History Flashcards
(7 cards)
1
Q
CC
A
Health problem, in patient’s own words
2
Q
HPI
A
- Age, sex, race
- OLDCARTS via “What’s been going on? Start at the beginning”
Where is it, when did it start,
How often does it happen, how long does it last,
What’s it like / describe, severity,
What makes it better / what makes it worse,
Self treatment,
Associated symptoms, pertinent negatives
3
Q
PMH
A
General wellness Childhood / Adult illnesses Hospitalizations Surgeries Immunizations / Screenings Meds Allergies
4
Q
FH
A
Age, health/death of parents, siblings,
DM, CAD, HTN, CVA, CA, Bleeding
5
Q
SH
A
Employment
Marriage / Divorce / Single
Diet, Exercise
Tobacco, Alcohol, Drugs
6
Q
ROS/PE
A
At least 3 systems
7
Q
Plan
A
Pharm tx Non-pharm tx Labs / imaging Consults Education Follow up
