U 9 Taking a Medical Hx

Taking a History/Interview 90% of a diagnosis can come from a good medical history/interview.

Culture Gender/race Language barriers White coat syndrome Be aware of….. Culture Gender/race Language barriers White coat syndrome

Culture The spouse/partner of the patient does all the talking.

Different medical practice…acupuncture and herbs Culture Spouse of patient does all the talking Different medical practice…acupuncture and herbs

Gender/Race Pt may not be comfortable with opposite sex, or from a different race/nationality.

Gender/Race Pt may not be comfortable with opposite sex, or from a different race/nationality Pt may not be comfortable with sexual orientation

Language Barriers Hard to get information when you can not communicate . ESL’s

White Coat Syndrome Some people are afraid of healthcare workers, this fear changes the response to questions, test and procedures.

Components of a Medical Hx Past medical hx

Components of a Medical Hx Past medical hx Family medical hx

Components of a Medical Hx Past medical hx Family medical hx ROS-review of systems-usually done by the doctor

Components of a Medical Hx Past medical hx Family medical hx ROS-review of systems Current CC—chief complaint

What not to write in a pts chart. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.

What not to write in a pts chart. Patient was released to outpatient department without dressing. I have suggested that he loosen his pants before standing, and then, when he stands with the help of his wife, they should fall to the floor.

Discharge status: Alive but without permission. What not to write in a pts chart. Discharge status: Alive but without permission.

The patient refused an autopsy. What not to write in a pts chart. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful. The patient refused an autopsy. The patient has no past history of suicides.

Past medical hx SHIMS

Surgeries- any operations or procedures in the last 5 years? Past medical hx SHIMS Surgeries- any operations or procedures in the last 5 years?

Past medical hx SHIMS Surgeries Hospitalizations- have ever been in the hospital for any reason in the last 5 years

Injuries- any broken bones, cuts etc… Past medical hx SHIMS Surgeries Hospitalizations Injuries- any broken bones, cuts etc…

Medications- are you on any medication Past medical hx SHIMS Surgeries Hospitalizations Injuries Medications- are you on any medication (includes asa, or other over the counter meds, also includes…….

Sickness- flu, colds etc… in the last year Past medical hx SHIMS Surgeries Hospitalizations Injuries Medications Sickness- flu, colds etc… in the last year

What not to write in a pts chart. The patient’s past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days. The patient had waffles for breakfast and anorexia for lunch. Between you and me, we ought to be able to get this lady pregnant. The patient was in his usual state of good health until his airplane ran out of gas and crashed.

Family History Are parents still alive?—if not, what did they die from?

Family History Are parents still alive?—if not what did they die from? Any history of the following in the pts family- (family includes parents, grand parents, aunts, uncles, brothers and sisters)

Family History Are parents still alive?—if not what did they die from? Any history of the following in the family Heart disease-any form Diabetes-type 1 or 2 Cancer-any form Liver disease Mental disorders

ROS-Review of Systems Usually a check off sheet, filled out by the pt about their current health status.

What not to write in a pts chart. Since she can't get pregnant with her husband, I thought you would like to work her up. She is numb from her toes down. The skin was moist and dry.

What not to write in a pts chart. Coming from Detroit, this man has no children. Patient was alert and unresponsive. When she fainted, her eyes rolled around the room. While in the ER, she was examined, X-rated and sent home.

CC-Chief Complaint CC- Why they are seeing the doctor today. Head ache, do not feel good, pain, bleeding etc…….

CC Components OPPQRST

CC Components OPPQRST O-onset of s+s

P-palliative- any thing that make it better CC Components OPPQRST P-palliative- any thing that make it better

P-Provocative- any thing that makes it worse CC Components OPPQRST P-Provocative- any thing that makes it worse

CC Components OPPQRST Q-Quality- if there is pain what does it feel like—i.e. stabbing, burning, pinching, dull, sharp etc….

CC Components OPPQRTS R- Radiation- does the pain or discomfort radiate/travel to other areas of the body, down the leg, up the back etc…

CC Components OPPQRST S- severity- how bad does it hurt—pain scale 1-10. 1 being very little pain, and 10 being child birth/kidney stone type of pain

CC Components OPPQRST T- timing- when does/did the cc happen? All the time , tid, qid, mornings, night etc…

Progress Notes SOAPE

S-subjective- why they are in the office Progress Notes S-subjective- why they are in the office

O-objective-procedures, tests, exam results Progress Notes S-subjective- why they are in the office O-objective-procedures, tests, exam results

A-assessment/dx of the problem Progress Notes S-subjective- why they are in the office O-objective-procedures, tests, exam results A-assessment/dx of the problem

P-plan- what is the plan for care Progress Notes S-subjective- why they are in the office O-objective-procedures, tests, exam results A-assessment/dx of the problem P-plan- what is the plan for care

E- evaluation of pts understanding Progress Notes S-subjective- why they are in the office O-objective-procedures, tests, exam results A-assessment/dx of the problem P-plan- what is the plan for care E- evaluation of pts understanding