History Taking Flashcards
What is the first thing to do when approaching the patient room?
Knock three times then enter
First thing to do in the patient room
Sanitize Hands
How you introduce yourself to the patient?
Use the last name and title
What is the first things to say to the patient before starting?
Gain consent and establish confidentiality.
What is the path of history taking?
I Can Help All My Patients Find Some Relief
I Can Help All My Patients Find Some Relief
What does I stand for?
ID
I Can Help All My Patients Find Some Relief
What is Can?
CC; Chief Complaint
I Can Help All My Patients Find Some Relief
What is Help?
HPI (SOCRATES)
I Can Help All My Patients Find Some Relief
What is All?
Allergies
I Can Help All My Patients Find Some Relief
What is My?
Medication
I Can Help All My Patients Find Some Relief
What is Patients?
Past Medical History
I Can Help All My Patients Find Some Relief
What is Find?
Family History
I Can Help All My Patients Find Some Relief
What is Some?
Social History
I Can Help All My Patients Find Some Relief
What is Relief?
Review of Systems
What is the path to take in HPI?
SOCRATES (S=site, O=onset, C=characteristics, R=radiation, A=associated signs/symptoms, T=timing, E=Exacerbating/relieving factors, S=severity)
SOCRATES
What is the S?
Site
SOCRATES
What is the O?
Onset
SOCRATES
What is the C?
Characteristics
SOCRATES
What is the R?
Radiation
SOCRATES
What is the A?
Associated signs/symptoms
SOCRATES
What is the T?
Timing
SOCRATES
What is the E?
Exacerbating/Alleviating Factors
SOCRATES
What is the last S?
Severity
What mnemonic can be used for past history?
VAMP THIS
V-vitamins/vices, A-allergies, M-medications, P-preexisting medical conditions, T-trauma, H-hospitalizations, I-immunizations, S-surgeries
What is the V in VAMP THIS?
V-vitamins
What is the A in VAMP THIS?
A-allergies; be sure to ask what happens when having an allergic reaction
What is the M in VAMP THIS?
M-medications
What is the P in VAMP THIS?
P-preexisting medical conditions
What is the T in VAMP THIS?
T-trauma
What is the H in VAMP THIS?
H-hospitalization
What is the I in VAMP THIS?
I-immunization
What is the S in VAMP THIS?
S-surgeries; if yes, any complications in hospital?
What mnemonic can be used for Social History?
FED-TACOS
F-food/diet, E-exercise, D-drugs, T-tobacco, A-alcohol, C-caffeine, O-occupation, S-sexual history
What is the F in FED-TACOS?
F-food/diet
What is the E in FED-TACOS?
E-exercise
What is the D in FED-TACOS?
D-drugs
What is the T in FED-TACOS?
T-tobacco; to calculate pk/yr: (20/20) / # of years
What is the A in FED-TACOS?
A-alcohol
What is the C in FED-TACOS?
C-caffeine
What is the O in FED-TACOS?
O-occupation; stressful? support system? stress relief?
What is the S in FED-TACOS?
S-sexual history