Week 1 Flashcards
Components of a comprehensive history
Chief complaint
History of present illness
Allergies
Medications
Past history
Family history
Personal/social history
Review of systems
Physical exam (all systems)
Assessment plan
Components of a focused history
Chief complaint
History of present illness
Allergies
Meds
Past history
Pertinent family history
Pertinent social/personal
Pertinent review of systems
Physical exam of pertinent systems
Focused assessment
Focused plan
Objective
Vitals
Lab values
Imaging
MY physical exam
Subjective
Whatever the patient says
Up to and including review of systems
Chief complaint
Always use the patients own words
OLDCARTS
onset
Location
Duration
Characteristics
Aggravating/alleviating
Radiation
Timing
Severity
OPQRST
onset
Provocation
Quality
Radiation
Severity
Timing
History of present illness
An expansion of the chief complaint
Paints a picture of why the patient is seeking medical treatment
Examples of allergies
Medications
Food
Environmental
Latex
Components of the past history
Medical history (childhood and adult)
Surgical history
Traumatic history
OBGYN
Psychiatric history
Family history
Parents, grandparents, siblings, children
Age with health status
Age of death and cause
General medical history in family
Personal and social history
Health promotion and maintenance
Tobacco use (pack years)
Alcohol use
Illicit drug use
Sexual history
Home/living situation
Concerning health history findings
Changes in weight- rapid or gradual
Nutrition vs medical causes vs psychosocial
Fatigue and weakness
Fever, chills, night sweats
Nociceptive (somatic) pain
Damage to tissue or viscera but sensory nerves intact
Dull, pressing, pulling, throbbing, boring, spasmodic, colicky
Neuropathic pain
Direct trauma to the peripheral or central nervous system
Shock-like, stabbing, burning, pins and needles
Idiopathic pain
No identifiable etiology
Psychogenic pain
Related to factors that influence the patients report of pain (psych conditions, personality and coping styles, cultural norms, social support system)
Chronic pain
Not due to cancer or illness lasting >3-6 months
Lasting >1 month beyond the course of an illness
Recurring at intervals over months or years
Purpose of a clinical note
A way to accurately record information
Assists provider in making an accurate diagnosis and provide the best treatment plan
A written record that provides interprofessional communication
SOAP format for comprehensive and focused notes
Subjective
Objective
Assessment
Plan
Optimal Bp conditions
Avoid smoking or drinking caffeine 30 min prior
Seated in chair w feet on ground for 5 min
Quiet warm room
Bare arm
How to get orthostatic BP
measure BP and HR with patient supine, wait 3 minutes, then have patient stand up, now repeat the measurements
Orthostatis
Systolic BP drops >20 mmHg or diastolic BP drops >10 mmHg
General survey
Paint the picture of what you see when you enter the patients room and as you observe the patient
Must be completed of every clinical note
General appearance (paint the description)
Apparent state of health
LOC
signs of distress
Skin color/obvious lesions
Dress, grooming, personal hygiene
Facial expression
Odor or body/breath
Posture, gait
Height weight
