History taking

Question 1

What is the difference between signs and symptoms?

Answer 1

Signs: physical or functional abnormalities found on a physical exam
Symptoms: Something that the pt feels or observed themselves (what they report to you)

Question 2

What are the components of the medical history?

Answer 2

Pt name, age and gender, CC, HPI and source of hx, meds and allergies, PMH, Past surgical hx, family hx, social hx and ROS

Question 3

What is the chief complaint?

Answer 3

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

Question 4

What do you use the HPI for?

Answer 4

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”)

Question 5

What is OLD CARTS?

Answer 5

• 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

Question 6

What are pertinent positives?

Answer 6

Details that highlight features associated with the chief complaint and your ddx that the pt admits to having

Question 7

What are pertinent negatives?

Answer 7

details that may be expected based on the CC, but the pt denies having them

Question 8

What should you ask the patient about medications?

Answer 8

• 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

Question 9

What does gravida, parity and abortions refer to?

Answer 9

Gravida: pregnancy
Parity: live births
Abortions: abortions

Question 10

Who do you ask about/include when asking about pt’s family hx?

Answer 10

First-degree relatives

Question 11

What questions should be asked in the social hx?

Answer 11

Tobacco, Alcohol use, Illicit drug use, sexual hx, occupation

Question 12

What is the ROS?

Answer 12

“head to toe” questions that pertain to the CC and HPI, at least 3 questions for each system

Question 13

What is the order that you want to follow when you perform a PE?

Answer 13

• inspection
• palpation
• percussion
• auscultation
  (except for abdomen, where you auscultate before you palpate)
• smelling

Question 14

What is the optimal lighting to inspect countours, elevations and depressions?

Answer 14

Tangential lighting

Question 15

What are you trying to determine when you are palpating? (what features are you looking out for)

Answer 15

size, consistency, pulses, texture, location, temperature, tenderness of an organ or a body part, moisture

Question 16

What are the types of palpation?

Answer 16

• light palpation
• deep palpation
  
  • deep slipping palpation
  • bimanual palpation
  • deep press palpation
  • ballottement

Question 17

What are the two types of rigidity that you may palpate?

Answer 17

• diffuse

- localized

Question 18

What are you looking for during percussion?

Answer 18

• size
• consistency
• borders between organs
• presence of fluid in body organs

Question 19

When would you hear resonance on percussion?

Answer 19

over a structure with air; high amplitude, low pitch (the lung)

Question 20

When would you hear tympany on palpation?

Answer 20

over a hollow air-containing structure; has high pitch, hollow quality (stomach, abdomen)

Question 21

When would you hear hyperresonance?

Answer 21

• in children and emphysema; sound is between resonance and tympany

Question 22

When would you hear dullness?

Answer 22

• over the liver; sound is dull, low amplitude, short duration w/out resonance

Question 23

When would you hear flatness?

Answer 23

• over the muscle, bone; is very short, high pitched, no air in the tissue

Question 24

What are you listening for on auscultation?

Answer 24

• frequency
• intensity
• number
• quality

Question 25

What type of sound do you detect with the diaphragm of the stethoscope?

Answer 25

high pitched sounds

use firm pressure, used to listen to bowel sounds, normal heart sounds and lung sounds

Question 26

What type of sound to you detect with the bell of the stethoscope?

Answer 26

low pitched sounds (use light pressure, used for BP, abnormal heart sounds, bruits)

Question 27

What would you notice on the smelling aspect of the PE?

Answer 27

ketoacidosis, alcohol, foetor hepaticus, wound breakdown, calciphylaxis

Question 28

What should you think about in the process of diagnosis?

Answer 28

• considering several ddx
• consider killers first
• think “most common”
• keep “least common at the bottom of the list”
• consider “age appropriate illness”

Question 29

Why do you order tests?

Answer 29

To confirm clinical suspicion; tx the pt not the numbers

Question 30

What does SOAP stand for?

Answer 30

Subjective, objective, Assessment and Plan

Question 31

What factors are in the subjective portion?

Answer 31

CC, HPI, OLD CARTS, pertinent positives and negatives

Question 32

What do you include in the assessment?

Answer 32

restate pt data, complaints and exam findings

Question 33

What do you include in the plan?

Answer 33

you state each problem and what you are doing about it

Question 34

What are some special challenge pt’s you may encounter?

Answer 34

• Anger and Hostility
• intoxicated pt’s
• poor historian
• limited intelligence