I.G. & P.L.C. combo Case History
Terms in this set (31)
CC= Chief Complaint Questions
"Hi! I'm Doctor ___. What seem to be the problem today?"
PI= Present Illness
Pneumonic think: O.P.Q.R.S.T.
"When did you first notice this?"
"What were you doing at the time?"
"What makes your problem better or worse?" "Position, activity, ice/heat?"
"Can you describe your problem in your words?"
R= Radiating or Referral
"Where is your pain? Can you please outline it?"
"Is there any other problem or pain anywhere else, even if seems unrelated?"
"How would you rate your pain?
From 1- 10, 10 being worst imaginable? Now and when it started."
T= Timing or Frequency
"Is there any time where this problem seems better or worse?"
PMHx= Past Medical History
Pneumonic think: S.H.I.T.A.
"Have you had any recent surgeries?"
H/O= Hospitalizations or Other providers
"Have you ever been hospitalized?"
"Have you seen any other providers for this problem?"
I/I=Illnesses or Immunizations
"Have you had a recent infection or shot/vaccine?"
"Any history of traumas?"
"Any history of allergies, seasonal, meds,?"
-"Anyone in your family (you siblings, parents, grandparents) have history of: Diabetes? Cancer? Heart Dz example Stroke or High blood pressure?"
-"Anyone in your family have this problem?"
-"What do you do for work?"
-"Is this problem affecting your work?"
P/S.Hx= Personal/Social History
Pneumonic think: 3S, 3D, & E.
"Do you smoke? [Yes?]"
"How much and for how long?"
"How is your sleep? Does your problem affect your sleep?"
-"Are you sexually active? [Yes/No?]"
-"Any use of birth control? Any use of Viagra?"
"Any use of prescription, over the counter, or recreational drugs?"
Dk= Drink particularly alcohol consumption
"Any alcohol consumption?"
"How is your diet?"
"Any unexpected weight gain or loss?"
"Do you exercise?"
"How long and how often?"
A.Sx= Associated Symptoms
= ROS: r/t CC
E= E.E.N.T., Neurophysch
"Any vision changes, HA's, confusion, problems with ears, nose or throat?"
"Any difficulty breathing? Cough? Wheezing?"
-"Any heart related sign or symptoms such as palpations? Coldness? Or pressure in jaw or shoulders?"
-"Any vascular symptoms such as: throbbing, pale or blue skin?"
G= G.I. or Gastro-Intestinal
"Any problems with foods, spicy or fried? Any changes w/ stool, Diarrhea Constipation, Color?"
G= G.U. or Genito-Urinary
"Any flank/low back pain? Difficulties with urinating or menstrual changes?"
signs or symptoms
you have noticed related to your complaint you need to let me know?"