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History (3 PAM HS FOSS (Past medical history PMH - do you have any PMH ?…
History
3 PAM HS FOSS
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Medications - Do you take any medications ? If yes try to know them ? For example you know the patient is suffering from HTN then you can be like "Oh does it maybe end with olol"
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Family history FH - are your parents healthy ? Also ask about if she/he has any siblings ? again if yes ask about what they have
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Social history - do you work ? is it a stressful environment ? (if yes then say im sorry to hear that). Do you smoke ? if yes then how many packs per day and for how many years ? Do you drink alcohol ? if yes then how many drinks a week ? Have you ever used recreational drugs ?
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"Thank you, now I would like to ask you few questions about your health in the past"
2 ROS
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Oki, for the next set of questions ill be asking you quick yes or no questions to get a better understanding of your overall health :)
Start with general : Fever, chills, loss of appetite, changes in weight
OB/GYN
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Vaginal discharge ? If yes then ABCD approach - Amount, blood, color, oDor
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Sexual history
Always start with "Thank you for answering my questions. Now the next set of questions are a bit personal but these are standard questions that I ask all my patients in order to get a complete history so I can provide you with the best possible care, is that oki ?"
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1 HPI
If it's pain, OPQRS AA - Onset. Progress. Quality. Radiate. Severity. Aggravating & Alleviating symptoms.
Non pain, DOC PAA. Duration. Onset. Color. Progress. Aggravating & Alleviating symptoms.
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Hello, Mr/Mrs .... ? My name is Hassan and im a 4th yr medical student working with the doctors here. I'm going to get an understanding of what brought you in today, is that oki ?
Closure
Thank you for answering all my questions and for letting me examining you, now i'd like to sit down with you and give you my impression
Mr/Mrs.... based on the history and physical examination, your ..... can be caused by variety of factors. im suspecting ..... and ..... So i would like to do ..... and ..... Do you have any questions for me ?
After telling the patient about the diagnosis and tests, if they're smokers or alcoholics then consult them about this.
Smoker : Mr... i would like to talk to you about your smoking habits, as a concern physician, i strongly recommend that you quit smoking. Smoking is a major cause of cancer and heart disease. Are you interested in trying to quit ? If yes then - That's great news, taking the first step is always the hardest and im very glad you're making this decision. We have a lot of recourses here, and ill get you in contact with our social workers as soon as possible.
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