History Taking

Question 1

what is the general structure of history taking? name, in order, the 9 general components

Answer 1

1. chief complaint
2. establish rapport
3. history of present illness (HPI)
4. PMH
5. medications, allergies
6. FHx
7. social history
8. ROS
9. closure (summary)

Question 2

how should the chief concern be described in the post note?

Answer 2

quote the patient’s own words

Question 3

Do physical exam findings or test results belong in the history section of a post note?

Answer 3

NOOOO

Question 4

OPQRSTU

Answer 4

to describe pain/chief complaint:
Onset (when did it start)
Palliating, precipitating (what makes it worse or better), Place
Quality (describe it)
Radiation (does it spread)
Severity (1 to 10)
Temporal (time of day?)
Understanding (what patient thinks may have caused it)

Question 5

what are important aspects to include in a patient’s past surgical history (PSHx)?

Answer 5

each surgery, the date and age they were performed, any complications

Question 6

what are important aspects to include for a patient’s medication list during history taking and in the post note?

Answer 6

list each prescription (Rx) by generic name, route of administration, dose, and dosing schedule

include OTC meds, integrative therapies (home remedies, supplements), vaccinations

Question 7

what important aspects of a patient’s allergies should you take note of during history taking and in the post note?

Answer 7

separate allergy list by medication, food, and environmental

record associated allergies reactions for each allergy (what happens when they encounter allergen)

Question 8

what are important aspects of a patients family history to include during history taking and in the post note?

Answer 8

any disease in first degree relatives

obtain ages either if alive or at passing

ask specifically about FHx related to chief complaint (CC)

Question 9

what should the summary statement of the post note include?

Answer 9

3 sentences:
1. summary of key history findings
2. key physical exam findings
3. key diagnostic testing results

Question 10

how should a problem list be presented on the post note?

Answer 10

numbered list of each problem

include patient’s chronic problems that require active medical follow-up and may need to be addressed today

as well as chief complaint for the appointment

Question 11

general ROS

Answer 11

changes in weight, fatigue, fever/chills

Question 12

cardio ROS

Answer 12

chest pain, irregular heartbeat, palpitations, leg swelling

Question 13

derm ROS

Answer 13

rashes, skin changes

Question 14

gastro-urinary ROS

Answer 14

pain urinating, blood in urine, incontinence

Question 15

GI ROS

Answer 15

abdominal pain, constipation, diarrhea, nausea/vomiting, difficulty swallowing

Question 16

gyn ROS

Answer 16

change in periods, vaginal discharge, breast pain/discharge

Question 17

HEENT ROS

Answer 17

vision changes, hearing changes, ear pain, sore throat, nasal discharge, ear discharge

Question 18

muscular ROS

Answer 18

joint paint or swelling, muscle aches

Question 19

neuro ROS

Answer 19

headache, dizziness, fainting, weakness

Question 20

psych ROS

Answer 20

sad, depressed, anxious, trouble with memory

Question 21

respiratory ROS

Answer 21

SOB (lying down or active), wheezing, coughing