U 9 Taking a Medical Hx

U 9 Taking a Medical U 9 Taking a Medical HxHx

Taking a History/InterviewTaking a History/Interview

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

Be aware of…..Be aware of…..

►Culture Culture ►Gender/race Gender/race ►Language barriersLanguage barriers►White coat syndromeWhite coat syndrome

CultureCulture

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

CultureCulture

►Spouse of patient does all the talkingSpouse of patient does all the talking

►Different medical practice…Different medical practice…acupuncture and herbs acupuncture and herbs

Gender/RaceGender/Race

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

Gender/RaceGender/Race

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

►Pt may not be comfortable Pt may not be comfortable with sexual orientationwith sexual orientation

Language BarriersLanguage Barriers

►Hard to get information Hard to get information when you can not when you can not communicate .communicate .

►ESL’sESL’s

White Coat SyndromeWhite Coat Syndrome

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

Components of a Medical HxComponents of a Medical Hx

►Past medical hxPast medical hx

Components of a Medical HxComponents of a Medical Hx

►Past medical hxPast medical hx

►Family medical hxFamily medical hx

Components of a Medical HxComponents of a Medical Hx

►Past medical hxPast medical hx►Family medical hxFamily medical hx

►ROS-review of systems-ROS-review of systems-usually done by the doctorusually done by the doctor

Components of a Medical HxComponents of a Medical Hx

►Past medical hxPast medical hx►Family medical hxFamily medical hx►ROS-review of systemsROS-review of systems

►Current CC—chief Current CC—chief complaintcomplaint

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.

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.

What not to write in a pts chart.

Discharge status: Alive but without permission.

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 hxPast medical hx

►SHIMSSHIMS

Past medical hxPast medical hx

►SHIMSSHIMS

SSurgeries- any operations or urgeries- any operations or procedures in the last 5 years?procedures in the last 5 years?

Past medical hxPast medical hx

►SHIMSSHIMS SurgeriesSurgeries

HHospitalizations- have ever been in ospitalizations- have ever been in the hospital for any reason in the last the hospital for any reason in the last 5 years5 years

Past medical hxPast medical hx

►SHIMSSHIMS SurgeriesSurgeries HospitalizationsHospitalizations

IInjuries- any broken bones, cuts njuries- any broken bones, cuts etc…etc…

Past medical hxPast medical hx

►SHIMSSHIMS SurgeriesSurgeries HospitalizationsHospitalizations InjuriesInjuries

MMedications- are you on edications- are you on anyany medication medication

(includes asa, or other over the (includes asa, or other over the counter meds, also includes…….counter meds, also includes…….

Past medical hxPast medical hx

►SHIMSSHIMS SurgeriesSurgeries HospitalizationsHospitalizations InjuriesInjuries MedicationsMedications

SSickness- flu, colds etc… in the last ickness- flu, colds etc… in the last yearyear

What not to write in a pts What not to write in a pts chart.chart.

The patient’s past medical history has been The patient’s past medical history has been remarkably insignificant with only a 40 pound remarkably insignificant with only a 40 pound weight gain in the past three days. weight gain in the past three days. ►The patient had waffles for breakfast and The patient had waffles for breakfast and anorexia for lunch. anorexia for lunch. ►Between you and me, we ought to be able to Between you and me, we ought to be able to get this lady pregnant. get this lady pregnant. ►The patient was in his usual state of good The patient was in his usual state of good health until his airplane ran out of gas and health until his airplane ran out of gas and crashed. crashed.

Family HistoryFamily History

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

Family HistoryFamily History

►Are parents still alive?—if not what did Are parents still alive?—if not what did they die from?they die from?

►Any history of the following in the pts Any history of the following in the pts family- (family includes parents, family- (family includes parents, grand parents, aunts, uncles, brothers grand parents, aunts, uncles, brothers and sisters)and sisters)

Family HistoryFamily History

►Are parents still alive?—if not what did Are parents still alive?—if not what did they die from?they die from?

►Any history of the following in the Any history of the following in the familyfamily Heart disease-any formHeart disease-any form Diabetes-type 1 or 2Diabetes-type 1 or 2 Cancer-any formCancer-any form Liver diseaseLiver disease Mental disordersMental disorders

ROS-Review of SystemsROS-Review of Systems

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

What not to write in a pts What not to write in a pts chart.chart.

►Since she can't get pregnant with her Since she can't get pregnant with her husband, I thought you would like to husband, I thought you would like to work her up. work her up.

►She is numb from her toes down. She is numb from her toes down. ►The skin was moist and dry. The skin was moist and dry.

What not to write in a pts What not to write in a pts chart.chart.

►Coming from Detroit, this man has no Coming from Detroit, this man has no children. children.

►Patient was alert and unresponsive. Patient was alert and unresponsive. ►When she fainted, her eyes rolled When she fainted, her eyes rolled

around the room. around the room. ►While in the ER, she was examined, X-While in the ER, she was examined, X-

rated and sent home. rated and sent home.

CC-Chief ComplaintCC-Chief Complaint

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

CC ComponentsCC Components

►OPPQRSTOPPQRST

CC ComponentsCC Components

►OPPQRSTOPPQRST

O-onset of s+sO-onset of s+s

CC ComponentsCC Components

►OPPQRSTOPPQRST

P-palliative- any thing P-palliative- any thing that make it betterthat make it better

CC ComponentsCC Components

►OPPQRSTOPPQRST

P-Provocative- any thing P-Provocative- any thing that makes it worsethat makes it worse

CC ComponentsCC Components

►OPPQRSTOPPQRST

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

CC ComponentsCC Components

►OPPQRTSOPPQRTS

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

CC ComponentsCC Components

►OPPQRSTOPPQRST

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

CC ComponentsCC Components

►OPPQRSTOPPQRST

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

Progress NotesProgress Notes

►SOAPESOAPE

Progress NotesProgress Notes

►S-subjective- why they S-subjective- why they are in the officeare in the office

Progress NotesProgress Notes

►S-subjective- why they are in the officeS-subjective- why they are in the office

►O-objective-O-objective-procedures, tests, procedures, tests, exam resultsexam results

Progress NotesProgress Notes

►S-subjective- why they are in the officeS-subjective- why they are in the office►O-objective-procedures, tests, exam O-objective-procedures, tests, exam

resultsresults

►A-assessment/dx of A-assessment/dx of the problem the problem

Progress NotesProgress Notes

►S-subjective- why they are in the officeS-subjective- why they are in the office►O-objective-procedures, tests, exam O-objective-procedures, tests, exam

resultsresults

►A-assessment/dx of the problemA-assessment/dx of the problem ►P-plan- what is the P-plan- what is the plan for careplan for care

Progress NotesProgress Notes

►S-subjective- why they are in the officeS-subjective- why they are in the office►O-objective-procedures, tests, exam O-objective-procedures, tests, exam

resultsresults

►A-assessment/dx of the problemA-assessment/dx of the problem ►P-plan- what is the plan for careP-plan- what is the plan for care

►E- evaluation of pts E- evaluation of pts understanding understanding