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06102013

#1

ifss
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Howtogatherhistoryinanorganizedfashion?

Hi,
IjuststartedpracticingforthecsandmyhistorytakingisverydisorganizedwithalotofpausesduringtheinterviewbecauseIhave
tothink.Ittakesmewaymorethantherecommended6to7mins.Iwashopingsomebodycouldhelpmeoutwithstandardquestions
thatmustbeaskedandhowtoaskquestionsrelevanttotheCCinasystematicwaysonothingwillbemissed.Thanks.

06102013

#2

Smashingdude
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Ihadthesameprobleminitially.Thekeyistousemnemonic.ThisishowIproceed:
1Normalintroductionprotocol(yourname,his/hername,greeting,draping,"Hello","Everythingcomfortable?",Explainwhatyouare
goingtodo,"MayIsitdownandtakesomenotes?"
2PresentIllnessLIQOPRAAA{Justdigin,askin/outaboutthepresentproblem}
3ROSAskscreeningquestionsforthesystems.Startwiththemostrelevant,andyoucanskipthelessimportantones.
4PAMHITSFOSS(AlthoughIusemyownextendedmnemonicforsocial)
5Summarize
6Washhands/weargloves+askconcerns.

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6/18/2015

Howtogatherhistoryinanorganizedfashion?USMLEForums

7P/EAskanyquestionsyoumissedduringthehistory
8Counsel
9Getout!
Dontforgettousetransitionsentences."NowIamgoingtoaskaboutSocialhistory"etc
LasteditedbySmashingdude06102013at07:55PM.

Theabovepostwasthankedby:
aknz(06112013),ifss(06112013),venky2600(06112013)
06112013

#3

ifss
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Thanksalotsmashingdude.Iwilltrythat.

06112013

#4

ifss
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Ihaveanotherquestion.IhavetowritedowneverythingtheptsaysbecauseIdon'ttrustmymemorywhenIgetnervous,anxious
andstressed.I'vebeenwritingdownallthesymptomsI'maskingandwriting"yes"or"no"basedonthept'sresponse.Thatobviously
takesmoretimeandagainleadstoalotofsilenceasI'mwriting.ShouldItrainmyselfonlytowritedownthe"yes"answersand
assumewhatIdidn'twriteisa"No"?
Thanks.

06112013

#5

Smashingdude
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Quote:

OriginallyPostedbyifss
Ihaveanotherquestion.IhavetowritedowneverythingtheptsaysbecauseIdon'ttrustmymemorywhenIgetnervous,
anxiousandstressed.I'vebeenwritingdownallthesymptomsI'maskingandwriting"yes"or"no"basedonthept's
response.ThatobviouslytakesmoretimeandagainleadstoalotofsilenceasI'mwriting.ShouldItrainmyselfonlyto
writedownthe"yes"answersandassumewhatIdidn'twriteisa"No"?
Thanks.
Iknowthetimeconstraintswhenwritingdown.Havethesameproblem.ThatswhyIhavedevelopedmyownabbreviations,andthen
justcrossthemoutiftheanswerisno.
Eg,IfirstwritedownLIQOPRAA,andthennexttoeachwritetheappropriatethingthatthepatientsaid.Then,inreviewofsystem,I
justuseabbreviations(egN/Vfornausea/vomiting,Hdforheadache,W/Nforweakness/numbess,D/Cfordiarhea/constipation,
ChP/Dysforchestpain,Dyspneaetc).Ijustaskthem,andifrelevant,Iwritethemdown,otherwisejustcrossthem.Samein
PAMHITSFOSS.Justcrossthemifirrelevant(egparentsarehealthy,justcrossF).Ifrelevant,egFatherdiedofMI,writenexttoF.
Butuseyourownabbreviations!!!ThisiswhatIamdoingnow.Makeabbreviationsforeverything,andsticktoit.Itsforyour
understandinganyway,soitcanverywellbesymbols,letters,shapesorwhateversuitsyou.

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Theabovepostwasthankedby:
add1(07262013),ifss(06112013)

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