History taking Flashcards
What is the difference between signs and symptoms?
Signs: physical or functional abnormalities found on a physical exam
Symptoms: Something that the pt feels or observed themselves (what they report to you)
What are the components of the medical history?
Pt name, age and gender, CC, HPI and source of hx, meds and allergies, PMH, Past surgical hx, family hx, social hx and ROS
What is the chief complaint?
The one or more sx for which the pt is seeking medical care. It must be addressed even if subsequent evaluation reveals a more serious problem/condition
What do you use the HPI for?
To identify the CC and provide a full, clear, chronological account of the sx.
(duration should be written accurately in hours, days, months or years and not vaguely like “since monday”)
What is OLD CARTS?
- Onset: when did it start
- Location: Where is it located?
- Duration: how long has it been a problem; how long does it last?
- Character: Is it dull/sharp/annoying?
- Aggravating/relieving factors
- Radiation: does it move anywhere else?
- Timing: Constant or intermittent
- Severity: scale of 1-10, how bothersome is it
What are pertinent positives?
Details that highlight features associated with the chief complaint and your ddx that the pt admits to having
What are pertinent negatives?
details that may be expected based on the CC, but the pt denies having them
What should you ask the patient about medications?
- Name, dose, route and frequency
- whether they are compliant
- Any OTC, non-prescription medication
- If the pt has any medication allergies and what the allergy is
What does gravida, parity and abortions refer to?
Gravida: pregnancy
Parity: live births
Abortions: abortions
Who do you ask about/include when asking about pt’s family hx?
First-degree relatives
What questions should be asked in the social hx?
Tobacco, Alcohol use, Illicit drug use, sexual hx, occupation
What is the ROS?
“head to toe” questions that pertain to the CC and HPI, at least 3 questions for each system
What is the order that you want to follow when you perform a PE?
- inspection
- palpation
- percussion
- auscultation
(except for abdomen, where you auscultate before you palpate) - smelling
What is the optimal lighting to inspect countours, elevations and depressions?
Tangential lighting
What are you trying to determine when you are palpating? (what features are you looking out for)
size, consistency, pulses, texture, location, temperature, tenderness of an organ or a body part, moisture
What are the types of palpation?
- light palpation
- deep palpation
- deep slipping palpation
- bimanual palpation
- deep press palpation
- ballottement
What are the two types of rigidity that you may palpate?
- diffuse
- localized
What are you looking for during percussion?
- size
- consistency
- borders between organs
- presence of fluid in body organs
When would you hear resonance on percussion?
over a structure with air; high amplitude, low pitch (the lung)
When would you hear tympany on palpation?
over a hollow air-containing structure; has high pitch, hollow quality (stomach, abdomen)
When would you hear hyperresonance?
- in children and emphysema; sound is between resonance and tympany
When would you hear dullness?
- over the liver; sound is dull, low amplitude, short duration w/out resonance
When would you hear flatness?
- over the muscle, bone; is very short, high pitched, no air in the tissue
What are you listening for on auscultation?
- frequency
- intensity
- number
- quality
What type of sound do you detect with the diaphragm of the stethoscope?
high pitched sounds
use firm pressure, used to listen to bowel sounds, normal heart sounds and lung sounds
What type of sound to you detect with the bell of the stethoscope?
low pitched sounds (use light pressure, used for BP, abnormal heart sounds, bruits)
What would you notice on the smelling aspect of the PE?
ketoacidosis, alcohol, foetor hepaticus, wound breakdown, calciphylaxis
What should you think about in the process of diagnosis?
- considering several ddx
- consider killers first
- think “most common”
- keep “least common at the bottom of the list”
- consider “age appropriate illness”
Why do you order tests?
To confirm clinical suspicion; tx the pt not the numbers
What does SOAP stand for?
Subjective, objective, Assessment and Plan
What factors are in the subjective portion?
CC, HPI, OLD CARTS, pertinent positives and negatives
What do you include in the assessment?
restate pt data, complaints and exam findings
What do you include in the plan?
you state each problem and what you are doing about it
What are some special challenge pt’s you may encounter?
- Anger and Hostility
- intoxicated pt’s
- poor historian
- limited intelligence
