%
    
    • 5 or more drinks on a single occasion, usually within 2 hours
  • having 15 drinks or more per week

Question 18

5 Factors that Contribute to Addiction

Answer 18

1. genetics
2. mental illness
3. home and social environment
4. stress
5. trauma/abuse