Medical History Taking (Quiz 1) Flashcards
Patient Identification
New patient vs established
Chief concern/chief complaint
reason the person is seeking care
may be referred to as problem or diagnoses
History of Present Illness
detailed account elicited from the patient regarding the CC
Past Medical and surgical history
general health
chronic and episodic illness
operations and injuries
previous hospitalizations
past P&O management
Patient-Centered Model
participatory
patient autonomy
individual needs and preferences the focus
improved patient adherence
7 cardinal features of symptoms
- location and radiation
- quality
- quantification
- chronology
- setting
-modifying factors
OPQRST
Onset
Position
Quality & Quantification
Related Symptoms
Setting
Transforming factors
OLDCARTS
Onset
Location
Duration
Character
Alleviating/Aggravating
Radiation
Timing
Severity
Patient-Centered Interview Framework
1) Set the stage
2) obtain the chief complaint/concern and set the agenda
3) open the history of present illness
4) continue the patient-centered history of present illness
5) transition to clinician-centered process