Transcript U 12 Taking a Medical Hx

U 9 Taking a Medical Hx
Taking a History/Interview
►90%
of a diagnosis
can come from a good
medical
history/interview.
Be aware of…..
►Culture
►Gender/race
►Language
barriers
►White coat syndrome
Culture
►The
spouse/partner of the
patient does all the talking.
Culture
► Spouse
of patient does all the talking
►Different
medical
practice…acupuncture and
herbs
Gender/Race
►Pt
may not be comfortable with
opposite sex, or from a different
race/nationality.
Gender/Race
►Pt
may not be comfortable with
opposite sex, or from a different
race/nationality
►Pt may not be comfortable with
sexual orientation
Language Barriers
►Hard
to get information when
you can not communicate .
►ESL’s
White Coat Syndrome
►Some
people are afraid of
healthcare workers, this fear
changes the response to
questions, test and
procedures.
Components of a Medical Hx
►Past
medical hx
Components of a Medical Hx
► Past
medical hx
►Family
medical hx
Components of a Medical Hx
► Past
medical hx
► Family medical hx
►ROS-review
of systems-usually
done by the doctor
Components of a Medical Hx
► Past
medical hx
► Family medical hx
► ROS-review of systems
►Current
CC—chief complaint
What not to write in a pts chart.
She has had no rigors or
shaking chills, but her
husband states she was
very hot in bed last night.
What not to write in a pts chart.
Patient was released to
outpatient department
without dressing. I have
suggested that he loosen
his pants before standing,
and then, when he stands
with the help of his wife,
they should fall to the
floor.
What not to write in a pts chart.
Discharge status:
Alive but without
permission.
What not to write in a pts chart.
Healthy appearing decrepit 69
year-old male, mentally alert but
forgetful.
The patient refused an autopsy.
The patient has no past history
of suicides.
Past medical hx
►SHIMS
Past medical hx
► SHIMS
Surgeries- any operations or procedures
in the last 5 years?
Past medical hx
► SHIMS
 Surgeries
Hospitalizations- have ever been in the
hospital for any reason in the last 5 years
Past medical hx
► SHIMS
 Surgeries
 Hospitalizations
Injuries- any broken bones, cuts etc…
Past medical hx
► SHIMS
 Surgeries
 Hospitalizations
 Injuries
Medications- are you on any medication
 (includes asa, or other over the counter
meds, also includes…….
Past medical hx
► SHIMS
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Surgeries
Hospitalizations
Injuries
Medications
Sickness- flu, colds etc… in the last year
What not to write in a pts chart.
The patient’s past medical history has been
remarkably insignificant with only a 40 pound
weight gain in the past three days.
► The patient had waffles for breakfast and
anorexia for lunch.
► Between you and me, we ought to be able
to get this lady pregnant.
► The patient was in his usual state of good
health until his airplane ran out of gas and
crashed.
Family History
► Are
parents still alive?—if not, what did they
die from?
Family History
► Are
parents still alive?—if not what did they
die from?
► Any history of the following in the pts
family- (family includes parents, grand
parents, aunts, uncles, brothers and sisters)
Family History
► Are
parents still alive?—if not what did they
die from?
► Any history of the following in the family
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Heart disease-any form
Diabetes-type 1 or 2
Cancer-any form
Liver disease
Mental disorders
ROS-Review of Systems
► Usually
a check off sheet, filled out by the
pt about their current health status.
What not to write in a pts chart.
► Since
she can't get pregnant with her
husband, I thought you would like to work
her up.
► She is numb from her toes down.
► The skin was moist and dry.
What not to write in a pts chart.
► Coming
from Detroit, this man has no
children.
► Patient was alert and unresponsive.
► When she fainted, her eyes rolled around
the room.
► While in the ER, she was examined, X-rated
and sent home.
CC-Chief Complaint
► CC-
Why they are seeing the doctor today.
Head ache, do not feel good, pain, bleeding
etc…….
CC Components
►OPPQRST
CC Components
► OPPQRST
O-onset of s+s
CC Components
► OPPQRST
P-palliative- any thing that
make it better
CC Components
► OPPQRST
P-Provocative- any thing
that makes it worse
CC Components
► OPPQRST
Q-Quality- if there is pain
what does it feel like—i.e.
stabbing, burning, pinching,
dull, sharp etc….
CC Components
► OPPQRTS
R- Radiation- does the pain
or discomfort radiate/travel
to other areas of the body,
down the leg, up the back
etc…
CC Components
► OPPQRST
S- severity- how bad does it
hurt—pain scale 1-10. 1
being very little pain, and
10 being child birth/kidney
stone type of pain
CC Components
► OPPQRST
T- timing- when does/did
the cc happen? All the time
, tid, qid, mornings, night
etc…
Progress Notes
►SOAPE
Progress Notes
►S-subjective-
the office
why they are in
Progress Notes
► S-subjective-
why they are in the office
►O-objective-procedures,
tests, exam results
Progress Notes
► S-subjective-
why they are in the office
► O-objective-procedures, tests, exam results
►A-assessment/dx
problem
of the
Progress Notes
► S-subjective-
why they are in the office
► O-objective-procedures, tests, exam results
► A-assessment/dx
►P-plan-
for care
of the problem
what is the plan
Progress Notes
► S-subjective-
why they are in the office
► O-objective-procedures, tests, exam results
► A-assessment/dx
of the problem
► P-plan- what is the plan for care
►E-
evaluation of pts
understanding