Introduction to Clinical Medicine - Key Terms (SOAP & H&P)

Flashcards covering essential terms and concepts from the Introduction to Clinical Medicine lecture, with a focus on SOAP notes, H&P structure, and interview techniques.

SOAP note

A structured method of documenting a patient encounter with four components: Subjective, Objective, Assessment, and Plan.

Subjective

Information obtained from the patient via interview (patient-reported), including CC, HPI, PMH, PSH, FH, SH, Meds, and Allergies.

Objective

Data obtained by the clinician through examination and testing; unbiased, observable findings such as vitals and physical exam results.

Assessment

The clinician’s conclusions based on the synthesis of subjective and objective data, including diagnoses or differential diagnoses.

Plan

The course of action to manage the patient’s condition, including treatments, further testing, referrals, and patient education; must reflect the assessment.

Chief Complaint (CC)

Presenting problem from the patient’s perspective; a clear, concise statement of the main issue prompting the visit.

History of Present Illness (HPI)

The main body of the subjective portion; elaborates the CC with a timeline and descriptive details from the patient’s viewpoint.

COLDERAS

Mnemonic for HPI components:

Character

Onset

Location

Duration

Exacerbating factors

Relieving factors

Associated symptoms

Severity

Character

What the symptom feels like (quality) e.g., sharp, dull, burning.

Onset

When the symptom began; timing or event at onset.

Location

Where the symptom is located; may include radiation.

Duration

How long the symptom lasts; constant vs. intermittent.

Exacerbating factors

Factors that make the symptom worse (e.g., activity, meals, medications).

Relieving factors

Factors that improve the symptom (e.g., medications, rest).

Associated symptoms

Other symptoms that occur with the main complaint.

Severity

Intensity of the symptom, often on a 0–10 scale.

Past Medical History (PMH)

Medical diagnoses, immunizations, past illnesses, injuries, and chronic conditions.

Past Surgical History (PSH)

Prior surgeries or procedures, with dates/ages and relevant hospitalizations.

Family History (FH)

Health status and diseases of immediate relatives, plus age, cause of death, and relevant psychosocial factors.

Social History (SH)

Lifestyle factors affecting health: alcohol/tobacco/drug use, occupation exposures/hazards, living situation, diet, exercise, hobbies.

Allergies

Allergic reactions to medications, foods, insects, or animals; NKDA = No Known Drug Allergies.

NKDA

No Known Drug Allergies.

Open-ended questions

Questions that require more than yes/no answers and encourage detailed responses (What, How, Why, Where).

Guided questioning

Start with open-ended questions, then use focused questions and confirmation to clarify details.

Active listening

listening approach: paraphrase, clarify, and reflect to ensure understanding and build rapport.

Transitions

Signals changing topics during the interview to help the patient follow the flow.

Summarization

Restating key points to confirm accuracy and aid shared understanding.

Header (H&P)

Top section of the History and Physical document with patient identifiers and visit details.

Pain assessment tool

A scale (often 0–10) to rate current and worst pain, aiding objective documentation.

Standard Drinks

A unit of alcohol quantity used to quantify intake: 375 mL beer, 100 mL wine, 30 mL 80-proof liquor.

Pack-years

A measure of tobacco exposure: packs per day × years smoked.

(20 cigarettes= 1 pack)

CAGE questionnaire

Alcohol screening tool: Cut down, Annoyed, Guilty, Eye-opener; positive responses suggest problematic use.

Genderbread model

A framework describing gender identity, gender expression, biological sex, and sexual orientation for taking sexual history.

sexual health

Partners – How many, Gender, type of relationship Practices – Types of sex, body part involved, environment Protection – What methods, how often used Past Hx of STI – Past testing, diagnosis, treatments, symptoms Pregnancy – Interest vs prevention, history, current practices