W 10

Question 1

Why is the history important?

Answer 1

1. about 80% of medical diagnosis can be made with history alone
2. relatively low-cost, low-harm, with potentially high information return

Question 2

what do you need as part of history taking?

Answer 2

1. sufficient info to complete patient illness script and to cross threshold
2. explore the chief concern
   
   • history of the present illness (HPI)
3. additional potentially-relevant history
4. review of symptoms (ROS)

Question 3

In what parts the additional potentially-relevant history is divided into?

Answer 3

• medications
• past personal medical history
• family history
• social history

Question 4

SOCRATES- exploring the chief concern

Answer 4

• Site
• Onset (when, how)
• Character (quality, description)
• Radiation
• Associated symptoms
• Timing (change over time)
• Exacerbating/ relieving factors
• Severity (often 0-10)

Question 5

Other medical history includes:

Answer 5

SMASH FM
- Social
- Medical (past medical history)
- Allergies
- Surgeries
- Hospitalizations
- Family history
- Medications

Question 6

ICE?

Answer 6

• Ideas (about their diagnosis, prognosis, or treatment)
• Concerns (any elements)
• Expectations (for visit, treatment)

Question 6

Social history includes:

Answer 6

FED-TACOS
- Food/diet
- Exercise
- Drugs (recreational ones)
- Tobacco
- Alcohol
- Caffeine
- Occupation/hobbies (stress)
- Sexual
(spiritual/religious imp components including relationships)

Question 7

What is Review Of Symptoms (ROS)?

Answer 7

asking questions ordered by body system
(may lead to over diagnosis if used for screening)

Question 8

Most common method of charting?

Answer 8

SOAP
- Subjective (info gathered from history taking)
- Objective (info gathered from physical exams)
- Assessment (clinical impression and differential diagnosis)
- Plan (management- therapeutic choices, patient education, further diagnostic work-up recommendations, referral plans)