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
