History Taking Flashcards
Why is history important?
- about 80% of medical diagnoses can be made w/ history alone
- relatively low-cost, low-harm, w/ potentially high information return
What do you need from history taking?
need sufficient information to complete a patient illness script and, ideally, to cross a threshold
Review of Systems (ROS)
How is history taking elicited?
by both exploring the patient’s reason for the visit (chief complaint or chief concern, “CC”) – i.e. the history of the present illness (HPI)
other potentially medically-relevant features of their history
Additional potentially-relevant history often includes?
medications, past personal medical history, family history, social history
What is the SMASH FM mnemonic for medical history?
social
medical (past, current)
allergies
surgeries
hospitalizations
family history
medications
What is the FED-TACOS mnemonic for social history?
food/diet
exercise
drugs
tobacco
alcohol
caffeine
occupation/hobbies
sexual
What should you do after gathering history?
summarize key points back to pt to check for errors
What is the ICE mneomic? What is it used for?
Ideas (about their diagnosis, prognosis, or treatment)
Concerns (about any of the elements above)
Expectations (for the visit, including treatment)
ask the patient about what they think is going on and what their goals are for the visit
What is Review of Systems (ROS)?
Asking questions ordered by body system
asking about eye symptoms (vision changes, red eye, eye discharge etc.) then moving on through e.g. chest symptoms (cough, wheezing, shortness of breath, chest pain etc.) and so on is an example of what?
Review of Systems (ROS)
What is the potential harm for ROS?
may lead to overdiagnosis, side tracking
What helps avoid the issue of over diagnosis with ROS?
targeted approach
What does the SOAP mnemonic stand for with reference to charting?
Subjective
Objective
Assessment
Plan
