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Flashcards in Powerpoint: The Medical History Deck (18)
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1

When is the comprehensive history used?
3

1. admission history & physical exams (H&P)
2. new patient intake sessions
3. pre-operative

2

When is the focused or problem oriented exam is used?

used for most episodic patient visits

3

What are the components of the complete history?
11

1. Identifying Data
2. Chief Complaint (CC) [In quotes—patient’s own words]
3. History of Present Illness (HPI)
4. Past History (PMHx) {chronic illnesses/hospitalization}
5. Past Surgical History (PSHx)
6. Medications: Meds
7. Immunizations***
8. Allergies
9. Family History (FHx)
10. Personal/Social History (SHx)
11. Review of Systems (ROS)

4

How should the chief complaint be written down?

Quote the patient. In their own words

5

What kind of questions should you be asking for history taking?

open ended questions

6

How should we list the events in HPI?

in chronilogical order

7

What do we ask about all current medications?
5

Dose
Frequency
Route of Administration
Why they are taking it
Ask if they are missing doses and why?

8

What do we ask about allergies?
3

1. Any drug allergies
2. What type of reaction did they have
3. Any rechallange of the event

9

Whats a big problem we should educate the patient on for medications?

non-compliance/confusion on complex regimens when patients are older. Could be congitively impaired or just disinterested

10

Ask about adult immunizations. Which ones?
4

Gardisil
Flu,
pneumovax,
shingles

11

Questions to ask for past surgeries?
6

1. If so – what, where, WHY
2. Any complications?
3. What type of anesthesia?
4. Any personal or family history of problems with anesthesia?
5. Did you have to stay in hospital? How long?
6. Any advice to HAVE surgery which you ignored or declined?

12

For family history what relatives are we asking about?

first or second degree realtives

13

If they say they have a family history of a disease what would we ask about?
2

Age of onset of relative
Age at death and cause of death

14

Alwats ask the big five for family history. What are they?

Cancer
Cardiovascular disease (CVD)
Stroke
Diabetes mellitus (DM)
Hypertension (HTN)

15

Also ask anything that is related to the chief complaint. Example?

GI issue then ask about ulcers

16

How do you calculate pack years?

most they've ever smoked (pack a day for ex) X total number of years they smoked

17

What questions are part of the CAGE questionnaire?

1. Felt the need to Cut-Down drinking

2. Felt Annoyed by criticism regarding drinking

3. Guilty feelings about drinking

4. Ever drank first thing in the a.m. as an
Eye-opener

18

How many positives of the CAGE test indicate abuse?

2 or more