Week 1 History Taking

Question 1

Focused assessment

Answer 1

For established patients. Focused concerns or symptoms. Assesses symptoms restricted to a specific body system.

Question 2

Subjective data

Answer 2

What the patient tells you. State in their own words.

Question 3

Objective data

Answer 3

What you detect during examination. Physical examination findings (vital signs, bloodwork, other testing, etc).

Question 4

reliability

Answer 4

Varies according to patients memory, trust, mood. Could be affected by symptoms (eg, Alzheimer’s)

Question 5

Chief complaint

Answer 5

One or more symptoms causing the patient to seek care

Question 6

present illness

Answer 6

amplifies the chief complaint > patient’s thoughts and feelings > pertinent positives and negatives > medications, allergies, smoking and alcohol use

Question 7

past history

Answer 7

Childhood illnesses and adult issues involving medical, surgical, OBGYN, and psychiatric episodes. Also includes immunizations, screenings, lifestyle issues, home safety

Question 8

family history

Answer 8

3 generations. Either patient’s parents, siblings and children or if no children than siblings, parents and grandparents

Question 9

personal and social history

Answer 9

educational level, family of origin, current household, personal interests, lifestyle

Question 10

Review of systems

Answer 10

Documents presence or absence of common symptoms related to each body system

Question 11

Present illness OLDCARTS

Answer 11

Onset, location, duration, character, aggravating / alleviating, radiation, timing

Question 12

Family history diseases to include

Answer 12

hypertension, coronary artery disease, elevated cholesterol, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, allergies, history of breast, ovarian, colon, or prostate cancer, genetically transmitted diseases

Question 13

review of systems - psychiatric referral

Answer 13

if patient admits suicidal ideation we must refer them for care

Question 14

Pack Year History calculations

Answer 14

x cigarettes / day x X years = pack year history

ex: 20 cig / day for 40 years = 1x40 = 40 pack years
40 cig / day for 10 years = 2x10 = 20 pack years
5 cig / day for 15 years = .25 x 15 = 3.75 pack years

Question 15

Adult illnesses - OBGYN

Answer 15

pregnancies - # deliveries - # abortion / miscarriage - #live birth

Question 16

Comprehensive History

Answer 16

Appropriate for first time patients. Provides baseline for future assessments.