History Taking Flashcards
What are the components of Comprehensive assessment?
NEW PATIENTS
BASELINE DATA
o Provides fundamental and personalized knowledge about the patient o Strengthens the clinician-patient relationship o Helps identify or rule out physical causes related to patient concerns o Provides a baseline for future assessments o Creates a platform for health promotion through education and counseling o Develops proficiency in the essential skills of physical examination
What are the components of Focused assessment?
OLD PATIENT
FOLLOW_UPS
o Is appropriate for established patients, especially during routine or urgent care visits o Addresses focused concerns or symptoms o Assesses symptoms restricted to a specific body system o Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible
What are the essential elements as a physician for taking Patient History?
● Empathic listening
● Ability to interview patients of all ages, moods & backgrounds – adapt, adjust based on the mood & age of the patient
● Techniques for examining different body systems
Enumerate the different steps of Clinical Reasoning
- Identify problems
- symptoms, abnormal findings - Link findings to Pathophysiology or
Psychopathology
- should be able to explain why a particular symptom is present & present a working diagnosis - Establish & test a set of explanatory
hypotheses
Components of Adult Health History
Identifying data Reliability Chief complaint HPI PH FH P&S H ROS
what are the various components of Identifying data?
● Name ● Age ● Gender ● Religion ● Occupation ● Marital Status ● Citizenship ● Source of History – ideally the patient ● Source of the referral – private physician, hospital, insurance ● Date and time of history taking
How can you determine if the data is Reliable?
1) Memory of Patient
2) Trust
3) Mood
4) Source of data (unconscious or psych patients, ask the patient’s family)
What is the Chief Complaint?
● The main reason or concern that is causing the patient to go to you or to the hospital or to the clinic
● One or more symptoms/concerns causing the patient to seek care
● You should use the patient’s own words
● Should be written in English layman’s terms
What should be included in CC
Quote the patient directly
NO NEED TO WRITE EVERYTHING IN CHIEF COMPLAINT
Only a maximum if 2 complaints
<2,HPI
What is HPI?
● Amplifies the chief complaint ● A story of the problem or chronology of events or a timeline ● Include significant parts such as: ○ ..but there are no accompanying signs and symptoms of nausea or vomiting. There is relieve of bloatedness after food intake. Two weeks prior to consult, patient experienced epigastric discomfort with radiation to the back. One week prior to consultation, patient notices ictericia. 5 days prior to consult, there is fever and persistence of ictericia.
What should be the last part of HPI
The present illness, no need for date or etc.
Should ROS be a part of HPI?
should be part of the History taking ○ Along the way in the history taking, there are signs and symptoms related to the History of Present Illness. These should be removed from the Review of Systems and included in the History of Present Illness. ○ Ex.: Alcohol intoxication is included in History of Present Illness
Are Risk Factors a part of HPI
Yes.
How are pack-years Calculated?
no. of sticks per day/sticks per pack * No. of Years Example: 1 pack/day for 10 years Pack years = 0 years 20 sticks per day/20 sticks per pack × 1 = 10 pack years
What are the attributes of symptoms?
● “OLD CART”
O – Onset, since when, setting, treatment given
L – Location, where
D – Duration, how long
C – Character, quantity (pain scale) / severity / quality (dull/ sharp/ burning/ type)
A – Aggravating/relieving factors, associated
symptoms
R – Radiation
T – Time, trigger, how often, when, setting
● OPQRST O – Onset P – Palliating/Provoking factors Q – Quality R – Radiation S – Site T – Timing
What should be included in PMH?
● Childhood illnesses o Mumps, measles, rubella, chickenpox, fever, polio, congenital illnesses ● Adult illnesses o Medical – Diabetes, hypertension, hepatitis, asthma, HIV, hospitalizations, number & gender of sexual partners & risk-taking sexual practices o Surgical – Date/s, indication/s & type/s of procedure/s o OB/Gyn – Obstetric history, menstrual history, methods of contraception & sexual function o Psychiatric – Illness & time frame, diagnoses, hospitalizations & treatments o Lifestyle/Environmental – usual diet, exercise, exposure to chemicals o Health maintenance ▪ Screening tests ▪ Immunizations – for children and adults (recently received)
Components of Family History
● Familial/hereditary illnesses
● Presence or absence of certain conditions in the family
MEDICINE: HISTORY TAKING
● HPN, DM, CVA, Asthma, sudden death (<40 y/o), Arthritis, CA, Bleeding disorders, CAD,
Cholesterol, TB (more on exposure, not
hereditary), seizure disorder, mental illness, alcohol/drug addiction, allergies.
● Make an outline or a diagram
● Age, health & cause of death of each immediate relative, including parents, grandparents,
siblings, children & grandchildren
● Ask about any history of breast, ovarian, colon, or prostate cancer. Ask about any genetically transmitted diseases.
Components of Personal and Social History
- personality of patient
- Family relationship
- Educational Level
- Lifestyle
- Stress Factors
Components of ROS
● Noting for other possible problems that may or
may not be related to the present illness
● Going over all of the organ systems through question & answer
● At the end of the interview
● Questions that are related to the chief complaint
● Presence or absence of common symptoms
related to each major body system
● Uncover problems unrelated to the present illness
● If related to the CC include it in the HPI, not in the ROS
Parts of ROS
general/Constiutional Skin HEENT Neck Breast Respiratory Cardiovascular GIT UrinoGenital Vascular Musculo-skeletal Psych Neurologic Hematologic Endocrine
● Do not forget to ask the about the patient’s bowel movement
o Normal bowel movement of the patient
o Bowel movement differs from one
person to another
S.O.A.P.
Subjective- family data
Objective- PE and testing
Assessment- analysis and interpretation
Plan- interventions
What are the essential skills for Interviewing?
● Key skills for successful interviewing ○ Keen on observing ○ Good at communicating ○ Act as a facilitator and help your patient to verbalize
What are the 7 attributes of Symptoms?
○ Location: “Where is it?” “Does it radicate?” ○ Quality: “What is it like?” ○ Quantity & Severity: “How bad is it?” For pain rate from 1-10 ○ Timing: “When did it start?” “How long does it last?” “How often does it come?” ○ Onset: other circumstances that may contribute to the illness ○ Remitting or Exacerbating Factors: is there anything that makes it better or worse? ○ Associated Manifestations: Have you noticed anything else that accompanies it?
Last Queue of Qouta Saves Time Over Recent Addmissions
How is a hypothesis generated and tested?
Identifying the various attributes of the patient’s symptoms & pursuing specific details are fundamental to recognizing patterns of disease & differentiating one disease from another
How do you negotiate a plan for the patient?
CINE: HISTORY TAKING
● Learning about the disease and conceptualizing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consultations, etc.). Motivational interviewing techniques may
help the patient achieve desired behavior
changes.
PLANNING A FOLLOW-UP AND CLOSING THE INTERVIEW
● Make sure the patient fully understands the plans you have developed together: “We need to stop now. Do you have any questions about
what we’ve covered?”
● Review future evaluation, treatments, and follow-up.
● Give the patient a chance to ask any final questions.
● Ask the patient to repeat the plan back to you.
