Lab #1: History taking and SOAP note

Question 1

mnemonic for history of the chief complaint (Cc)/ history of present illness (HPI)

Answer 1

CODIERS: chronology, onset, description, intensity, exacerbation, remission, social/psychological history

Question 2

Chronology questions

Answer 2

Does it follow any time pattern, how long does it last?

Question 3

Onset questions

Answer 3

when did it start, was it constant/intermittent, gradual/sudden?

Question 4

Description questions

Answer 4

what is the pain like, e.g. is it sharp, burning, dull?

Question 5

Intensity questions

Answer 5

how would you rate the pain on a scale of 1-10?

Question 6

Exacerbation questions

Answer 6

is there anything that makes it worse?

Question 7

Remission questions

Answer 7

Is there anything that makes it better?

Question 8

past medical history (PMhx) mnemonic to use

Answer 8

MIMASH: medical illnesses, injuries, medications (Meds), allergies (All), surgical history (PSHx), hospitalizations

Question 9

what do you ask about after you ask about the history of the chief complaint, and the past medical history?

Answer 9

family medical history (FHx), social history (SocHx), health care maintenance (HCM), review of all the systems ROS (ask 2 important questions per system)

Question 10

SOAP note abbreviation

Answer 10

Subjective, objective, assessment, and plan

Question 11

what goes at the end of a SOAP note?

Answer 11

signed and name printed with title, with date and time

Question 12

subjective part of SOAP note

Answer 12

history obtained from the patient written organized

Question 13

chief complaint

Answer 13

“what the patient complains about in a few words”

Example: “My chest hurts”

Question 14

HPI: history of present illness

Answer 14

bulk of the history; what is going on with the current problem
written in a short succinct paragraph, bullet points recommended, use medical abbreviations

Question 15

HPI acronyms for questioning

Answer 15

SAMPLE: symptoms, allergies, medications, past history, last intake/output, events leading up to the problem
OPQRST: onset (what they were doing when it started/got worse), palliative (what makes it better), quality, radiates/refers, severity, time (onset, duration, frequency, progression over time)

Question 16

asking about PMHx

Answer 16

ask if the patient has any medical problems or illnesses. Be sure to ask specifically about common medical diseases, like HTN, heart disease, stroke, lung disease, DM, cancer, obesity, depression, dementia

Question 17

asking about medications

Answer 17

ask about all current prescriptions and non-prescriptions, medications including dosage, frequency, compliance

Question 18

asking about allergies

Answer 18

ask about allergies to medications and foods or environmental, and ask what happens

Question 19

asking about FamHx

Answer 19

ask about diseases in the family, parents, their age, deceased, why? ask about siblings and children

Question 20

asking about SocHx

Answer 20

ask about their occupation, home life, status, exercise, diet, hobbies. Ask about sex, if protection used, STI Hx, gender preference; ask about drugs; ask about alcohol (how much, how often, for how long); smoking (how many packs a day for how many years)

Question 21

asking about HCM

Answer 21

ask when their last physical was, flu vaccines/IMM, mammograms, colonoscopies

Question 22

common ROS questions for constitutional

Answer 22

wt loss, fever, night sweats, fatigue, wt gain

Question 23

common ROS questions for HEENT

Answer 23

vision changes, double vision, hearing loss, tinnitus, congestion, nose bleeds, sore throat, difficulty swallowing

Question 24

common ROS questions for cardiology

Answer 24

chest pain, palpitations, syncope

Question 25

common ROS questions for chest

Answer 25

cough, trouble breathing, wheezing

Question 26

common ROS questions for GI

Answer 26

vomiting, diarrhea, abdominal pain, constipation

Question 27

common ROS questions for Ext

Answer 27

joint pains, cramping, swelling

Question 28

common ROS questions for neuro

Answer 28

headaches, dizziness, numbness, weakness

Question 29

common ROS questions for skin

Answer 29

rashes, hives, lumps

Question 30

Objective

Answer 30

vitals, general assessment, skin, HEENT, CVS, Resp, Ab, Ext/Back, Neuro, genital, OMM
sometimes the physical will be focused based on the history, ONLY document what you actually observed
do not document “normal,” need to document specific negatives

Question 31

what are the vitals?

Answer 31

BP, Ht, Wt, BMI, HR, RR, Temp, PulseOx

Question 32

Review of systems

Answer 32

organized questions about each organ system to elicit other problems that may have not been elicited in the HPI
can’t document that the review of systems was negative

Question 33

Assessment

Answer 33

your differential diagnosis of what is going on based on the history and physical; your impression of the problem
list in order of most likely to least likely, at least 3 possibilities and the osteopathic D
do not use words “rule out, consider, possible, probable)

Question 34

Plan

Answer 34

what is going to be done about the most likely diagnosis

labs, imaging, other tests, medications, lifestyle changes, referrals, follow-up, osteopathic treatment