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7 Cards in this Set
- Front
- Back
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Components of a Medical History
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1. Chief Complaint 2. other active problems 3. history of present illness 4. past medical history 5. family history 6. social history 7. review of systems
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7 ways to facilitate obtaining the history of present illness
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1. ask open ended questions 2. use non-verbal encouragement 3. follow with wh questions to characterize 4. give interchangeable responses 5. avoid leading questions 6. give the patient time 7. summarize and clarify
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Describe the process of agenda setting
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look at what is important to the patient and try to make the visit about them
collaborate your agenda with theirs |
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Past Medical History
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-serious illness? -hospitalizations? -surgeries? -accidents? -pregnancies? - allergies? -medications? -immunizations?
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Family History
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Who?- parents, siblings, children or ppl who live with the patient
What?- inheritable diseases, familial, family traits?, illnesses among family?, current infectious diseases |
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Social History
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occupation, lifestyle, spirituality and beliefs, relationships
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5 guidelines for conducting a review of systems
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1. start with general questions 2. short in emergency situations 3. differentiate between the trivial and important 4. ambiguous terms are ok 5. do this after you have sized up the patient
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