Week 1: Comprehensive Health History
● Describe and organize the process of obtaining subjective patient data.
○ 80% of diagnoses are made based on history alone, PE adds 10%
○ Always start with open ended questions and to clarify and focus, use closed ended questions.
Restate to confirm accuracy of the information
○ Subjective what a patient feels/describes with words; symptoms/patient history/what the
patient is telling us; shouldn’t be in the physical exam/objective part
■ ID- age, gender, source of information, new or established patient, reliable source
(patient, family), insurance status, date and time of visit, marital status
■ CC- what prompted the patient to seek healthcare - quote pt.
■ History of presenting illness- OLDCARTS (Onset, Location/radiation, Duration,
Character, Aggravating/Associated factors, Relieving factors, Timing and Severity)
■ PMH- diagnosis, dates, sequence, management, children (pregnancy and birth history)
■ Past Surgical History - type, dates, any complications, transfusions
■ Medications- Rx: name, dose, route, frequency (when last used), OTC, herbal,
vitamins, oral contraceptives; current and those that have been discontinued.
■ Allergies- drug, environmental, food, latex and the date they found out/reaction they
had- triggers, duration, severity, have they been treated for it, any emergency visits
related to allergy,
■ Social history- habits (sleep, exercise, caffeine, smoking (2nd hand exposure), ETOH,
drug use, occupation, religious/cultural beliefs, sexual orientation
● Add screenings, nutrition (24 diet recall), safety and mental health is a
comprehensive exam (annual and physicals) rather than a focused exam like
document above
■ Immunizations- vaccine and year, any adverse reactions
● Don’t say “up-to-date”, say “unknown” or “no known record”
● Mention vaccines appropriate for specific patient (PNA, tDAP, influenza,
shingles, etc)
■ Family history
● Focused = r/t CC (chest pain and + family history of premature CAD)
● Comprehensive- family history for 3 generations (MGM, MGF, PGM, PGF, M,
F, siblings, children) (always start with grandparents, parents, siblings, and
children)
■ Reproductive history- always ask LMP and any possibility of pregnancy, number of
pregnancies (miscarriage?) GPAL, type of delivery, contraceptive use, sexually active,
history of STI.
■ ROS- general, cardiac, respiratory must be included in every history
● Focused = only pertinent symptoms that were not covered in HPI (compliments
the HPI including pertinent + and -)
● Comprehensive = review all systems
○ General/constitutional
○ Skin
○ HEENT
○ Respiratory
○ Cardiovascular
○ GI
○ GU
○ Musculoskeletal
, ○ Neurological
○ Endocrine
○ Psych
○ Objective physiological manifestation observed directly; signs/the findings of the physical exam;
shouldn’t be in the patient history section
■ Focused = include systems that are pertinent to list of differential diagnoses (usually
the same as ROS)
■ Comprehensive = include all systems
● Elicit a chief complaint and obtain all critical elements of the history of a present illness (HPI).
○ Chief complaint: 2-3 words from the patient, try to quote directly what they are saying
○ HPI: utilize OLDCARTS to obtain all information; complaints of a specific body system need to
be included (pertinent – and +) and if more than 1 body system symptom, each symptom merits
its own paragraph and a full description/OLDCARTS
■ O- onset
■ L- location/radiation
■ D- duration
■ C- characteristics
■ A- aggravating/associated symptoms
■ R- relieving factors
■ T- timing
■ S- severity
● Use OLD CARTS to identify the seven dimensions/attributes of a symptom.
■ Onset—when did it start?
■ Location/Radiation—where is it located?
■ Duration—how long has this gone on?
■ Character—does it change with any specific activities? Does the patient use any
descriptive words to describe the quality of the symptom?
■ Aggravating factors – what makes it worse?
■ Relieving factors – what makes it better?
■ Timing—is it constant, cyclic, or does it come and go?
■ Severity—how bothersome, disruptive, or painful is the problem?
● Differentiate the components of the Review of Systems (ROS). (ROS IS SUBJECTIVE- what the
patient tells you)
○ Cardinal Symptoms
○ General/ Constitutional: Wellbeing, energy, fever, chills, night sweats, weight changes, sleep
○ Skin: Rashes, lesions, changing or suspicious nevi.
○ HEENT: Headaches, ear pain, hearing loss, tinnitus, vertigo, eye pain, discharge, photophobia,
or visual disturbances. Nasal discharge, sinus pain, pharyngitis.
○ Respiratory: Cough, shortness of breath, wheezing, sputum,hemoptysis, dyspnea, pleurisy
○ Cardiovascular: Chest pain, palpitations, dyspnea on exertion, exertional leg pain, peripheral
edema
, ○ Gastrointestinal: Abdominal pain, nausea or vomiting, melena,hematochezia, constipation,
diarrhea, GERD, dysphagia
○ Genitourinary: Female - vaginal discharge, dysuria, pelvic pain
○ Males - dysuria, hesitancy, frequency, urethral discharge
○ Musculoskeletal: Myalgias, arthralgias, stiffness, gait, mobility
○ Neurological: Headaches, dizziness, sensation, weakness, memory loss, LOC
○ Endocrine: Heat / cold intolerance, polyuria, polyphagia, polydipsia
○ Psych: Anxiety, depression, suicidal ideation homicidal ideation
● Describe techniques used interview process to obtain a health history
○ Communication – respect, non-judgmental, systemic manner, enough time
○ General principles- introduction, start with open ended followed by closed ended
○ Interviewing skills- encourage participation, focus on discussion (don’t get ahead of what
patient is saying), use pauses effectively, place symptoms in sequence, reflect, clarify,
summarize
○ Unhelpful interviewing techniques- ask “how” or “why”, using probing or persisting questions,
using inappropriate or technical jargon, giving advice or false reassurance, changing the
subject or interrupting, jumping to conclusions, asking leading questions, focusing on the
diagnosis and not the symptom
● Identify the components of the complete physical exam.
○ The interview- listen to the story
○ Begin the patient encounter (review chart, review identifying information, note, record date/time,
knock on the door)
○ Subjective information-- HISTORY SYMPTOMS, SAYS
○ List of differential diagnosesàhelp to focus on specific body systems
○ ROS-- yes or no answers
○ Objective information-- PHYSICAL EXAM VITAL SIGNS, OBSERVE
○ Assessment-- include acute/current diagnoses and chronic diagnoses
○ Plan-- include diagnostics, therapeutics, education, follow up/referral for acute and chronic
conditions
Week 2: Intro to Professional Documentation and Diagnostic Reasoning
● Correctly categorize subjective and objective data in SOAP format.
○ Chief complaint, differential diagnoses
○ S: Subjective
■ HPI
■ Review of systems
○ O: Objective
■ Vital Signs
■ Physical Exam
○ A: Assessment
■ Diagnosis
○ P: Plan
■ Diagnostic
■ Therapy
■ Education
■ Follow up
, ■ Referral
● Differentiate between a comprehensive history and physical and a focused history and exam
Comprehensive Assessment Focused Assessment
Is appropriate for new patients Is appropriate for established
in the office or hospital patients, especially during
routine or urgent care visits
Provides fundamental and Addresses focused concerns or
personalized knowledge about symptoms
the patient
Strengthens the clinician-patient Assesses symptoms restricted
relationship to a specific body system
Helps identify or rule out Applies examination methods
physical causes related to relevant to assessing the
patient concerns concern or problem as
thoroughly and carefully as
possible
Provides a baseline for future
assessments
Creates a platform for health
promotion through education
and counseling
Develops proficiency in the
essential skills of the
examination
● Identify pertinent positives and negatives within the chief complaint of a given patient.
Review of System questions compliments the History of Present Illness. “Pertinent positives and
negatives” are the yes-no questions from the ROS section. Ask the patient questions related to
system(s) relevant to their Chief Complaint to establish “pertinent positives and negatives”. Pertinent
positives and negatives help clarify the diagnosis. A pertinent positive would be a sign or symptom that
might be expected based on the CC that the patient admits to having. A pertinent negative is a sign or
symptom that might also be expected based on the CC that the patient denies having. For example, a
patient with the CC of chest pain, you may ask, “Do you have any shortness of breath?” If the patient
says yes, this would be pertinent positive finding.
● Discuss the diagnostic reasoning process.
○ Analytical ability to correlate, integrate, and conceptualize clinical data in order to develop a
differential diagnoses, a working hypothesis and a problem list- diagnostic hypothesis
● Describe and organize the process of obtaining subjective patient data.
○ 80% of diagnoses are made based on history alone, PE adds 10%
○ Always start with open ended questions and to clarify and focus, use closed ended questions.
Restate to confirm accuracy of the information
○ Subjective what a patient feels/describes with words; symptoms/patient history/what the
patient is telling us; shouldn’t be in the physical exam/objective part
■ ID- age, gender, source of information, new or established patient, reliable source
(patient, family), insurance status, date and time of visit, marital status
■ CC- what prompted the patient to seek healthcare - quote pt.
■ History of presenting illness- OLDCARTS (Onset, Location/radiation, Duration,
Character, Aggravating/Associated factors, Relieving factors, Timing and Severity)
■ PMH- diagnosis, dates, sequence, management, children (pregnancy and birth history)
■ Past Surgical History - type, dates, any complications, transfusions
■ Medications- Rx: name, dose, route, frequency (when last used), OTC, herbal,
vitamins, oral contraceptives; current and those that have been discontinued.
■ Allergies- drug, environmental, food, latex and the date they found out/reaction they
had- triggers, duration, severity, have they been treated for it, any emergency visits
related to allergy,
■ Social history- habits (sleep, exercise, caffeine, smoking (2nd hand exposure), ETOH,
drug use, occupation, religious/cultural beliefs, sexual orientation
● Add screenings, nutrition (24 diet recall), safety and mental health is a
comprehensive exam (annual and physicals) rather than a focused exam like
document above
■ Immunizations- vaccine and year, any adverse reactions
● Don’t say “up-to-date”, say “unknown” or “no known record”
● Mention vaccines appropriate for specific patient (PNA, tDAP, influenza,
shingles, etc)
■ Family history
● Focused = r/t CC (chest pain and + family history of premature CAD)
● Comprehensive- family history for 3 generations (MGM, MGF, PGM, PGF, M,
F, siblings, children) (always start with grandparents, parents, siblings, and
children)
■ Reproductive history- always ask LMP and any possibility of pregnancy, number of
pregnancies (miscarriage?) GPAL, type of delivery, contraceptive use, sexually active,
history of STI.
■ ROS- general, cardiac, respiratory must be included in every history
● Focused = only pertinent symptoms that were not covered in HPI (compliments
the HPI including pertinent + and -)
● Comprehensive = review all systems
○ General/constitutional
○ Skin
○ HEENT
○ Respiratory
○ Cardiovascular
○ GI
○ GU
○ Musculoskeletal
, ○ Neurological
○ Endocrine
○ Psych
○ Objective physiological manifestation observed directly; signs/the findings of the physical exam;
shouldn’t be in the patient history section
■ Focused = include systems that are pertinent to list of differential diagnoses (usually
the same as ROS)
■ Comprehensive = include all systems
● Elicit a chief complaint and obtain all critical elements of the history of a present illness (HPI).
○ Chief complaint: 2-3 words from the patient, try to quote directly what they are saying
○ HPI: utilize OLDCARTS to obtain all information; complaints of a specific body system need to
be included (pertinent – and +) and if more than 1 body system symptom, each symptom merits
its own paragraph and a full description/OLDCARTS
■ O- onset
■ L- location/radiation
■ D- duration
■ C- characteristics
■ A- aggravating/associated symptoms
■ R- relieving factors
■ T- timing
■ S- severity
● Use OLD CARTS to identify the seven dimensions/attributes of a symptom.
■ Onset—when did it start?
■ Location/Radiation—where is it located?
■ Duration—how long has this gone on?
■ Character—does it change with any specific activities? Does the patient use any
descriptive words to describe the quality of the symptom?
■ Aggravating factors – what makes it worse?
■ Relieving factors – what makes it better?
■ Timing—is it constant, cyclic, or does it come and go?
■ Severity—how bothersome, disruptive, or painful is the problem?
● Differentiate the components of the Review of Systems (ROS). (ROS IS SUBJECTIVE- what the
patient tells you)
○ Cardinal Symptoms
○ General/ Constitutional: Wellbeing, energy, fever, chills, night sweats, weight changes, sleep
○ Skin: Rashes, lesions, changing or suspicious nevi.
○ HEENT: Headaches, ear pain, hearing loss, tinnitus, vertigo, eye pain, discharge, photophobia,
or visual disturbances. Nasal discharge, sinus pain, pharyngitis.
○ Respiratory: Cough, shortness of breath, wheezing, sputum,hemoptysis, dyspnea, pleurisy
○ Cardiovascular: Chest pain, palpitations, dyspnea on exertion, exertional leg pain, peripheral
edema
, ○ Gastrointestinal: Abdominal pain, nausea or vomiting, melena,hematochezia, constipation,
diarrhea, GERD, dysphagia
○ Genitourinary: Female - vaginal discharge, dysuria, pelvic pain
○ Males - dysuria, hesitancy, frequency, urethral discharge
○ Musculoskeletal: Myalgias, arthralgias, stiffness, gait, mobility
○ Neurological: Headaches, dizziness, sensation, weakness, memory loss, LOC
○ Endocrine: Heat / cold intolerance, polyuria, polyphagia, polydipsia
○ Psych: Anxiety, depression, suicidal ideation homicidal ideation
● Describe techniques used interview process to obtain a health history
○ Communication – respect, non-judgmental, systemic manner, enough time
○ General principles- introduction, start with open ended followed by closed ended
○ Interviewing skills- encourage participation, focus on discussion (don’t get ahead of what
patient is saying), use pauses effectively, place symptoms in sequence, reflect, clarify,
summarize
○ Unhelpful interviewing techniques- ask “how” or “why”, using probing or persisting questions,
using inappropriate or technical jargon, giving advice or false reassurance, changing the
subject or interrupting, jumping to conclusions, asking leading questions, focusing on the
diagnosis and not the symptom
● Identify the components of the complete physical exam.
○ The interview- listen to the story
○ Begin the patient encounter (review chart, review identifying information, note, record date/time,
knock on the door)
○ Subjective information-- HISTORY SYMPTOMS, SAYS
○ List of differential diagnosesàhelp to focus on specific body systems
○ ROS-- yes or no answers
○ Objective information-- PHYSICAL EXAM VITAL SIGNS, OBSERVE
○ Assessment-- include acute/current diagnoses and chronic diagnoses
○ Plan-- include diagnostics, therapeutics, education, follow up/referral for acute and chronic
conditions
Week 2: Intro to Professional Documentation and Diagnostic Reasoning
● Correctly categorize subjective and objective data in SOAP format.
○ Chief complaint, differential diagnoses
○ S: Subjective
■ HPI
■ Review of systems
○ O: Objective
■ Vital Signs
■ Physical Exam
○ A: Assessment
■ Diagnosis
○ P: Plan
■ Diagnostic
■ Therapy
■ Education
■ Follow up
, ■ Referral
● Differentiate between a comprehensive history and physical and a focused history and exam
Comprehensive Assessment Focused Assessment
Is appropriate for new patients Is appropriate for established
in the office or hospital patients, especially during
routine or urgent care visits
Provides fundamental and Addresses focused concerns or
personalized knowledge about symptoms
the patient
Strengthens the clinician-patient Assesses symptoms restricted
relationship to a specific body system
Helps identify or rule out Applies examination methods
physical causes related to relevant to assessing the
patient concerns concern or problem as
thoroughly and carefully as
possible
Provides a baseline for future
assessments
Creates a platform for health
promotion through education
and counseling
Develops proficiency in the
essential skills of the
examination
● Identify pertinent positives and negatives within the chief complaint of a given patient.
Review of System questions compliments the History of Present Illness. “Pertinent positives and
negatives” are the yes-no questions from the ROS section. Ask the patient questions related to
system(s) relevant to their Chief Complaint to establish “pertinent positives and negatives”. Pertinent
positives and negatives help clarify the diagnosis. A pertinent positive would be a sign or symptom that
might be expected based on the CC that the patient admits to having. A pertinent negative is a sign or
symptom that might also be expected based on the CC that the patient denies having. For example, a
patient with the CC of chest pain, you may ask, “Do you have any shortness of breath?” If the patient
says yes, this would be pertinent positive finding.
● Discuss the diagnostic reasoning process.
○ Analytical ability to correlate, integrate, and conceptualize clinical data in order to develop a
differential diagnoses, a working hypothesis and a problem list- diagnostic hypothesis
