Terms in this set (136)
Onset,Location, Duration, Characteristics, Aggravating
OLDCARTS
factors, Relieving factors, Temporal factors, Severity
PQRST provocative/palliative, quality, region/radiation, severity, and timing
COLDPA characteristic, onset, location, duration, pattern, and associated factors
General health, childhood illnesses, adult illnesses or
chronic diseases, Immunizations, surgeries, serious injuries
PMH resulting in disability, medications, ability to complete ADLs,
allergies and reactions, transfusions, recent screening tests,
emotional status,
Investigate blood relatives in the immediate family with
features similar to the patient's. If a disease "runs in the
family", ask about everyone from grandparents to cousins.
FM
Ask about heart disease, hypertension, cancer, TB, stroke,
sickle cell, CF, kidney disease, thyroid disease, blood
diseases, Ascertain whether cancers are multiple, bilateral,
and occurring more than once in the family, or at a young
age.
, birthplace, home environment, cultural and ethnic
background, education, occupation, marital status,hobbies or
interests, sources of stress, habits of self-care (self breast
SH
exams, etc), habits regarding smoking, alcohol and drug use,
and sexual history. Five Ps of sexual history-partners,
practices, protection, past history of STIs, pregnancy
prevention.
general, skin hair and nails, head and neck, eyes, ears, nose,
ROS throat and mouth, lymph nodes, chest and lungs, breasts,
heart and blood vessels, peripheral vasculature, hematologic,
GI, diet, endocrine, GU, musculoskeletal, neurologic,
psychiatric.
A primary objective is to discover the details about a
concepts of developing a patient's concern, explore expectations for the encounter
relationship with the patient and display interest, curiosity and partnership. Identifying
underlying worries, believing them, and trying to deal with
them optimizes your ability to be of help
effective communication Communication built on courtesy, comfort, connection, and
strategies confirmation.
respecting and responding to patients wants and needs so
patient-centered care
they can make choices that best fit their circumstances
potential barriers of patient and moments of tension this includes: patient curiosity about
provider communication you, anxiety, silence, depression, seduction, anger,
crying, financial issues, and avoidance.
a brief statement about why the patient is seeking care.
Chief Concern
Many interviewers include duration in the CC
Females- start and character of meneses, LMP, last PAP smear, pregnancies
Males puberty onset, difficulty with erections, emissions, testicular pain and
libido.
objective direct observation, what you see, hear, smell and touch
information patients offer about their condition or
Subjective feelings. This includes chief complaint, past medical history,
history or present illness, family history, and review of
symptoms.
Provide privacy
Do not waffle be, direct and firm. Avoid asking, leading