Lecture 1 & 2

Question 1

Read the first 2 POM lectures on History Taking.

Answer 1

-

Question 2

Write down the correct order of 10 items on the history taking checklist & the 8 items under HPI

Answer 2

ID - identifying data

CC = chief complaint

HPI (OLDCARTS) = history of present illness 
• Onset and context
• Location
• Duration
• Character
• Aggravating/associated factors
• Relieving/Radiating
• Temporal factors
• Severity of symptoms

PMH - past medical history

PSH - past surgical history

SH - social & personal history

FH - family history

ALL - allergies

Rx - medications

Exam

Labs/Imaging Data

Assessment (Problem list & Differential Diagnosis)
Plan

Question 3

VINDICATE mnemonic for differential diagnosis

Answer 3

Vascular
Inflammatory/Infection
Neoplasm
Degenerative/Deficiency/Drugs
Idiopathic/Intoxication/Iatrogenic (caused by medical examination or treatment)
Congenital
Autoimmune/Allergic/Anatomic
Traumatic
Endocrine/Environmental

Question 4

Number of pregnancies ______, and births ______.

Answer 4

Number of pregnancies (Gravida), and births (Para).

In Spanish, giving births is parto.

Question 5

1) Give equation for Pack-Year history.

2) If Tom smokes 1 pack per day & has smoked for 60 years, what is his Pack-Year history?

Answer 5

1) Pack-Year History = #PPD x #years

2) (i.e. 1 ppd x 60 years = 60 pack-year history)

Question 6

In family history, we ask about ______ degree relatives.

Answer 6

• Ask about first degree relatives

Question 7

Define pertinent positives & negatives.

Answer 7

Pertinent Negative: absence of a sign or symptom that helps substantiate or identify a patient’s condition.

Pertinent Positive: presence of a sign or symptom that helps substantiate or identify a patient’s condition.

Question 8

Write down the mnemonic for the focused history.

Answer 8

SOAP

S – Subjective Includes CC, HPI, and summarized PMH, PSH, SH, allergies, medications ,and ROS that are RELEVANT to the cc.

O - Objective: Vital signs and your physical exam.

A – Assessment

P–Plan

Question 9

1) Give pack-year equation:

2 Patient smokes 1 pack per day for 60yrs, what is their ppd?)

Answer 9

PPDx#years = PackYearhistory

i.e. 1 ppd x 60 years = 60 pack year history