U 9 Taking a Medical Hx

1
U 9 Taking a Medical Hx
2
Taking a History/Interview

• 90 of a diagnosis can come from a good medical
  history/interview.

3
Be aware of..

• Culture
• Gender/race
• Language barriers
• White coat syndrome

4
Culture

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

5
Culture

• Spouse of patient does all the talking
• Different medical practiceacupuncture and herbs

6
Gender/Race

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

7
Gender/Race

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

8
Language Barriers

• Hard to get information when you can not
  communicate .
• ESLs

9
White Coat Syndrome

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

10
Components of a Medical Hx

• Past medical hx

11
Components of a Medical Hx

• Past medical hx
• Family medical hx

12
Components of a Medical Hx

• Past medical hx
• Family medical hx
• ROS-review of systems-usually done by the doctor

13
Components of a Medical Hx

• Past medical hx
• Family medical hx
• ROS-review of systems
• Current CCchief complaint

14
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.
15
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.

16
What not to write in a pts chart.

Discharge status Alive but without permission.
17
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.

18
Past medical hx

• SHIMS

19
Past medical hx

• SHIMS
• Surgeries- any operations or procedures in the
  last 5 years?

20
Past medical hx

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

21
Past medical hx

• SHIMS
• Surgeries
• Hospitalizations
• Injuries- any broken bones, cuts etc

22
Past medical hx

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

23
Past medical hx

• SHIMS
• Surgeries
• Hospitalizations
• Injuries
• Medications
• Sickness- flu, colds etc in the last year

24
What not to write in a pts chart.

• The patients 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.

25
Family History

• Are parents still alive?if not, what did they
  die from?

26
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)

27
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

28
ROS-Review of Systems

• Usually a check off sheet, filled out by the pt
  about their current health status.

29
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.

30
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.

31
CC-Chief Complaint

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

32
CC Components

• OPPQRST

33
CC Components

• OPPQRST
• O-onset of ss

34
CC Components

• OPPQRST
• P-palliative- any thing that make it better

35
CC Components

• OPPQRST
• P-Provocative- any thing that makes it worse

36
CC Components

• OPPQRST
• Q-Quality- if there is pain what does it feel
  likei.e. stabbing, burning, pinching, dull,
  sharp etc.

37
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

38
CC Components

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

39
CC Components

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

40
Progress Notes

• SOAPE

41
Progress Notes

• S-subjective- why they are in the office

42
Progress Notes

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

43
Progress Notes

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

44
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

45
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