Intro to CC and HPI Flashcards
What is the Chief complaint?
a sentence or a couple of words asking regrading why a patient is seeking medical treatment/advise
What brought you in today?
What is the difference between disease and illness?
disease is explanations doctors bring to symptoms and illness is how the patient preceives their disease and how it influences their life and relationships, outlook on everyday life, etc.
What is the FIFE mnemonic used for?
Exploring the patients perspective- digging into the patients feelings about what’s happening
F- the patients Feelings, including fears or concerns about the problem
I- the patients Ideas about the nature and/or cause of the problem
F- the effect of the problem on the patients life and Function
E- the patients Expectations of the disease, of the physician (often based on prior history of experience)
What is the NURes mnemonic used for?
Naming,
Understanding/Legitimizing,
Respective
What is the OLDCARTS mnemonic used for?
obtaining history of present illness
O- Onset. When did it begin? Chronic vs. Acute Setting
L- Location. What symptoms could be involved
D- Duration. How long has it been going on? How long does it last?
C- Character (Quality)- What’s it like? Burning?
A- Aggrevating/Alleviating Factors Is there anything that makes it better or worse?
R- Radiation. Does the pain travel?
T- Timing. How often does the pain come? Does it seem like any particular time?
S- Severity. On a scale of 1 to 10. How has it impacted your life?
What are Pertinent Positives and Negatives?
a list of symptoms that are associated with a disease that you may think the patient has after gone through OLDCARTS
Rule of Thumb: Always start out with general and then move to specific organs in the location of pain
What is the SOAP mnemonic?
S- subjective (what the patient tells you)
O- objective (what you observe)
A- Assessment (what you think the problem is)
P- Plan (what you want to do)
What three things do you want as part of ‘patient identifiers’. These things should be listed after date and time
Full Name
Date of Birth
Reliability (ability of the patient to answer questions in a truthful and accurate manner) and in the case that someone is providing info (in the case of a child/baby), who is the source of the information
T or F. Always document the chief complaint in the patient’s own words
T. ALWAYS do this. If quoting the patient, make sure to include quotes. If you paraphrase, do not put in quotes
The chief complaint should always be on its own line. There may be more than one chief complaint
The chief complaint is followed by the HPI (History of present illness)
Always start out with age, gender, any chronic illness, and race/ethnicity if necessary
How quickly do clinicians interrupt patient during office visits?
18 seconds. this is too fast
T or F. HPI should start with non directive questions like “Tell me more about (patient’s chief complaint)”
T.
