History Taking

Precision

Precision

Finding the "real value" of what the patient says

Specificity vs Sensitivity of symptoms

Specificity: specific, one and has 1 symptom for a disease

Sensitivity: more general, many patients with X disease have XYZ symptom (a cough with pneumonia)

reliabiliy

Consistency of the patients story

Do they keep changing it? Adding more details? Etc

poor historian

patient's answers are vague and unreliable

Who is more responsible for being a historian

The clinician! You gotta know how to get the information

Objectivity

Removing your own beliefs, not being biased

Accuracy/Validity

OPPQRST

Onset - when did it start?
Provocative-what makes it worse?
Palliative-what makes it better?
Quality-how would you describe your pain?
Radiation-does the pain radiate ?
Site-where does it hurt?
Timing-how often does it hurt?

HPI

history of present illness

asking the OPPQRST

Chief Complaint

the main reason for the patient's visit

iatrotropic stimulus

WHY the patient decided to seek care

(Ex: symptoms got worse)

What 2 acronyms help obtain the HPI

OILD CARTS

OPPQRST

OILD CARTS

Onset
Intensity
Location
Duration

Character (quality)
Aggravation/Alleviation
Radiation
Timing
Setting

ADLs

activities of daily living

Important to ask if affected during HPI!

Types of questions to avoid

Leading questions
Rapid fire
Med Jargon

Always ask females gynecological history!!!

Pap smears/LKMS/complications

:)

ALWAYS document allergies AND reaction

:)

Types of questions

Open ended: start with these!!!

Close ended: as you narrow in/summarize

PMHx questions

Current medications/conditions
Mental health
Females: Gyno
ALLERGIES!!
Immunization
Screening procedures (cscope/egd/mammo/stress test)

Social History questions

Occupation/mental heath
Nutrition/diet
Exercise
Alcohol/tobacco/drugs
Spiritual
education
Sexual Hx/relationships

How many generations for family history?

3!!!!!

Family history questions

Hereditary diseases
Family illnesses/traits
Mental health/addiction

How should smoking be documented?

Pack years!!!

(Packs per day X years smoking)
Ex: 2 ppd X 10 yrs = 20 pack years

Dependent and Demanding patient

Needs special attention
Constantly calling
Tries to be the "good patient"

Other names for dramatic patients

Hysterical
Histrionic
Manipulative
Seductive

Orderly and Controlled patient

Comes in with a list
100 questions
Very organized, taking notes

Dramatic and Manipulative Patients

Over exaggerates
"Haven't slept in weeks, pain is 12/10"

Long suffering/masochistic patient

Something is always wrong
Don't look on the bright side-there isn't one for them
Doesn't respond to optimism

Guarded, Paranoid patient

Long history of bad providers
Complains of the healthcare system
Can be anxious/suspicious

Superior patient

"I want the doctor"

5 P's of sexual history

Partners
Practices (oral/anal/etc)
Past STDs
Pregnancy
Protection

How many differentials do you need to have?

3! (Plus the diagnosis- so 4!!!!)

pertinent negatives

Symptoms that may be expected with presentation but not had by the patient

Pt with a cough doesn't have SOB

Helps you rule OUT a diagnosis

pertinent positives

Symptoms patient reports during ROS

Helps you rule IN a diagnosis

Know ROS systems and which ones relate to each other

:D

oral presentation structure

1. CC/HPI (w/ pt info)
2. Pertinent pos/neg — ROS findings
3. Physical exam findings
4. Differentials
5. Plan of action

After summarizing HPI to patient, what do you move on to?

PMHx

7 Standards of Critical Thinking

Clarity
Accuracy
Precision
Relevance
Depth
Breadth
Logic

5 stages of grief

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

What status do you need to know for an end of life patient?

DNR
(Do not resuscitate)

Don't tell patients you'll call them by XYZ

Tell patient to call YOU
Put some responsibility on the patient

SOAP abbreviation

Subjective
Objective
Assessment
Plan

What is included in the Subjective (S)

CC
HPI
Fam Hx
Social Hx
Psych Hx
Specialized Hx related to CC
PERTINENT ROS

How is ROS documented?

Head to toe format

What is included in the Objective (O)

Vitals
PE
Labs/Results
Procedures

What do you list first: pertinent positives or negs?

Positive

What is included in Assessment (A)

Primary and Secondary Assessments

(Diagnoses and DDx)

Primary Assessment

Diagnosis and DDx

Secondary Assessment

"Problem list"

Things you find that aren't related to CC
(Ex: obesity for a sore throat visit)

"VINDICATE"

Vascular
Inflammatory
Neoplasm
Degenerative and Deficiency
Intoxication
Congenital
Autoimmune/Allergies
Trauma
Endocrine

What is included in plan (P)

Tests
Referrals
Pharm
Patient education
Follow up instructions

What is ICD-XX-CM

Standardized system for applying a numeric code to a diagnosis

What are CPT codes used for?

Procedures/services done by provider

CPT category 1 sections

Evaluation and management
Anesthesiology
Surgery
Radiology
Path/Lab
Medicine