Lecture 2 Flashcards
What are the eight parts of the history?
CC- Chief complaint HPI - History of Present Illness PMH - Past Medical History PSH - Past Surgical History Allergies Medications SH - Personal and Social History FH - Family History ROS - Review of Systems (ROS)
Past Medical History:
How do you transition?
How is the past medical history recorded?
- “Next, I am going to ask you questions about your medical history/ overall health”
- Recorded as a list, with recent events first.
What are the six parts of the PMH?
** Start open ended, if they say no, ask a couple more pointed questions**
- Medical Illnesss
- Hospitalizations
- Accidents
- Obstetric and GYN History
- Immunizations
- Health maintenance (Disease prevention)
What are three examples of major adult illnesses?
Hypertension, Diabetes, Ulcers
What are three examples of major childhood illnesses? (primarily those that impact upon adult health)
Mumps, polio, meningitis
How do you ask about hospitalizations?
“Have you ever been in the hospital overnight for a medical illness?” i.e. pneumonia, heart attack, bowel problem
What 5 categories of significant accidents or injuries?
- Serious motor vehicle accidents
- Major work-related injuries or sport-related injuries
- Any functional limitations, and do they affect ADLs (Activities of Daily Living)?
- Required a blood transfusion?
- Any hardware/ devices in place?
What needs to be covered in obstetric and GYN history?
- Depends on the age of your patient
- Age of menarche, cycle length, last menstrual period (and age at menopause if relevant)
- Number of pregnancies (Gravida), and births (Para) Florida Power and Light (Full term, Premature, Abortions, Live births)
What is a questions to ask about immunizations?
What do you ask for:
-Adults
-Children
Have you had any reactions to immunizations?
Adults: Have you received immunizations as an adult? AND Did you receive childhood immunizations?
Children: Is he/she up to date on his/her immunizations?
What do you ask about preventative services/health maintenance?
Do you go to check-ups regularly?
Do you get your blood pressure, fasting lipid profile, mammography, pap smear, colonoscopy, eye/dental exams regularly?
What do you ask about past surgical history?
have you had any surgeries, operations, or minor surgical procedures? (i.e. getting your gallbladder, appendix removed, pacemaker)
make sure to include indication for surgery and when surgery was
Did you have any complications?
What do you need to record about allergies?
List allergen (medication and non-medication) List reaction - allergic reaction v/ adverse reaction
(When you take XYZ and get a reaction, what happens?)
What do you record about medication?’
What do you ask in addition to medication?
Name, dose, route, frequency:
Lipitor 10mg orally, daily
Do you take any home remedies, vitamins, or nonprescription drugs (OTC drugs)
i.e. Melatonin, advil, centrum silver
How do you transition into social history?
“I’d like to ask you a few questions about your personal/social habits.”
What are 12 topics for social history?
Tobacco use Alcohol use Drug use Exercise and diet habits Marital status & social support at home Sexual history Family violence Occupation Travel History Living Situation Hobbies Functional capacity/ADLs
How do you ask about tobacco use and what are points to cover?
PPD (packs per day) X # years = Pack Year History
Have you ever used any tobacco products? When did you quit?
Present and past tobacco use
Experience with quitting?
What are questions to ask about alcohol use?
Type, quantity and frequency
CAGE questions (any two is a potential sign for abuse): Concern or "tried to cut down?" Annoyed by criticism Guilty Eye-opener
What are questions to ask about drug use?
- Prescription abuse?
- Recreational? Have you ever used…IV drug use…“Shared needles”…
- Any experience with rehabilitation?
What are questions to ask about exercise and diet habits?
- Do you follow a special diet?
- Have you tried to lose weight?
- Do you have any regular exercise?
What are questions to ask about sexual history?
“Are you sexually active?”
“Are your partners male female or both?”
“Do you have any concerns about your sexuality?”
What are questions to ask about family violence?
S: Do you feel safe in your relationship?
A: Are you ever afraid? Have you or your children ever been physically abused?
F: Are your friends or family aware?
E: What would you do in an emergency? Do You have an escape plan?
