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
