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    rawan.sharari0911
    This document provides guidelines for comprehensively assessing a patient's history and symptoms. It includes templates for evaluating: 1. OCD (Onset, Course, Duration, etc.), Red Flags, and recent trauma or symptoms like night sweats. 2. Past medical history including allergies, medications, medical conditions, hospitalizations, and surgeries. 3. Family history and social history including living situation, employment, diet, exercise, smoking, drinking, drug use, and travel. 4. Templates are also provided for assessing pain, shortness of breath, cough, sputum, stool, vomiting, constipation, diarrhea, and dysphagia. Details include timing,

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    History

    Uploaded by

    rawan.sharari0911
    109 views5 pages
    This document provides guidelines for comprehensively assessing a patient's history and symptoms. It includes templates for evaluating: 1. OCD (Onset, Course, Duration, etc.), Red Flags, and recent trauma or symptoms like night sweats. 2. Past medical history including allergies, medications, medical conditions, hospitalizations, and surgeries. 3. Family history and social history including living situation, employment, diet, exercise, smoking, drinking, drug use, and travel. 4. Templates are also provided for assessing pain, shortness of breath, cough, sputum, stool, vomiting, constipation, diarrhea, and dysphagia. Details include timing,

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    This document provides guidelines for comprehensively assessing a patient's history and symptoms. It includes templates for evaluating: 1. OCD (Onset, Course, Duration, etc.), Red Flags, and recent trauma or symptoms like night sweats. 2. Past medical history including allergies, medications, medical conditions, hospitalizations, and surgeries. 3. Family history and social history including living situation, employment, diet, exercise, smoking, drinking, drug use, and travel. 4. Templates are also provided for assessing pain, shortness of breath, cough, sputum, stool, vomiting, constipation, diarrhea, and dysphagia. Details include timing,

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    109 views5 pages

    History

    Uploaded by

    rawan.sharari0911
    This document provides guidelines for comprehensively assessing a patient's history and symptoms. It includes templates for evaluating: 1. OCD (Onset, Course, Duration, etc.), Red Flags, and recent trauma or symptoms like night sweats. 2. Past medical history including allergies, medications, medical conditions, hospitalizations, and surgeries. 3. Family history and social history including living situation, employment, diet, exercise, smoking, drinking, drug use, and travel. 4. Templates are also provided for assessing pain, shortness of breath, cough, sputum, stool, vomiting, constipation, diarrhea, and dysphagia. Details include timing,

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    History:

    OCD PQRST AAA + Red Flags + B symptoms & any recent trauma + Past medical history +
    Family history + social history (SAD).
    1) OCD PQRST AAA
    - O: Onset – How it started? Setting: What were you doing?
    - C: Course – Continuous vs intermittent
    o Continuous:
     Frequency: is it your first time?
     Has it ↑ or ↓ or the same?
    o Intermittent:
     Frequency: how often did it happen?
     Are attacks similar or different in severity, duration, or frequency?
    - D: Duration – Usually given, if > 24 hours Empathize -> Are you able to sleep?
    - P: Position – Where did it start? Can you point with one finger on it?
    - Q: Quality – Can you describe how it feels? Squeezing, stabbing, sharp, tight, or burning?
    - R: Radiation – Does it shoot anywhere?
    - S: Severity – From 1-10, 10 being most severe. How much do you rate it?
    o If bad -> Empathize: It must be difficult.
    - T: Timing – Does it change with time?
    o Does it increase in the morning, end of the day? Any variations?
    - A: Alleviating – Anything makes it better?
    - A: Aggravating - Anything makes it worse?
    - A: Associated symptoms/ Relevant system – In addition to cc, did you notice any other
    symptoms?
    o Now, I’m going to ask you more questions to see if you have any other symptoms
    which can help me help you, ok?
    o By systems
     Same system
     Nearby systems

    2) Red Flags
    3) B symptoms: Night sweats, fever, or weight change?
    a. Any recent trauma?

    **Before I move on to your past medical history is there anything else you would like to
    let me know? **

    4) Past Medical History: Allergies, Meds, Medical illnesses, & Hospitalization/surgeries,


    LMP???
     B/c it’s the 1st time I see you, I need to ask you some questions about your PMHx. Is
    that ok with you?
    - Allergies:
    o Type of allergy: Drugs, food, animal, others.
    o What happens when in contact (reaction) with the allergens.
    - Medications: OTC, Rx meds, herbs, or supplements.
    - Medical Illnesses: What year, diagnosis, and treatment.
    - Hospitalization: What year, reason for admission, diagnosis, duration of stay, and
    treatment.
    - Surgery: What was diagnosis/ reason for surgery, year, and treatment.

    ** Thank you, I would like to ask a bit about your background and social history if you
    don’t mind? **

    5) Family history: General -> Specific


     B/c it’s the 1st time I see you, I need to ask you some questions about your family
    medical history, by this I mean of your parents and siblings. Is that ok with you?
    a. How would you describe their general health?
    b. Any long-term diseases in the family? DM, HTN, Heart attack, stroke?
    c. Any specific diseases run in the family?
    6) Social History:
    a. With whom do you live?
    i. Alone: Relationship? Sexually active?
    ii. With family: how is relationship? Are they supportive?
    b. How do you support yourself financially? -> What do you do? -> How many hours
    do you work?
    c. Do you have any issues sleeping?
    d. How is your diet?
    i. What do you eat? How often? Portions?
    ii. Are you happy with your current weight?
    e. Do you exercise? What kind? How often? Where? Time of day? a. Any other
    hobbies?
    f. Do you smoke?
    i. How many cigarettes?
    ii. Do you have any desire to quit? Offer help?!
    g. Do you drink alcohol?
    i. How much?
    ii. What kind?
    iii. How often?
    iv. Do you have any desire to quit? Offer help?!
    h. Do you do any illicit or recreational drugs I should know about?
    i. Which ones?
    ii. How long?
    iii. You might have to name a few cocaine, marijuana, heroin.
    i. Have you traveled out of the country recently?
    i. Where?
    ii. How long?

    Pain (chest / abdomen)


    =SOCRATES
    1) Site
    2) Onset
    3) Character
    4) Radiation/spread
    5) Associated symptoms
    6) Timing
    7) Elevating/relieving factor
    8) Severity

    *further explanation will be at The 15 wisdom of Dr. Htin Aung >>>

    Shortness of breath (SOB)


    1) Onset
    2) Duration
    3) Progression
    4) Aggravating / relieving
    5) Severity? Affecting sleep?
    6) Associated symptoms

    Cough
    1) Productive/non productive
    2) Intermittent / continuous
    3) Time of the day
    4) Blood
    5) Severity
    6) Aggravating / relieving factors
    7) Progression
    8) Associated symptoms

    Sputum
    1) Amount
    2) Volume
    3) Color
    4) Smell
    5) Consistency
    6) Blood
    Stool / Vomitus
    1) Amount
    2) Volume
    3) Color
    4) Blood
    5) Smell
    6) Consistency

    Constipation
    1. Frequency
    2. Feeling of incomplete evacuation
    3. Consistency of feaces
    4. Acute / chronic
    5. Associated symptoms – pain, bleeding.
    6. Time spent straining
    7. Stool?
    8. Aggravating / relieving factors

    Diarrhea
    1. Everything about stool, especially on consistency
    2. Frequency
    3. Urgency of defecation
    4. Abdominal pain
    5. Aggravating / relieving factors
    6. Severity

    Dysphagia
    1. Liquid / solid
    2. Painful
    3. Regurgitates? Into nose?
    4. Where (specific location) the food sticks

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