History Taking Flashcards
Why is patient history so important?
- About 80% of medical diagnoses can be made with history
alone - they are low-cost, low-harm with potentially high information return
What Do You Need?
- sufficient information to complete a patient illness script, ideally to cross a threshold
- elicited by exploring the patient’s reason for a reason (CC) ie. the history of the present illness as well as other potentially medically-relevant features of their history
Additional potentially relevant history is divided into different ways
but often includes:
- medications, past personal medical history, family history, social history
- review of systems (ROS) is also often included
Exploring the chief concern: OLD CARTS
Onset
Location
Duration
Character
Aggravating factors
Relieving factors
Timing
Severity
Mnemonic: “SMASH FM” of other medical history
Social
Medical (past medical history)
* All conditions currently being treated and/or that have an ongoing effect
on the patient’s health
Allergies: includes allergies to medications and the reaction they had
Surgeries (past surgical history)
Hospitalizations
Family History
Medications
Social History “FED-TACOS”
- Food/diet
- Exercise
- Drugs
- Tobacco
- Alcohol
- Caffeine
- Occupation/hobbies
- Sexual
After gathering a history, it can be useful to summarize the key
points back to the patient to check for errors
It can also be helpful to ask the patient about what they think is
going on and what their goals are for the visit. Use the ICE mnemonic
IDEAS - about their diagnosis, prognosis or treatment
CONCERNS - about any of the elements above
EXPECTATIONS - for the visit and treatment t
Asking questions ordered by body system
Review of Systems (ROS)
- E.g. asking about eye symptoms (vision changes, red eye, eye
discharge etc.) then moving on through e.g. chest symptoms
(cough, wheezing, shortness of breath, chest pain etc.) and so
on
May lead to overdiagnosis if used for screening. Use targeted approach based on risk factors for example.
Review of Systems
Charting using SOAP
Subjective: information gathered from history
Objective: information gather from physical exam
Assessment: clinical impression and (differential) diagnosis
Plan: how will this be managed include: therapeutic choices, patient education, further diagnostic work-up recommendations and referral plan
The patient’s history is a particularly important aspect of a
patient intake for multiple reasons, including:
including high information
yield and rapport building
