Patient History

Question 1

Chief Complaint(CC) - Chief Concern(CC)

Answer 1

She came in with a chief complaint of dyspnea.

Question 2

History of Present Illness(HPI)

Answer 2

History of present illness should include the details of the patient’s condition.

Question 3

Past Medical History(PMHx)

Answer 3

Past medical history is where you should ask about previous hospitalizations or comorbidities.

Question 4

Medication(Meds)

Answer 4

As a doctor you have to make sure you know all the medications your patient is currently taking.

Question 5

Allergies & Reactions(ALL & RXN)

Answer 5

Asking about allergies and reactions can be life saving for your patient.

Question 6

Social History(SHx)

Answer 6

Social history should include your patient’s lifestyle, what he or she works with and potentially harmful habits, like smoking

Question 7

Family History(FHx)

Answer 7

Family history is important to determine if there might be genetic risk factors for your patient.

Question 8

Review of Systems(ROS)

Answer 8

Review of the systems is useful to remind patients of other possible symptoms they might be forgetting to mention.

Question 9

CC(Chief Complaint / Chief Concern)

Patient Note = Anamnesis
Identification(ID)
Name(Last, First, M.I.)
Date of Birth(DOB) - MM/DD/YY
Gender(male or female)
Marital: Single/Partnered/Married/Separated/Divorced/Widowed
Previous or referring doctor:
# HPI(History of Present Illness)
# PMHx(Past Medical History) - Surgical History
# Medication
# Allergies and Reactions
# Social History(SHx)
# Family History(FHx)
# Obstetric History
# ROS(Review of Systems)

Answer 9

Anamnese
Identificação
Nome
Dia Nascimento
Sexo
Queixa Principal
História da Doença Atual
Antecedentes Pessoais
Medicamentos
Alergias
História Social
História Familiar
História Obstétrica
Revisão dos Sistemas

Question 10

Medication: Hours

Answer 10

• BID - Twice a day - 2 x a day
• TID - Three times a day - 3 x /day
• q8hr - every 8 hours: (q=every)

Question 11

S O A P

Answer 11

S - Subjective: what the patient tells you
O - Objective: Physical Exam, Laboratory Exams and Imaging Exams
A - Assessment: Diferencial Diagnosis(DD)
P - Plan: Management

Question 12

Electronic Medical Record - EMR
HTN - Hypertension
T2DM - Type 2 Diabetes mellitus
NKDA - No Know Drug Allergies

Answer 12

Prontuário Médico Eletrônico
Hipertensão - HAS
Diabetes Tipo 2
Nenhuma alergia conhecida

Question 13

Review of Systems(ROS)
SKIN: Rashes,Itching,Change in hair or nails
HEAD: Headaches,Head injury
EYES: Glasses or contacts,Change in vision, Eye pain, Double vision,Flashing lights,Glaucoma/Cataracts,Last eye exam
EARS: Change in hearing,Ear pain,Ear discharge,Ringing,Dizziness
NOSE/SINUSES: Nose bleeds,Nasal stuffiness,Frequent cold
MOUTH/THROA
RESPIRATORY
CARDIAC
GASTROINTESTINAL
URINARY
PERIPHERAL VASCULAR
MUSCULOSKELETAL

Answer 13

Revisão dos Sistemas
Pele
Cabeça
Olhos
Ouvidos
Nariz/Sinus
Boca/Garganta
Respiratório
Cardíaco
Gastrointestinal
Urinário
Vascular periférico
Músculo-esquelético