History taking Flashcards
Why is the history important?
-About 80% of medical diagnoses can be made with history alone
-Relatively low-cost, low-harm, with potentially high informatin
-Also see patient-centered interviewing lectures
What do you need?
-You need sufficient information to complete a patient illness script and, ideally, to cross a threshold
-Often, this is elicited (at least initially) by both exploring the patient’s reason for the visit (chief complaint or chief concern, “CC”)
ex) the history of the present illness (HPI) as well as other potentially medically relevant features of their history.
-Additional potentially-relevant history is divided in different ways but often includes:
Medications, past personal medical history, family history, social history
-Review of Systems (ROS) is also often included
The HPI: Exploring the CC:
Other medical history:
-Social (SocHx/SHx/SH)
-Medical (past medical history, PMHx/PMH)
All conditions currently being treated and/or that have an ongoing effect on the patient’s health.
-Allergies:
-includes allergies to medications and the reaction they had
-Surgeries
-Hospitalizations
-Family History (FHx/FH)
-Medications
-Mnemonic: “SMASH FM”
Social history (SocHx/SHx/SH):
-Food/diet
-Exercise
-Drugs
-Tobacco
-Alcohol
-Caffeine
-Occupation/hobbies
-Sexual
Mnemonic: “FED-TACOS”
Additional helpful items:
-After gathering a history, it can be useful to summarize the key points back to the patient to check for errors
-It can also be helpful to ask the patient about what they think is going on and what their goals are for the next visit
-The “ICE: mnemonic can be used here:
-Ideas (about their diagnosis, prognosis, or treatment)
-Concerns (about any elements above)
-Expectations (for the visit, including treatment)
Review Of Systems (ROS):
-Asking questions ordered by body system
ex) asking about eye symptoms (vision changes, red eye, eye discharge etc.) then moving on through…ex) chest symptoms (coughing, wheezing, shortness if breath, chest pain etc.) and so on
-Breadth of questioning is somewhat arbitrary: there is no single method of doing this
-May lead to overdiagnosis if used for screening (targeted approach (based on risk factors, for example) may help to avoid this issue in addition to being more efficient)
Diagnostic process and CMS 100:
Charting:
SOAP:
Subjective (information gathered from history-taking)
Objective (information gathered from physical exam
Assessment (clinical impression and (differential) diagnosis
Plan (how this will be managed, including: therapeutic choices, patient education, further diagnostic work-up recommendations, referral plans)
Summary:
1) The patient history is a particularly important aspect of a patient intake for multiple reasons, including high information yield and rapport building
2) There are multiple components and sub-components of a thorough patient history
