Scribd Logo
Upload

Welcome to Scribd!

  • 49 views

    Med School History Taking

    Uploaded by

    sxymd321
    Student doctor is evaluating a patient and taking their medical history. The summary includes introducing themselves, asking open-ended questions about the patient's chief complaint, and gathering detailed information on the history of present illness including onset, location, aggravating/alleviating factors, quality, radiation, severity, timing, and duration. The student also asks about medications, allergies, health habits, past medical history, family history, review of systems, and answers any questions from the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Med School History Taking

    Uploaded by

    sxymd321
    49 views4 pages
    Student doctor is evaluating a patient and taking their medical history. The summary includes introducing themselves, asking open-ended questions about the patient's chief complaint, and gathering detailed information on the history of present illness including onset, location, aggravating/alleviating factors, quality, radiation, severity, timing, and duration. The student also asks about medications, allergies, health habits, past medical history, family history, review of systems, and answers any questions from the patient.

    Original Description:

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Student doctor is evaluating a patient and taking their medical history. The summary includes introducing themselves, asking open-ended questions about the patient's chief complaint, and gathering detailed information on the history of present illness including onset, location, aggravating/alleviating factors, quality, radiation, severity, timing, and duration. The student also asks about medications, allergies, health habits, past medical history, family history, review of systems, and answers any questions from the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    49 views4 pages

    Med School History Taking

    Uploaded by

    sxymd321
    Student doctor is evaluating a patient and taking their medical history. The summary includes introducing themselves, asking open-ended questions about the patient's chief complaint, and gathering detailed information on the history of present illness including onset, location, aggravating/alleviating factors, quality, radiation, severity, timing, and duration. The student also asks about medications, allergies, health habits, past medical history, family history, review of systems, and answers any questions from the patient.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Patient Care - History

    Student Doctor: 1 2 3 4 Date: 6/18/2008 Evaluator: Patient's Answer

    Do or ask the following:


    Introduce self Greet patient by LAST name Sit down for interview Open ended question about chief complaint (eg. "What brings you in today?
    What can I do for you today?")

    History of Present Illness 5 6 7 8 9 10 11 12 13 14 Onset (when did it start?) Position (where is it located/ best felt?) Provoking factors (What triggers it?) Palliating factors (What makes it better?) Quality (What type?? Describe the pain) Radiation (Does it travel or move?) Severity (On a scale of 1 10,) Timing (When does it occur/recur?) Duration (How long does it last?) Associated symptoms: Asked about the following: 15 Yes Have you had... 16 19 20 21 22 23 25 26 27 28 29 Medication (name, dose, route, frequency of use) Allergies Tobacco Use (reported in pack-years) Alcohol Use (CAGE Questionnaire, if warranted) Use of illicit drugs Past Medical History (any hospitalizations or illnesses?) Childhood Illnesses Adult Illnesses (Medical, surgical, Ob/Gyn, psychiatric) Health Maintenance (Immunizations, screening tests) Family Medical History Personal/Social History Ask about work, education, lifestyle habits, diet, ADLs (activities of daily living), religious affiliation 30 Review of Systems (ALL systems that were not covered in the HPI) No 18 Communication Skills 31 Maintained a professional demeanor 17

    32 33 34

    Showed compassion and/or makes patient feel comfortable Gathered information efficiently Answered patient questions (Do you have any questions?)

    Comments

    You might also like