Term
Why Do a History and Physical?
-Also called: H & P
1.
2.
2.
4.
5.
6. |
|
Definition
1. Screen for Disease
2. Assess risk for future health concerns/problems
3. Encourage healthy lifestyle
4.Provide general and specific patient education
5. Update vaccinations
6. Establish and maintain relationship with patient in event of illness or injury |
|
|
Term
Types of H & P
1. __: the chief complaint dictates the history and examination
2.__: To screen for serious, preventable, life or
function threatening issues; usually driven by focal purpose
3. __: for new patients to gather comprehensive data, for hospitalized patients |
|
Definition
1. focused/brief/problem focused
2. screening
3. comprehensive |
|
|
Term
| some other types of h & p: |
|
Definition
| consultative, surgical, specialty specific, age specific, purpose specific |
|
|
Term
usual parts of the H&P
1.
2.
3.
4.
5.
6. |
|
Definition
1. patient interview
2. history
3. physical examination
4. differential diagnosis & assessment
5. plan (treatment and management)
6. legible and proper documentation |
|
|
Term
patient interview
- professional dress and demeanor/conduct
-- attire and hygiene issues
-- __, when asked to come in, smile and be friendly/welcoming to the patient |
|
Definition
|
|
Term
Patient Interview: establish rapport
- appropriate contact: __,__, __
- establish what to __
- doctor should __
- maintain ___ contact
-- adjust __ if possible
-- ensure __ to make patient feel comfortable
-- try not to __ --within limits |
|
Definition
- identify patient, wash hands, offer handshake
- call each other/what to avoid
- sit down
- eye level
-- environment
-- privacy
-- interrupt |
|
|
Term
| SEE JUSTNOTES ABOUT OTHER STUFF |
|
Definition
|
|
Term
Patient interview
- avoid:
1.
2.
3.
4.
5. |
|
Definition
1. false reassurance
2. personal advice
3. leading
4. assuming much of anything
5. being victim to your own prejudices |
|
|
Term
The History
-CC:
- history of chief complaint:
- OPQRSTa |
|
Definition
- chief complaint
- HPI
- onset, palliative, quality/quantity, radiation, severity, timing, associated findings |
|
|
Term
| questions to ask about past medical history |
|
Definition
- chonologic order of medical conditions, injuries/accidents, hospitilizations
- event, age/year, outcome
- communicable diseases: exposures, treated, risk factors
- transfusions
- psychiatric/mental health
- OB or GYN |
|
|
Term
| questions to ask about past surgical history |
|
Definition
- chronological order
- anesthesia (local or general) or drug reactions
- what was done, where, by whom, outcome |
|
|
Term
| questions about medications |
|
Definition
-Current: what, dose, frequency, why, side effects, for how long
- prescription, OTC, herbal/natural, home remedies |
|
|
Term
| questions about allergies |
|
Definition
| ask about allergies to medication, environmental, food |
|
|
Term
| what to ask about family history |
|
Definition
| ask about parents, age, alive or dead, same with siblings |
|
|
Term
| what to ask about social history |
|
Definition
| ask about tobacco and alcohol use, what kind, their job, sleep, diet, and exercise |
|
|
Term
Review of Systems (ROS)
- the systems are: |
|
Definition
| - general, skin, HEENT, neck, breast, chest/lungs, cardiac and vascular, GI, GU, musculoskeletal, neurological, hematological, endocrine, and psychiatric |
|
|
Term
| for SOAP you are expect to form __ differential diagnosis, and a ___ |
|
Definition
|
|
Term
assessment
- use the mnemonic VINDICATED for differential diagnosis, and make a ___ |
|
Definition
|
|
Term
-there are two halves to each interview: __ and __
- begin each medical history with a __ approach |
|
Definition
- patient centered; physician centered
- patient centered |
|
|
Term
|
Definition
1. date and time history
2. obtain identifying data
3. use open-ended questions initially |
|
|
Term
| a doctor should ___ the patient, address all __, and ___ for the visit |
|
Definition
| inform; pertinent issues; clarify patient's expectations |
|
|
Term
| -start medical history by taking the __, other __, and eliciting the ___ |
|
Definition
| - chief complaint(s) (CC); concerns; patient's story |
|
|
Term
- HPI = ___
-- should be in a ___ with __ |
|
Definition
- history of present illness
-- paragraph form; quotes |
|
|
Term
| most important for associated symptoms is __ |
|
Definition
|
|
Term
- the __ expands on primary history, info obtained is often supportive
-- examples include headache/ear problems |
|
Definition
|
|
Term
-___: brings in elements that have direct bearing on the patient's condition
-- examples include smoking or drinking |
|
Definition
|
|
Term
|
Definition
- past medical history
- past surgical history |
|
|
