Term
| What are the five fundamental steps of an efficient office visit? |
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Definition
OPENING the interview
ESTABLISHING the patient's expectations
UNDERSTANDING the patient's beliefs
MAKING DECISIONS with the patient
CLOSING the interview |
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Term
| What are the classic seven dimensions of pain related symptoms? |
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Definition
OTHER associate symptoms (fatigue irritability, weakness, nausea, fever, diarrhea)
PRECIPITATING/aggravating and alleviating/relieving factors
QUALITY
RADIATES or REFERRED
SEVERITY
SETTING - onset, duration, frequency
TIMING
TREATMENTS |
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Term
| What is the goal of the medical history? |
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Definition
| to integrate multiple symptoms with a description of the entire clinical problem in an appropriate manner in order to identify the underlying disease process. |
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Term
| What is the doctor-centered interviewing comprised of? |
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Definition
| coning down on the CC, HPI, PMH, FH, SH, and ROS |
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Term
| What Health Issues that are sensitive to the patient be discussed? |
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Definition
Ethical, Social, Spiritual issues
Functional status/ Health literact
health promoting issues
health maintenance habits
potential health hazards |
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Term
| What should the past medical history portion include? |
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Definition
Childhood illnesses and immunizations
major illnesses
injuries
previous hospitalizations
surgeries
screenings for major diseases
transfusions
medications
allergies
For females:
menstrual history
obstetrical history
contraception methods |
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Term
| What should the Social History include? |
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Definition
current personal or psychological problems
data about non-current issues such as early development, intimate relationships, recreational activities, life satisfactions, and culture |
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Term
| Why care about the social history? |
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Definition
helps define CAUSE of mechanism of disease
identifies sources of SUPPORT
identifies BARRIERS to wellness
provides a window into SUCCESSFUL APPROACHES
suggests patient's likely REACTIONS
elicits COPING MECHANISMS
identifies patient STRENGTHS
explores patient CONCERNS |
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Term
| What typ of information does the social history reveal? |
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Definition
the patient's environment
social support
social stressors
literacy and language
health beliefs and expectations
ritual |
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Term
| What is needed to create the family history |
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Definition
information for at least two generations
specific diseases
causes of death |
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Term
| What is the review of systems? |
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Definition
| a screening device to uncover potentially significant symptoms |
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Term
| What is the ROS good for? |
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Definition
| eliciting information that belongs in the HPI and PMH |
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Term
| What are the 14 categories of the ROS? |
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Definition
General
Integument
Hematopoietic
Endocrine
Musculoskeletal
Head and Neck
EENT
Breasts
Cardiovascular
Pulmonary
Gastrointestinal
Genitourinary
Neurologic
Psychiatric
Allergic/immunologic
Lymphatic |
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Term
| What do you do when you run out of questions? |
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Definition
Summarization
Examine the patient
Terminate the interview |
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Term
| What is in the medical history? |
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Definition
Chief Complaint
HPI
PMH (including birth history, growth and development, and childhood illnesses)
Immunizations
medications
allergies
FH
SH
ROS |
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Term
| What are the three age-defined stages of their psychosocial development? |
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Definition
early adolescence (11-14)
middle adolescence (15-17)
late adolescence (18-21) |
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Term
| What are the components of the psychosocial history for an adolescent? |
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Definition
Home
Education, employment, exercise, eating
Activites
Drugs, depression, diet
Spirituality
Sexual activity
Safety |
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