Introduction to Patient Evaluation Flashcards
Components of Patient History
source and reliability chief complaint (CC) history of present illness (HPI) past medical history (PMH) social history (SH) family history (FH) review of systems (ROS) summary/oral presentation
Source and Reliability
Important Factors...
coming from patient or parent/guardian
date that history was recorded
-is it an old chart?
reliability
-age
-mental competence
***bias is a big problem typically with family membersTechniques for Obtaining Medical History
medical interview
printed questionnaire
-*problem: patient may not understand everything on it
combination of both
Chief Complaint (CC)
statement IN PATIENT’S OWN WORDS of why they are presently seeking care
use quotation marks
***do NOT translate patient’s description into medical jargon
-already being bias if you do
History of Present Illness (HPI)
chronological order of events leading to the current complaint
-underlying illness maybe affecting cc
-local or general symptoms of cc
-previous treatment for cc
a narrative written in paragraph form
symptom development “7 attributes”
Symptom Development “7 Attributes”
quality - description: “sharp”, “throbbing”, etc.
severity
location and radiation
timing and course - how long? how frequent?
context - when they feel pain (ex. eating)
modifying factors - what makes it better or worse
associated symptoms
-pertinent negatives - (ex. headache with pain)
Past Medical History (PMH)
current medications
-prescription, OTC, herbal and vitamin supplements
allergies - SHOULD BE DISPLAYED PROMINENTLY ON CHART
-record specific reaction (rash vs. nausea)
***upset stomach is NOT an allergic reaction
history of certain diseases
hospitalizations
-chronologically
Personal and Social History (SH)
occupation and hazards
-mucosal disease: chemical exposure?
marital status/children
-sexual preference/activity
lifestyle (living alone? disabled?)
use of...
-tobacco: what and how much?
-alcohol: what and how much?
-recreational drugs: what, how, and how often?Family History (FH)
genetic transmission of or predisposition to a disease
communicable diseases within household
focus on immediate family
-parents
-siblings
-children
***alive or dead?; significant diseases?
screen patients who may be at riskReview of Systems (ROS)
systematic review of common medical problems (symptoms) that affect organ systems
allows doctors to survey various bodily systems to uncover significant symptoms that may not have already been revealed
make sure data isn’t omitted that may aid in diagnosis
important to distinguish those with actual problems from those with “laundry list” of complaints
***asking about any symptoms, NOT just CC
Organ Systems
skin eyes ears, nose, mouth, throat pulmonary cardiovascular digestive genitourinary hematologic immune endocrine musculoskeletal neurological psychiatric
Summary/Oral Presentation
summary of historical data collected on a patient
-CC and related symptoms
-medical illnesses
-anything possibly related to CC that may require special attention during subsequent data collection
NOT a written medical history
Medical Interview Background
primary goal: well-being of the patient
three-fold purpose
-establish a trusting and supportive relationship
-to gather info
-to offer infoFive Kinds of History Taking Information
evidence
context
-circumstances
insight
-what you know
impact
personApproach to the Interview
self-reflection reviewing the chart setting goals for the interview reviewing clinician behavior and appearance improving the environment taking notes
