History and Physical Exam

  1. What brings patients to clinicians office?
    • Well checks
    • New Acute problems
    • Continued treatment of an existing problems
    • Post operative followup visits
  2. What are the Interview Skills of a clinician?
    • Self-Reflection
    • Empathetic listener
    • Ability to relate to patients of all ages
    • Non-judgmental, non-biased interviewing
    • Ethnicity and cultural considerations
    • Other considerations
  3. What are the parts of a comprehensive health history?
    • Identifying data
    • Source of history
    • Chief Complaint (CC)
    • History of Present Illness (HPI)
    • Past Medical History (PMHx)
    • Family History (FHx)
    • Social History (SocHx)
    • Review of Systems (ROS)
  4. What is the detail of the Chief Complaint section?
    It is the reason for the visit
  5. What is the detail of the History Present Illness?
    • Narrative of why patient is being seen by you
    • Document in patient's own words
    • Include the seven attributes
  6. What are the 7 attributes of HPI?
    • Location
    • Quality
    • Quantity/Severity
    • Timing (onset, duration, frequency)
    • Factors that aggravate
    • Factors that relieve
    • Associated symptoms per organ system
  7. What is the parts of the Past Medical History?
    • Past Surgical History (PSHx)
    • OB/GYN History
    • Psychiatric History
    • Hospitalizations
  8. What is the Details of the Health Maintenance?
    • Immunizations
    • Screening
    • Medications
    • Allergies to medications and environment
    • Side effects to medications
  9. What is the details of the Family History?
    • Narrative
    • Pedigree with legend
  10. What is the detail of the Social History (SocHx)?
    • Personal history - Tobacco, alcohol, illicit drug use
    • Spiritual history
  11. What are the details of the Review of Systems?
    Per all organ systems
  12. What are the illnesses listed under Childhood Illnesses?
    • measles, mumps, rubella
    • chicken pox
    • whooping cough
    • scarlet fever
    • Rheumatic fever
    • Chronic conditions
  13. What are the illness listed under Adult Health?
    • Medical Illnesses
    • Surgical Procedures
    • Obstetrical History
    • Psychiatric History
    • Accidents and Injuries
    • Allergies
    • Immunizations
  14. What are the details of the adult surgical procedure?
    • Patient’s age at surgery
    • Type of procedure
    • Dates--Procedure and Hospitalization
    • Hospital
    • Surgeon
    • Sequela
    • Reaction to anesthesia
  15. What is the detail of the Adult OB history?
    • chronological order of pregnancies
    • explore each pregnancy
    • Type of delivery
    • Date of delivery
    • Complications
    • Length of gestation
    • Condition and weight of infant
  16. What is the details of the Adult Immunization?
    • MMR
    • DPT
    • HBV
    • Chicken Pox/Zoster
    • Influenza
  17. What is the detail of Adult Health Screen?
    • PPD
    • Pap Smear
    • Mammograms
    • Occult Blood
    • Cholesterol - Results, When performed
  18. What is the detail of the Adult Allergies?
    • Medication, food, insect, environmental
    • Patients age and date of reaction
    • Cause--name of drug or allergen
    • Type of reaction
    • Frequency of problem
    • Treatment
    • Effect on quality of life
  19. What are the components of Health Risk Assessment?
    • Diet and exercise
    • Sleep patterns
    • Tobacco
    • Alcohol
    • Drug use
    • Environmental hazards
    • Safety precautions
    • Safe Sex Practices?
    • Screen for Domestic Violence
  20. What is the CAGE questionnaire?
    • Have you ever felt the need to cut down on your drinking?
    • Have you ever felt annoyed at criticism of your drinking?
    • Have you ever felt guilty about your drinking
    • Have you every had a drink first thing in the morning (eye-opener) for hangover or to steady your nerves
Card Set
History and Physical Exam
History Taking