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Flashcards in History Deck (7)
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1

CC

Health problem, **in patient's own words**

2

HPI

- 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

PMH

General wellness
Childhood / Adult illnesses
Hospitalizations
Surgeries
Immunizations / Screenings
Meds
Allergies

4

FH

Age, health/death of parents, siblings,

DM, CAD, HTN, CVA, CA, Bleeding

5

SH

Employment
Marriage / Divorce / Single
Diet, Exercise
Tobacco, Alcohol, Drugs

6

ROS/PE

At least 3 systems

7

Plan

Pharm tx
Non-pharm tx
Labs / imaging
Consults
Education
Follow up