Powerpoint: The Medical History

Question 1

When is the comprehensive history used?

3

Answer 1

1. admission history & physical exams (H&P)
2. new patient intake sessions
3. pre-operative

Question 2

When is the focused or problem oriented exam is used?

Answer 2

used for most episodic patient visits

Question 3

What are the components of the complete history?

11

Answer 3

1. Identifying Data
2. Chief Complaint (CC) [In quotes—patient’s own words]
3. History of Present Illness (HPI)
4. Past History (PMHx) {chronic illnesses/hospitalization}
5. Past Surgical History (PSHx)
6. Medications: Meds
7. Immunizations***
8. Allergies
9. Family History (FHx)
10. Personal/Social History (SHx)
11. Review of Systems (ROS)

Question 4

How should the chief complaint be written down?

Answer 4

Quote the patient. In their own words

Question 5

What kind of questions should you be asking for history taking?

Answer 5

open ended questions

Question 6

How should we list the events in HPI?

Answer 6

in chronilogical order

Question 7

What do we ask about all current medications?

5

Answer 7

Dose
Frequency
Route of Administration
Why they are taking it
Ask if they are missing doses and why?

Question 8

What do we ask about allergies?

3

Answer 8

1. Any drug allergies
2. What type of reaction did they have
3. Any rechallange of the event

Question 9

Whats a big problem we should educate the patient on for medications?

Answer 9

non-compliance/confusion on complex regimens when patients are older. Could be congitively impaired or just disinterested

Question 10

Ask about adult immunizations. Which ones?

4

Answer 10

Gardisil
Flu,
pneumovax,
shingles

Question 11

Questions to ask for past surgeries?

6

Answer 11

1. If so – what, where, WHY
2. Any complications?
3. What type of anesthesia?
4. Any personal or family history of problems with anesthesia?
5. Did you have to stay in hospital? How long?
6. Any advice to HAVE surgery which you ignored or declined?

Question 12

For family history what relatives are we asking about?

Answer 12

first or second degree realtives

Question 13

If they say they have a family history of a disease what would we ask about?
2

Answer 13

Age of onset of relative

Age at death and cause of death

Question 14

Alwats ask the big five for family history. What are they?

Answer 14

Cancer
Cardiovascular disease (CVD)
Stroke 
Diabetes mellitus (DM)
Hypertension (HTN)

Question 15

Also ask anything that is related to the chief complaint. Example?

Answer 15

GI issue then ask about ulcers

Question 16

How do you calculate pack years?

Answer 16

most they’ve ever smoked (pack a day for ex) X total number of years they smoked

Question 17

What questions are part of the CAGE questionnaire?

Answer 17

1. Felt the need to Cut-Down drinking
2. Felt Annoyed by criticism regarding drinking
3. Guilty feelings about drinking
4. Ever drank first thing in the a.m. as an
   Eye-opener

Question 18

How many positives of the CAGE test indicate abuse?

Answer 18

2 or more