Intro to PMH, SX, MEDS,

Question 1

History of Present Illness can be summarized using what mnemoic?

Answer 1

OLDCARTS

Question 2

What should the HPI start with?

Answer 2

patient age, sex, and gender

Question 3

When should past medical history be discussed?

Answer 3

after CC, HPI, and pertinent +/-

Question 4

What is included in PMH?

Answer 4

past medical history, past surgery, medications, allergies, social and family history

Question 5

What should be included in past medical history?

Answer 5

medical illness/disease- who has been treating that illness
blood transfusions
obstetric/gyn history
pertinent childhood illness

Question 6

Notes on past surgical history

Answer 6

list chronologically, list surgeon, dates, hospital, complications, did they have a blood transfusion, outpatient or inpatient

PSX: Patient had an open appendectomy at Erlanger hospital in 2004 by Dr. Smith; no complications; 1 day stay; he had a laparascopic cholecystectomy at Emory University in Atlanta in 2001 by Dr. Jones; no complications; outpatient surgery.

Question 7

Notes on obgyn history

Answer 7

menstrual onset (menarche), menstrual frequency, describe the bleeding during menstrual cycle (how long does it last?), contraceptives (“Are you planning on trying to have a baby in the next year”), age at menopause

obstretics- any pregnancies, were they full term (37-42 weeks), any abortions, any living children

Question 8

Best way to ask physicatric questions

Answer 8

Have you ever had any mental health issues that have required treatment? If so, what kind of treatment, how long, diagnosis (would go in medical history)- also get name of consouler

Question 9

Notes on medication recording

Answer 9

need name of drug, dose, route of administration of drug, frequency of use (per day, per week?), and for what- IN THAT ORDER*

i.e. Synthroid 125mcg oral once daily for hypothyroidism

put medications in a simple, numbered list**

don’t forget about OTC and herbs (these can interact with drugs)

Question 10

Notes on Drug Allergies

Answer 10

What is the drug name?
What happens when you take it?
How severe is the reaction?

Any food or environmental allergies?

Question 11

Mneomic for illness/infection

Answer 11

SICK HEALTH SCAMS

Question 12

Onset of first period is called what?

Answer 12

menarche

Question 13

Mneomonic for pregnancy history

Answer 13

TPAL (full semester, premature, abortions, living children)

Question 14

A 42 year-old female provides you the following maternity history: she has had 4 pregnancies, one of which was twins. All deliveries were full term, except for the twins who delivered at 32 weeks. She lost one pregnancy at 12 weeks. She has three living children at home (son was shot at age 10). What is the quick shorthand way to document this?

Answer 14

G4P2213

How many pregnancies? (gravida)
How many deliveries? (para)
   How many full-term?
   How many pre-term?
   How many abortions/miscarriages?
   How many living children?